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Bodini S, Pieralice S, D'Onofrio L, Mignogna C, Coraggio L, Amendolara R, Risi R, Salducci M, Buzzetti R, Maddaloni E. No Differences in Kidney Function Decline Between People With Type 2 Diabetes Starting a Sodium-Glucose Cotransporter 2 Inhibitor or a Glucagon-like Peptide-1 Receptor Agonist: A Real-world Retrospective Comparative Observational Study. Clin Ther 2024:S0149-2918(24)00088-2. [PMID: 38964935 DOI: 10.1016/j.clinthera.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 03/08/2024] [Accepted: 04/15/2024] [Indexed: 07/06/2024]
Abstract
PURPOSE Diabetic nephropathy represents the leading cause of end-stage kidney disease in developed countries. Cardiovascular outcome trials have found that in participants who received a glucagon-like peptide-1 receptor agonist (GLP1RA) and a sodium-glucose cotransporter 2 inhibitor (SGLT2i), the risk of incidence and progression of diabetic nephropathy in type 2 diabetes mellitus was reduced. The aim of this study was to compare the decline in estimated glomerular filtration rate (eGFR) among people taking a GLP1RA with that among people taking an SGLT2i in a real-world setting. METHODS Data for 478 patients with type 2 diabetes mellitus who initiated therapy with a GLP1RA (n = 254) or an SGLT2i (n = 224) between January 1, 2018 and December 31, 2021 were extracted. The primary outcome was any reduction ≥30% in eGFR after the start of therapy. Weight loss and drug discontinuation were also assessed. FINDINGS Over a median follow-up of 24 months, an eGFR reduction ≥30% occurred in 34 of 254 patients (13.4%) starting a GLP1RA and in 26 of 223 patients (11.6%) starting an SGLT2i (hazard ratio = 0.89; 95% CI, 0.54-1.49; P = 0.67). Median eGFR change over the whole follow-up was similar between groups (SGLT2i: median, -2 mL/min/1.73 m2; 25th, 75th percentile, -13, 8 mL/min/1.73 m2; GLP1RA: median, 0 mL/min/1.73 m2; 25th, 75th percentile, -10, 7 mL/min/1.73 m2; P = 0.54). No worsening of kidney function was observed, even when considering the ratio eGFR mean. The value of eGFR at baseline indicated a statistically significant indirect correlation with the observed absolute value of eGFR change over the follow-up (ρ = -0.36; P < 0.001). The difference in eGFR changes over time observed by eGFR categories was statistically significant (P = 0.0001) in both treatment groups. No significant differences in weight loss and drug discontinuations were observed between groups. IMPLICATIONS Although acting on different molecular mechanisms, both GLP1RA and SGLT2i might have similar effects on eGFR decline in diabetes, as suggested by the results of the present study conducted in a real-world setting. (Clin Ther. 2024;46:XXX-XXX) © 2024 Elsevier HS Journals, Inc.
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Affiliation(s)
- Sara Bodini
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Silvia Pieralice
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Luca D'Onofrio
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Carmen Mignogna
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Lucia Coraggio
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Rocco Amendolara
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Renata Risi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Mauro Salducci
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Raffaella Buzzetti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.
