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Edmonston D, Mulder H, Lydon E, Chiswell K, Lampron Z, Shay C, Marsolo K, Jones WS, Butler J, Shah RC, Chamberlain AM, Ford DE, Gordon HS, Hwang W, Chang A, Rao A, Bosworth HB, Pagidipati N. Kidney and Cardiovascular Effectiveness of Empagliflozin Compared With Dipeptidyl Peptidase-4 Inhibitors in Patients With Type 2 Diabetes. Am J Cardiol 2024; 221:52-63. [PMID: 38641191 DOI: 10.1016/j.amjcard.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 03/13/2024] [Accepted: 04/09/2024] [Indexed: 04/21/2024]
Abstract
Placebo-controlled trials of sodium-glucose co-transporter-2 inhibitors demonstrate kidney and cardiovascular benefits for patients with type 2 diabetes and chronic kidney disease (CKD). We used real-world data to compare the kidney and cardiovascular effectiveness of empagliflozin to dipeptidyl peptidase-4 inhibitors (DPP4is), a commonly prescribed antiglycemic medication, in a diverse population with and without CKD. Using electronic health record data from 20 large US health systems, we leveraged propensity overlap weighting to compare the outcomes for empagliflozin and DPP4i initiators with type 2 diabetes between 2016 and 2020. The primary composite kidney outcome included 40% estimated glomerular filtration rate decrease, incident end-stage kidney disease, or all-cause mortality through 2 years or censoring. We also assessed cardiovascular and safety outcomes. Of 62,197 new users, 20,279 initiated empagliflozin and 41,918 initiated DPP4i. Over a median follow-up of 1.1 years, empagliflozin prescription was associated with a lower risk of the primary outcome (hazard ratio [HR] 0.75, 95% confidence interval [CI] 0.65 to 0.87) than DPP4is. The risks for mortality (HR 0.76, 95% CI 0.62 to 0.92) and a cardiovascular composite of stroke, myocardial infarction, or all-cause mortality (HR 0.81, 95% CI 0.70 to 0.95) were also lower for empagliflozin initiators. No difference in heart failure hospitalization risk between groups was observed. Genital mycotic infections were more common in patients prescribed empagliflozin (HR 1.72, 95% CI 1.58 to 1.88). Empagliflozin was associated with a lower risk of the primary outcome in patients with CKD (HR 0.68, 95% CI 0.53 to 0.88) and those without CKD (HR 0.79, 95% CI 0.67 to 0.94). In conclusion, the initiation of empagliflozin was associated with a significantly lower risk of kidney and cardiovascular outcomes than DPP4is over a median of just over 1 year. The association with a lower risk for clinical outcomes was apparent even for patients without known CKD at baseline.
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Affiliation(s)
- Daniel Edmonston
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.
| | - Hillary Mulder
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Elizabeth Lydon
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Zachary Lampron
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Christina Shay
- Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, Connecticut
| | - Keith Marsolo
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - William Schuyler Jones
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas
| | - Raj C Shah
- Department of Family & Preventive Medicine and the Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, Illinois
| | - Alanna M Chamberlain
- Department of Quantitative Health Sciences; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Daniel E Ford
- Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Howard S Gordon
- University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Wenke Hwang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Alexander Chang
- Department of Nephrology, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania
| | - Ajaykumar Rao
- Department of Endocrinology, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Hayden B Bosworth
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina; Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, Connecticut; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina; Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Medical Center, Durham, North Carolina; Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina; Duke University School of Nursing, Durham, North Carolina
| | - Neha Pagidipati
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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Wondimkun YA, Caughey GE, Inacio MC, Hughes GA, Air T, Jorissen RN, Hogan M, Sluggett JK. National trends in utilisation of glucose lowering medicines by older people with diabetes in long-term care facilities. Diabetes Res Clin Pract 2024; 212:111701. [PMID: 38719026 DOI: 10.1016/j.diabres.2024.111701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/26/2024] [Accepted: 05/04/2024] [Indexed: 05/13/2024]
Abstract
AIMS To examine national trends in glucose lowering medicine (GLM) use among older people with diabetes in long-term care facilities (LTCFs) during 2009-2019. METHODS A repeated cross-sectional study of individuals ≥65 years with diabetes in Australian LTCFs (n = 140,322) was conducted. Annual age-sex standardised prevalence of GLM use and number of defined daily doses (DDDs)/1000 resident-days were estimated. Multivariable Poisson or Negative binomial regression models were used to estimate adjusted rate ratios (aRRs) and 95 % confidence intervals (CIs). RESULTS Prevalence of GLM use remained steady between 2009 (63.9%, 95 %CI 63.3-64.4) and 2019 (64.3%, 95 %CI 63.9-64.8) (aRR 1.00, 95 %CI 1.00-1.00). The percentage of residents receiving metformin increased from 36.0% (95 %CI 35.3-36.7) to 43.5% (95 %CI 42.9-44.1) (aRR 1.01, 95 %CI 1.01-1.01). Insulin use also increased from 21.5% (95 %CI 21.0-22.0) to 27.0% (95 %CI 26.5-27.5) (aRR 1.02, 95 %CI 1.02-1.02). Dipeptidyl peptidase-4 inhibitor use increased from 1.0% (95 %CI 0.9-1.1) to 21.1% (95 %CI 20.7-21.5) (aRR 1.24, 95 %CI 1.24-1.25), while sulfonylurea use decreased from 34.4% (95 %CI 33.8-35.1) to 19.3% (95 %CI 18.9-19.7) (aRR 0.93, 95 %CI 0.93-0.94). Similar trends were observed in DDDs/1000 resident days. CONCLUSIONS The increasing use of insulin and ongoing use of sulfonylureas suggests a need to implement evidence-based strategies to optimise diabetes care in LTCFs.
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Affiliation(s)
- Yohanes A Wondimkun
- University of South Australia, UniSA Allied Health and Human Performance, Adelaide, South Australia, Australia; Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia; Hawassa University, College of Medicine and Health Sciences, Hawassa, Sidama, Ethiopia.
| | - Gillian E Caughey
- University of South Australia, UniSA Allied Health and Human Performance, Adelaide, South Australia, Australia; Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Maria C Inacio
- University of South Australia, UniSA Allied Health and Human Performance, Adelaide, South Australia, Australia; Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Georgina A Hughes
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia; University of South Australia, UniSA Clinical and Health Sciences, Adelaide, South Australia, Australia
| | - Tracy Air
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Robert N Jorissen
- University of South Australia, UniSA Allied Health and Human Performance, Adelaide, South Australia, Australia; Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Michelle Hogan
- Australian Government Aged Care Quality and Safety Commission, Adelaide, South Australia, Australia
| | - Janet K Sluggett
- University of South Australia, UniSA Allied Health and Human Performance, Adelaide, South Australia, Australia; Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
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Zhao Z, Ma R, Ma Y, Zhao L, Wang L, Fang Y, Zhang Y, Wu X, Wang X. Discovery of Nine Dipeptidyl Peptidase-4 Inhibitors from Coptis chinensis Using Virtual Screening, Bioactivity Evaluation, and Binding Studies. Molecules 2024; 29:2304. [PMID: 38792165 PMCID: PMC11123979 DOI: 10.3390/molecules29102304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 05/07/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
The objective of this study was to identify multiple alkaloids in Coptis chinensis that demonstrate inhibitory activity against DPP-4 and systematically evaluate their activity and binding characteristics. A combined strategy that included molecular docking, a DPP-4 inhibition assay, surface plasmon resonance (SPR), and a molecular dynamics simulation technique was employed. The results showed that nine alkaloids in Coptis chinensis directly inhibited DPP-4, with IC50 values of 3.44-53.73 μM. SPR-based binding studies revealed that these alkaloids display rapid binding and dissociation characteristics when interacting with DPP-4, with KD values ranging from 8.11 to 29.97 μM. A molecular dynamics analysis revealed that equilibrium was rapidly reached by nine DPP-4-ligand systems with minimal fluctuations, while binding free energy calculations showed that the ∆Gbind values for the nine test compounds ranged from -31.84 to -16.06 kcal/mol. The most important forces for the binding of these alkaloids with DPP-4 are electrostatic interactions and van der Waals forces. Various important amino acid residues, such as Arg125, His126, Phe357, Arg358, and Tyr547, were involved in the inhibition of DPP-4 by the compounds, revealing a mechanistic basis for the further optimization of these alkaloids as DPP-4 inhibitors. This study confirmed nine alkaloids as direct inhibitors of DPP-4 and characterized their binding features, thereby providing a basis for further research and development on novel DPP-4 inhibitors.