| | - Ernesto Maddaloni
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
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Siddiqui R, Obi Y, Dossabhoy NR, Shafi T. Is There a Role for SGLT2 Inhibitors in Patients with End-Stage Kidney Disease? Curr Hypertens Rep 2024:10.1007/s11906-024-01314-3. [PMID: 38913113 DOI: 10.1007/s11906-024-01314-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2024] [Indexed: 06/25/2024]
Abstract
PURPOSE OF REVIEW Chronic kidney disease and end-stage kidney disease (ESKD) are well-established risk factors for cardiovascular disease (CVD), the leading cause of mortality in the dialysis population. Conventional therapies, such as statins, blood pressure control, and renin-angiotensin-aldosterone system blockade, have inadequately addressed this cardiovascular risk, highlighting the unmet need for effective treatment strategies. Sodium-glucose transporter 2 (SGLT2) inhibitors have demonstrated significant renal and cardiovascular benefits among patients with type 2 diabetes, heart failure, or CKD at risk of progression. Unfortunately, efficacy data in dialysis patients is lacking as ESKD was an exclusion criterion for all major clinical trials of SGLT2 inhibitors. This review explores the potential of SGLT2 inhibitors in improving cardiovascular outcomes among patients with ESKD, focusing on their direct cardiac effects. RECENT FINDINGS Recent clinical and preclinical studies have shown promising data for the application of SGLT2 inhibitors to the dialysis population. SGLT2 inhibitors may provide cardiovascular benefits to dialysis patients, not only indirectly by preserving the remaining kidney function and improving anemia but also directly by lowering intracellular sodium and calcium levels, reducing inflammation, regulating autophagy, and alleviating oxidative stress and endoplasmic reticulum stress within cardiomyocytes and endothelial cells. This review examines the current clinical evidence and experimental data supporting the use of SGLT2 inhibitors, discusses its potential safety concerns, and outlines ongoing clinical trials in the dialysis population. Further research is needed to evaluate the safety and effectiveness of SGLT2 inhibitor use among patients with ESKD.
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Affiliation(s)
- Rehma Siddiqui
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, USA
| | - Yoshitsugu Obi
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, USA.
| | - Neville R Dossabhoy
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, USA
| | - Tariq Shafi
- Division of Kidney Diseases, Hypertension, & Transplantation, Houston Methodist Hospital, Houston, TX, USA
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Maddaloni E, Naciu AM, Mignogna C, Galiero R, Amendolara R, Fogolari M, Satta C, Serafini C, Angeletti S, Cavallo MG, Cossu E, Sasso FC, Buzzetti R, Pozzilli P. Saxagliptin/dapagliflozin is non-inferior to insulin glargine in terms of β-cell function in subjects with latent autoimmune diabetes in adults: A 12-month, randomized, comparator-controlled pilot study. Diabetes Obes Metab 2024; 26:1670-1677. [PMID: 38297915 DOI: 10.1111/dom.15469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/09/2024] [Accepted: 01/10/2024] [Indexed: 02/02/2024]
Abstract
AIM To compare the efficacy and safety of saxagliptin/dapagliflozin and insulin glargine in people with latent autoimmune diabetes in adults (LADA). METHODS In this phase 2b multicentre, open-label, comparator-controlled, parallel-group, non-inferiority study, we randomly assigned 33 people with LADA who had a fasting C-peptide concentration ≥0.2 nmol/L (0.6 ng/mL) to receive 1-year daily treatment with either the combination of saxagliptin (5 mg) plus dapagliflozin (10 mg) or insulin glargine (starting dose: 10 IU), both on top of metformin. The primary outcome was the 2-h mixed meal-stimulated C-peptide area under the curve (AUC), measured 12 months after randomization. Secondary outcomes were glycated haemoglobin (HbA1c) levels, change in body mass index (BMI), and hypoglycaemic events. RESULTS In the modified intention-to-treat analysis, the primary outcome was similar in participants assigned to saxagliptin/dapagliflozin or to insulin glargine (median C-peptide AUC: 152.0 ng*min/mL [95% confidence interval {CI} 68.2; 357.4] vs. 122.2 ng*min/mL [95% CI 84.3; 255.8]; p for noninferiority = 0.0087). Participants randomized to saxagliptin/dapagliflozin lost more weight than those randomized to insulin glargine (median BMI change at the end of the study: -0.4 kg/m2 [95% CI -1.6; -0.3] vs. +0.4 kg/m2 [95% CI -0.3; +1.1]; p = 0.0076). No differences in HbA1c or in the number of participants experiencing hypoglycaemic events were found. CONCLUSIONS Saxagliptin/dapagliflozin was non-inferior to glargine in terms of β-cell function in this 12-month, small, phase 2b study, enrolling people with LADA with still viable endogenous insulin production. Weight loss was greater with saxagliptin/dapagliflozin, with no differences in glycaemic control or hypoglycaemic risk.