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Affiliation(s)
- Zixi Zhao
- School of Traditional Chinese Medicine, Capital Medical University, Fengtai District, Beijing 100069, China; (Z.Z.); (R.M.); (Y.M.); (L.Z.)
| | - Ruonan Ma
- School of Traditional Chinese Medicine, Capital Medical University, Fengtai District, Beijing 100069, China; (Z.Z.); (R.M.); (Y.M.); (L.Z.)
| | - Yuqing Ma
- School of Traditional Chinese Medicine, Capital Medical University, Fengtai District, Beijing 100069, China; (Z.Z.); (R.M.); (Y.M.); (L.Z.)
| | - Liqiang Zhao
- School of Traditional Chinese Medicine, Capital Medical University, Fengtai District, Beijing 100069, China; (Z.Z.); (R.M.); (Y.M.); (L.Z.)
| | - Lele Wang
- School of Pharmacy, Minzu University of China, Haidian District, Beijing 100081, China; (L.W.); (Y.F.)
| | - Yuzhen Fang
- School of Pharmacy, Minzu University of China, Haidian District, Beijing 100081, China; (L.W.); (Y.F.)
| | - Yuxin Zhang
- School of Pharmacy, Minzu University of China, Haidian District, Beijing 100081, China; (L.W.); (Y.F.)
| | - Xia Wu
- School of Traditional Chinese Medicine, Capital Medical University, Fengtai District, Beijing 100069, China; (Z.Z.); (R.M.); (Y.M.); (L.Z.)
| | - Xing Wang
- School of Traditional Chinese Medicine, Capital Medical University, Fengtai District, Beijing 100069, China; (Z.Z.); (R.M.); (Y.M.); (L.Z.)
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Al-Hindi B, Mohammed MA, Mangantig E, Martini ND. Prevalence of sodium-glucose transporter 2 inhibitor-associated diabetic ketoacidosis in real-world data: A systematic review and meta-analysis. J Am Pharm Assoc (2003) 2024; 64:9-26.e6. [PMID: 37844733 DOI: 10.1016/j.japh.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/30/2023] [Accepted: 10/09/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND The U.S. Food and Drug Administration (FDA) revised the labels of sodium-glucose transporter 2 (SGLT2) inhibitors in December 2015 to inform users regarding the risk of diabetic ketoacidosis (DKA). As more drugs of this class are approved and their indications are expanded, this serious adverse effect has been increasingly reported. OBJECTIVE This review evaluated observational studies to inform the prevalence of SGLT2-inhibitor-associated DKA compared with other antihyperglycemic agents. METHODS A systematic review was conducted in PubMed and EMBASE until 19 July 2022 (PROSPERO: CRD42022385425). We included published retrospective cohort active comparator/new user (ACNU) and prevalent new user studies assessing SGLT2-inhibitor-associated DKA prevalence in adult patients with type 2 diabetes mellitus (T2DM) against active comparators. We excluded studies which lacked 1:1 propensity score matching. The JBI Checklist for Cohort Studies guided the risk-of-bias assessments. Meta-analysis was conducted based on the inverse variance method in R software. RESULTS Sixteen studies with a sample of 2,956,100 nonunique patients met the inclusion criteria. Most studies were conducted in North America (n = 9) and adopted the ACNU design (n = 15). Meta-analysis of 14 studies identified 33% higher DKA risk associated with SGLT2 inhibitors (HR = 1.33, 95% CI: 1.14-1.55, P < 0.01). Meta-regression analysis identified the study location (P = 0.02), analysis principle (P < 0.001), exclusion of chronic comorbidities (P = 0.007), and canagliflozin (P = 0.04) as significant moderator variables. CONCLUSIONS Despite limitations related to heterogeneity, generalizability, and misclassification, the results of this study show that SGLT2 inhibitors increase the prevalence of DKA among adult T2DM patients in the real world. The findings supplement evidence from randomized controlled trials (RCTs) and call for continued vigilance.
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Li CX, Liu TT, Zhang Q, Xie Q, Geng XH, Man CX, Li JY, Mao XY, Qiao Y, Liu H. Safety of sodium-glucose transporter 2 (SGLT-2) inhibitors in patients with type 2 diabetes: a meta-analysis of cohort studies. Front Pharmacol 2023; 14:1275060. [PMID: 37905204 PMCID: PMC10613530 DOI: 10.3389/fphar.2023.1275060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 09/21/2023] [Indexed: 11/02/2023] Open
Abstract
Aims: This study aimed to investigate the association between the use of sodium-glucose transporter 2 inhibitors (SGLT-2i) and the risk of diabetic ketoacidosis (DKA), lower limb amputation (LLA), urinary tract infections (UTI), genital tract infections (GTI), bone fracture, and hypoglycemia in cohort studies. Methods: A systematic search was conducted in the PubMed and Embase databases to identify cohort studies comparing the safety of SGLT-2i versus other glucose-lowering drugs (oGLD) in patients with type 2 diabetes mellitus (T2DM). The quality of the studies was assessed using the Newcastle-Ottawa Scale. Primary endpoints were DKA and LLA, while secondary endpoints included UTI, GTI, bone fracture, and hypoglycemia. Hazard ratios (HR) with 95% confidence intervals (CI) were calculated. Results: A total of 9,911,454 patients from 40 cohort studies were included in the analysis. SGLT-2i use was associated with a higher risk of DKA (HR: 1.21, 95% CI: 1.07-1.38, p = 0.003) and GTI (HR: 2.72, 95% CI: 2.48-2.98, p < 0.01). However, it was not associated with an increased risk of LLA (HR: 1.06, 95% CI: 0.92-1.23, p = 0.42), UTI (HR: 0.99, 95% CI: 0.89-1.10, p = 0.83), or bone fracture (HR: 0.99, 95% CI: 0.94-1.04, p = 0.66). Furthermore, SGLT-2i was associated with a reduced risk of hypoglycemia. Furthermore, compared to dipeptidyl peptidase 4 inhibitors, SGLT-2i as a class and individually was associated with an increased risk of DKA. Canagliflozin specifically increased the risk of LLA (HR: 1.19, 95% CI: 1.04-1.36, p = 0.01). The subgroup analysis suggested that SGLT-2i increased the risk of LLA among patients with a history of cardiovascular disease. Conclusion: SGLT-2i versus oGLD was associated with a similar occurrence of LLA, UTI, and bone fracture. However, SGLT-2i was associated with a higher risk of DKA and GTI than oGLD. These findings provide valuable information on the safety profile of SGLT-2i in patients with T2DM and can help inform clinical decision-making.