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Affiliation(s)
- Ernesto Maddaloni
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Anda M Naciu
- Unit of Metabolic Bone and Thyroid Diseases, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Carmen Mignogna
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Raffaele Galiero
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Rocco Amendolara
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Marta Fogolari
- Unit of Clinical Laboratory Science, Campus Bio-Medico University of Rome, Rome, Italy
- Laboratory Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Chiara Satta
- Diabetology Unit, Policlinico Universitario of Cagliari, Cagliari, Italy
| | - Chiara Serafini
- Diabetology Unit, Policlinico Universitario of Cagliari, Cagliari, Italy
| | - Silvia Angeletti
- Unit of Clinical Laboratory Science, Campus Bio-Medico University of Rome, Rome, Italy
- Laboratory Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | | | - Efisio Cossu
- Diabetology Unit, Policlinico Universitario of Cagliari, Cagliari, Italy
| | - Ferdinando Carlo Sasso
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Raffaella Buzzetti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Paolo Pozzilli
- Diabetes, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Centre of Immunobiology, Blizard Institute, St. Bartholomew's and London School of Medicine, London, UK
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Neumiller JJ, Alicic RZ, Tuttle KR. Optimization of guideline-directed medical therapies in patients with diabetes and chronic kidney disease. Clin Kidney J 2024; 17:sfad285. [PMID: 38213492 PMCID: PMC10783256 DOI: 10.1093/ckj/sfad285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Indexed: 01/13/2024] Open
Abstract
Diabetes is the leading cause of chronic kidney disease (CKD) and kidney failure worldwide. CKD frequently coexists with heart failure and atherosclerotic cardiovascular disease in the broader context of cardio-kidney-metabolic syndrome. Diabetes and CKD are associated with increased risk of all-cause and cardiovascular death as well as decreased quality of life. The role of metabolic and hemodynamic abnormalities has long been recognized as an important contributor to the pathogenesis and progression of CKD in diabetes, while a more recent and growing body of evidence supports activation of both systemic and local inflammation as important contributors. Current guidelines recommend therapies targeting pathomechanisms of CKD in addition to management of traditional risk factors such as hyperglycemia and hypertension. Sodium-glucose cotransporter-2 inhibitors are recommended for treatment of patients with CKD and type 2 diabetes (T2D) if eGFR is ≥20 ml/min/173 m2 on a background of renin-angiotensin system inhibition. For patients with T2D, CKD, and atherosclerotic cardiovascular disease, a glucagon-like peptide-1 receptor agonist is recommended as additional risk-based therapy. A non-steroidal mineralocorticoid receptor antagonist is also recommended as additional risk-based therapy for persistent albuminuria in patients with T2D already treated with renin-angiotensin system inhibition. Implementation of guideline-directed medical therapies is challenging in the face of rapidly accumulating knowledge, high cost of medications, and lack of infrastructure for optimal healthcare delivery. Furthermore, studies of new therapies have focused on T2D and CKD. Clinical trials are now planned to inform the role of these therapies in people with type 1 diabetes (T1D) and CKD.