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Affiliation(s)
- Chun Xing Li
- Department of Pharmacy, Aerospace Center Hospital, Beijing, China
| | - Tian Tian Liu
- Department of Pharmacy, Aerospace Center Hospital, Beijing, China
| | - Qian Zhang
- College of Pharmacy, Hebei Medical University, Shijiazhuang, China
| | - Qing Xie
- Department of Pharmacy, Aerospace Center Hospital, Beijing, China
| | - Xu Hua Geng
- Aerospace School of Clinical Medicine, Peking University, Beijing, China
| | - Chun Xia Man
- Department of Pharmacy, Aerospace Center Hospital, Beijing, China
| | - Jia Yi Li
- Department of Pharmacy, Aerospace Center Hospital, Beijing, China
| | - Xin Ying Mao
- Department of Pharmacy, Aerospace Center Hospital, Beijing, China
| | - Yue Qiao
- Department of Pharmacy, Aerospace Center Hospital, Beijing, China
| | - Hua Liu
- Department of Pharmacy, Aerospace Center Hospital, Beijing, China
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Huang W, Whitelaw J, Kishore K, Neto AS, Holmes NE, Marhoon N, Bellomo R, Ekinci EI. The epidemiology of ketosis and low bicarbonate concentration in inpatients treated with sodium-glucose linked cotransporter inhibitors or dipeptidyl peptidase-4 inhibitors. J Diabetes Complications 2023; 37:108522. [PMID: 37311358 DOI: 10.1016/j.jdiacomp.2023.108522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 05/21/2023] [Accepted: 05/29/2023] [Indexed: 06/15/2023]
Abstract
AIMS To compare the level of ketones and bicarbonate in inpatients treated with sodium-glucose linked cotransporter 2 inhibitors (SGLT2i) and those treated with dipeptidyl peptidase-4 inhibitors (DPP4i). METHODS We conducted an electronic medical records-based cohort study. We identified patients with type 2 diabetes, with ketone measurements available, who received SGLT2i (n = 82) or DPP4i (n = 308) during admission. We compared ketone levels between those who received SGLT2i or DPP4i using mixed ordinal logistic regression. The primary outcome was level of ketosis (<0.6, 0.6-1.5, 1.6-3.0, >3 mmol/L). Secondary outcomes included bicarbonate levels, hospital complications, ICU admission, and death. RESULTS SGLT2i use was not associated with greater ketosis than DPP4i use, after adjusting for age, weight, Charlson Comorbidity Index, HbA1c, estimated glomerular filtration rate, principal diagnosis category, admission type and insulin administration (OR 4.52 95 % CI (0.33, 61.82)). After adjustment, there was no difference in complications (p = 0.14), ICU admissions (p = 0.64), mortality (p = 0.30), or bicarbonate levels (p = 0.97). CONCLUSION Ketone levels were not greater in patients who received SGLT2i than those who received DPP4i. There were no differences in bicarbonate levels, complications, ICU admissions, or mortality, implying that, in inpatients, SGLT2i use is neither associated with ketosis nor adverse clinical outcomes.
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Affiliation(s)
- Warren Huang
- Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, University of Melbourne, Melbourne, Australia.
| | - Jack Whitelaw
- Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, University of Melbourne, Melbourne, Australia
| | - Kartik Kishore
- Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, University of Melbourne, Melbourne, Australia
| | - Ary Serpa Neto
- Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, University of Melbourne, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, @ Monash University, Melbourne, Australia; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Natasha E Holmes
- Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, University of Melbourne, Melbourne, Australia; Department of Infectious Diseases, Austin Health, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Nada Marhoon
- Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, University of Melbourne, Melbourne, Australia
| | - Rinaldo Bellomo
- Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, University of Melbourne, Melbourne, Australia; Department of Intensive Care, Austin Hospital, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; School of Medicine, University of Melbourne, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Elif I Ekinci
- The Australian Centre for Accelerating Diabetes Innovation, Melbourne Medical School, The University of Melbourne, Melbourne, Australia; Department of Endocrinology, Austin Health, Melbourne, Australia
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Koufakis T, Doumas MN, Bargiota A, Kotsa K, Maltese G. Sodium-glucose cotransporter 2 inhibitors in frail, older people with type 2 diabetes and heart failure: do we have enough evidence to confidently support the use? Expert Rev Clin Pharmacol 2023; 16:771-774. [PMID: 37577977 DOI: 10.1080/17512433.2023.2247977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/03/2023] [Accepted: 08/11/2023] [Indexed: 08/15/2023]
Affiliation(s)
- Theocharis Koufakis
- Division of Endocrinology and Metabolism and Diabetes Centre, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Michael N Doumas
- Second Propedeutic Department of Internal Medicine, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandra Bargiota
- Department of Endocrinology and Metabolic Diseases, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Kalliopi Kotsa
- Division of Endocrinology and Metabolism and Diabetes Centre, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Giuseppe Maltese
- Department of Diabetes and Endocrinology, Epsom & St Helier University Hospitals, Surrey, UK
- Unit for Metabolic Medicine, Cardiovascular Division, Faculty of Life Sciences & Medicine, King's College, London, UK
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Scheen AJ, Bonnet F. Efficacy and safety profile of SGLT2 inhibitors in the elderly: How is the benefit/risk balance? DIABETES & METABOLISM 2023; 49:101419. [PMID: 36640828 DOI: 10.1016/j.diabet.2023.101419] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 01/05/2023] [Indexed: 01/13/2023]
Abstract
Type 2 diabetes mellitus (T2DM) is a highly prevalent health condition in the aging population. Older adults with T2DM have higher risks of cardiovascular disease, heart failure (long underestimated) and premature death than those without diabetes. Sodium-glucose cotransporter 2 inhibitors (SGLT2is) have proven their ability to improve cardiovascular prognosis and reduce the risk of hospitalization for heart failure (hHF). However, several adverse events have been reported, whose incidence and severity might be increased in the elderly population. The aims of this comprehensive review were to analyze the benefit-risk ratio of SGLT2i therapy in older patients with T2DM by collecting data from (i) large prospective placebo-controlled cardiovascular outcome trials (including those dedicated to heart failure), using both original publications and dedicated post-hoc analyses across different age groups and (ii) observational cohort studies, describing the effects of SGLT2is versus other glucose-lowering agents on cardiovascular outcomes and hHF in elderly patients or these effects in different age groups. Overall, consistent results showed a similar relative risk reduction in cardiovascular mortality and hHF with SGLT2is independently of age. The absolute risk reduction may be greater in elderly because of a higher background risk in older versus younger patients. Similarly, the safety profile of SGLT2is appeared comparable in older versus younger patients. In conclusion, the benefit/risk balance favors the use of SGLT2is in older patients at risk of cardiovascular disease and/or heart failure. Caution may be required in very old frail patients, especially those exposed to an increased risk of volume depletion.
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Affiliation(s)
- André J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU, Liege, Belgium; Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM), Liège University, Liege, Belgium.
| | - Fabrice Bonnet
- Centre Hospitalier Universitaire de Rennes, Université ́ Rennes 1, Rennes, France; INSERM U1018, Villejuif, France
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Nakai M, Iwanaga Y, Kanaoka K, Sumita Y, Nishioka Y, Myojin T, Kubo S, Okada K, Soeda T, Noda T, Sakata Y, Imamura T, Saito Y, Yasuda S, Miyamoto Y. Contemporary use of SGLT2 inhibitors in heart failure patients with diabetes mellitus: a comparison of DPP4 inhibitors in a nationwide electric health database of the superaged society. Cardiovasc Diabetol 2022; 21:157. [PMID: 35964039 PMCID: PMC9375946 DOI: 10.1186/s12933-022-01586-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 07/31/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is a lack of recent data reflecting the actual use of sodium-glucose cotransporter-2 (SGLT2) inhibitors for heart failure (HF) and type 2 diabetes (DM) in the superaged society. The present study investigated the association between the use of SGLT2 inhibitors and one-year prognosis in patients hospitalized across a broad spectrum of HF patients with DM in the superaged society using the Nationwide Electric Health Database in Japan. METHODS The patients hospitalized with the first episode of acute HF were identified from the National Database of Health Insurance Claims and Specific Health Checkups of Japan between April 2014 and March 2019. A cohort of 2,277 users of SGLT2 inhibitors and 41,410 users of the active comparator, dipeptidyl peptidase-4 (DPP4) inhibitors were compared. A propensity score-matched cohort study of 2,101 users of each inhibitor was also conducted. A multivariable multilevel mixed-effects survival model was conducted with adjustments, and hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated. RESULTS Among 300,398 patients discharged with HF in 4,176 hospitals, 216,016 (71.9%) were 75 years or older, and 60,999 (20.3%) took antidiabetic medications. Among them, the patients treated with SGLT2 inhibitors were younger and had a more severe status than those treated with DPP4 inhibitors. Kaplan-Meier analysis showed that patients treated with SGLT2 inhibitors had a lower mortality risk and HF readmission. In propensity-matched cohorts, SGLT2 inhibitor use was associated with a lower risk of mortality and HF readmission than DPP-4 inhibitor use (HR [95% CI]; 0.70 [0.56, 0.89] and 0.52 [0.45, 0.61], respectively). Very elderly (≥ 75 years) patients showed similar results. Favorable effects were also observed across all age groups, including ≥ 75 years, in patients with coronary artery disease or atrial fibrillation and with concomitant β-blocker, diuretics, or insulin. CONCLUSION The use of SGLT2 inhibitors at discharge was associated with a lower risk of one-year mortality and HF readmission in patients across a broad spectrum of HF with DM in the superaged society. The findings further support the benefits of using SGLT2 inhibitors in very elderly HF care and complement the current evidence.
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Affiliation(s)
- Michikazu Nakai
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, 6-1 Kishibeshimmachi, Suita, Japan.,Department of Biostatistics, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshitaka Iwanaga
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, 6-1 Kishibeshimmachi, Suita, Japan.
| | - Koshiro Kanaoka
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, 6-1 Kishibeshimmachi, Suita, Japan
| | - Yoko Sumita
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, 6-1 Kishibeshimmachi, Suita, Japan
| | - Yuichi Nishioka
- Department of Public Health, Health Management and Policy, Nara Medical University, Kashihara, Japan
| | - Tomoya Myojin
- Department of Public Health, Health Management and Policy, Nara Medical University, Kashihara, Japan
| | - Shinichiro Kubo
- Department of Public Health, Health Management and Policy, Nara Medical University, Kashihara, Japan
| | - Katsuki Okada
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan.,Department of Transformative System for Medical Information, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tsunenari Soeda
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan
| | - Tatsuya Noda
- Department of Public Health, Health Management and Policy, Nara Medical University, Kashihara, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tomoaki Imamura
- Department of Public Health, Health Management and Policy, Nara Medical University, Kashihara, Japan
| | - Yoshihiko Saito
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Hospital, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshihiro Miyamoto
- Open Innovation Center, National Cerebral and Cardiovascular Center, Suita, Japan
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10
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[SEMERGEN positioning on approaching chronic heart failure in primary care]. Semergen 2021; 48:106-123. [PMID: 34924298 DOI: 10.1016/j.semerg.2021.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 10/24/2021] [Accepted: 10/27/2021] [Indexed: 12/11/2022]
Abstract
Heart failure (HF) is a public health problem that generates a large healthcare burden both in hospitals and in Primary Care (PC). The publication of numerous studies about HF in recent years has led to a paradigm shift in the approach to this syndrome, in which the work of PC teams is gaining greater prominence. The recent guidelines published by the European Society of Cardiology have fundamentally introduced changes in the management of patients with HF. The new proposed strategy, with drugs that reduce hospitalizations and slow the progression of the disease, should now be a priority for all professionals involved. This position document analyzes a proposal for an approach based on multidisciplinary teams with the leadership of family doctors, key to providing quality care throughout the entire process of the disease, from its prevention to the end of the life.
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11
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Scheen AJ, Delanaye P. Acute renal injury events in diabetic patients treated with SGLT2 inhibitors: A comprehensive review with a special reference to RAAS blockers. DIABETES & METABOLISM 2021; 48:101315. [PMID: 34910981 DOI: 10.1016/j.diabet.2021.101315] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 12/03/2021] [Indexed: 01/13/2023]
Abstract
Renin-angiotensin-aldosterone system (RAAS) blockers and sodium-glucose cotransporter type 2 inhibitors (SGLT2is) are two pharmacological classes that proved a remarkable nephroprotective effect, yet a risk of acute kidney injury (AKI) was also pointed out. In 2016, the US Food and Drug Administration recommended caution with the concomitant use of these medications. While the literature devoted to RAAS blockers remained surprisingly limited, numerous articles were published in recent years with SGLT2is. Safety analyses of large prospective cardiorenal trials showed a reduced rather than an increased number of AKI events in patients with type 2 diabetes treated with SGLT2is compared with those treated with placebo, despite the fact that a majority of patients received RAAS blockers at baseline. Interestingly, retrospective observational studies confirmed these reassuring findings in real-life conditions in more heterogeneous and possibly more frailty populations also commonly treated with RAAS blockers by showing a reduced risk of AKI with SGLT2is compared with other glucose-lowering drugs. Currently, there are no evidence of an increased risk of AKI with RAAS blocker-SGLT2i combinations in absence of haemodynamic instability. Several underlying mechanisms could explain a decreased rather than an increased risk of AKI with SGLT2is, including in patients treated with RAAS blockers.
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Affiliation(s)
- André J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège, Belgium; Division of Clinical Pharmacology, Center for Interdisciplinary Research on Medicines (CIRM), University of Liège (ULiege), Liège, Belgium.
| | - Pierre Delanaye
- Department of Nephrology-Dialysis-Transplantation, University of Liège (ULiege), CHU Sart Tilman, Liège, Belgium; Department of Nephrology-Dialysis-Apheresis, Hôpital Universitaire Carémeau, Nîmes, France
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12
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Scheen AJ. Efficacy / safety balance of DPP-4 inhibitors versus SGLT2 inhibitors in elderly patients with type 2 diabetes. DIABETES & METABOLISM 2021; 47:101275. [PMID: 34481962 DOI: 10.1016/j.diabet.2021.101275] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 08/07/2021] [Indexed: 12/14/2022]
Abstract
Dipeptidyl peptidase-4 inhibitors (DPP-4is) and sodium-glucose cotransporter type 2 inhibitors (SGLT2is) offer new options for the oral management of type 2 diabetes mellitus (T2DM), with the advantage in the elderly population to be devoid of a high risk of hypoglycaemia. SGLT2is have also shown benefits regarding cardiovascular (heart failure) and renal protection, including in patients with T2DM aged ≥ 65 years while DPP-4is have only proved cardiovascular and renal safety without superiority compared with placebo. The glucose-lowering efficacy of the two pharmacological classes is almost similar including in older patients with T2DM. However, the tolerance and safety profile may be highly different and overall more favourable with DPP-4is than with SGLT2is. Some adverse events have been reported with SGLT2is which may be more prevalent or severe in older patients than in younger patients. The present comprehensive review focuses on the benefit/risk balance in the elderly population with T2DM by comparing the profile of DPP-4is and SGLT2is regarding the following potential issues: metabolic disorders (hypoglycaemia and diabetic ketoacidosis); cardiac and vascular issues (atheromatous cardiovascular disease, heart failure, volume reduction hypotension, and lower limb amputations); renal endpoints including acute renal injury; risk of infections; digestive disorders; bone and skin adverse events; and cancer risk. Both DPP-4is and SGLT2is have their own advantages and disadvantages. Personalised treatment is recommended based upon the efficacy/safety profile of each drug class and individual patient characteristics that may be markedly different among the heterogeneous population of older individuals with T2DM.
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Affiliation(s)
- André J Scheen
- Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium; Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège, Belgium.
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13
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Scheen AJ. Careful use to minimize adverse events of oral antidiabetic medications in the elderly. Expert Opin Pharmacother 2021; 22:2149-2165. [PMID: 33823723 DOI: 10.1080/14656566.2021.1912735] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION An increasing number of older patients has type 2 diabetes treated with different oral antidiabetic agents whose safety may raise concern considering some particularities of a heterogeneous elderly population. AREAS COVERED This article discusses some characteristics of older patients that could increase the risk of adverse events, with a focus on hypoglycemia. It describes the most frequent and/or severe complications reported in the elderly in both randomized controlled trials and observational studies with metformin, sulfonylureas, meglitinides, alpha-glucosidase inhibitors, thiazolidinediones, dipeptidyl peptidase-4 inhibitors (gliptins) and sodium-glucose cotransporter type 2 inhibitors (gliflozins). EXPERT OPINION Old patients may present comorbidities (renal impairment, vascular disease, heart failure, risk of dehydration, osteoporosis, cognitive dysfunction) that could increase the risk of severe adverse events. Sulfonylureas (and meglitinides) induce hypoglycemia, which may be associated with falls/fractures and cardiovascular events. Medications lacking hypoglycemia should be preferred. Gliptins appear to have the best tolerance/safety profile whereas gliflozins exert a cardiorenal protection. However, data are lacking in very old or frailty old patients so that caution and appropriate supervision of such patients are required. Taking advantage of a large choice of pharmacotherapies, personalized treatment is recommended based upon both drug safety profiles and old patient individual characteristics.
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Affiliation(s)
- André J Scheen
- Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium.,Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège, Belgium
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