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Affiliation(s)
- Joshua J Neumiller
- College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA, USA
- Providence Medical Research Center, Providence Inland Northwest Health, Spokane, WA, USA
| | - Radica Z Alicic
- Providence Medical Research Center, Providence Inland Northwest Health, Spokane, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Katherine R Tuttle
- Providence Medical Research Center, Providence Inland Northwest Health, Spokane, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
- Nephrology Division, Kidney Research Institute, and Institute of Translational Health Sciences, University of Washington, Seattle, WA, USA
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Candido R, Nicolucci A, Larosa M, Rossi MC, Napoli R. Treatment intensification following glucagon-like peptide-1 receptor agonist treatment in type 2 diabetes: The RESTORE-G real-world study. Nutr Metab Cardiovasc Dis 2023; 33:2294-2305. [PMID: 37679243 DOI: 10.1016/j.numecd.2023.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 07/10/2023] [Accepted: 07/14/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND AND AIMS To assess intensification approaches with basal insulin (BI) following glucagon-like peptide-1 receptor agonist (GLP-1 RA) treatment in type 2 diabetes (T2D). METHODS AND RESULTS Real-world data were collected in electronic medical records by 32 Italian diabetes clinics between 2011 and 2021. Primary endpoint was the proportion of insulin-naïve T2D patients treated with GLP-1 RA who initiated (add-on or switch) BI. Secondary endpoints were: treatment approaches, mean time to BI start, effectiveness and safety. Among 7,962 eligible patients, BI was prescribed to 3,164 (39.7%; 95%CI 38.7; 40.8): 67.6% switched to BI (22.1% also starting 1-3 injections of short-acting insulin), 22.7% added BI while maintaining GLP-1 RA, and 9.7% switched to a fixed-ratio combination of GLP-1 RA and BI (FRC). Median time since the first GLP-1 RA to BI/FRC prescription was 27.4 (IQ range 11.8-53.5) months. In this study 60.3% of patients did not start BI/FRC, among whom 15.2% intensified GLP-1 RA therapy with other oral agents. Effectiveness and safety were documented in all intensification approaches with BI/FRC, but HbA1c level at intensification time of ≥9.0% and suboptimal BI titration suggested clinical inertia. Use of second generation BI and add-on to GLP-1 RA schemes increased over time and effectiveness improved. CONCLUSION Clinical inertia should be overcome using innovative insulin options. Timely combination therapy of BI and GLP-1 RA is a valuable choice.
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Affiliation(s)
- Riccardo Candido
- Diabetes Centre District 4, Azienda Sanitaria Universitaria Integrata, Trieste, Italy
| | - Antonio Nicolucci
- CORESEARCH, Center for Outcomes Research and Clinical Epidemiology, Pescara, Italy.
| | | | - Maria Chiara Rossi
- CORESEARCH, Center for Outcomes Research and Clinical Epidemiology, Pescara, Italy
| | - Raffaele Napoli
- Department of Translational Medical Sciences, Unit of Internal Medicine and Diabetes, Federico II University School of Medicine and Institute of Experimental Endocrinology and Oncology, National Research Council, Napoli, Italy
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Cavallari I, Crispino SP, Segreti A, Ussia GP, Grigioni F. Practical Guidance for the Use of SGLT2 Inhibitors in Heart Failure. Am J Cardiovasc Drugs 2023; 23:609-621. [PMID: 37620653 DOI: 10.1007/s40256-023-00601-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/30/2023] [Indexed: 08/26/2023]
Abstract
Despite continuous advances in both diagnosis and management, heart failure (HF) still represents a major worldwide health issue. Recently, sodium-glucose co-transporter 2 inhibitors (SGLT2i) have demonstrated to reduce cardiovascular death and hospitalization for HF across the entire spectrum of left ventricular ejection fraction. Therefore, dapagliflozin, empagliflozin and sotagliflozin are now recommended as part of the foundational therapy of HF. These agents are characterized by limited contraindications, low cost, non-relevant adverse effects and no need for titration. Although they have a prominent role in the latest recommendations for HF, drug prescriptions are definitely lower than the number of potentially eligible patients. In fact, awareness gaps, therapeutic inertia, concerns about safety and simultaneous initiation of comprehensive medical therapy may represent barriers to their use. This article aims to offer an overview of current knowledge on SGLT2i in HF and provide a comprehensive and updated practical guide on their use in de novo and chronic HF, including potential scenarios that a clinician, cardiologist or others, may face in everyday clinical practice.
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Affiliation(s)
- Ilaria Cavallari
- Department of Cardiovascular Science, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 21, 00128, Rome, Italy.
| | - Simone Pasquale Crispino
- Department of Cardiovascular Science, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 21, 00128, Rome, Italy
| | - Andrea Segreti
- Department of Cardiovascular Science, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 21, 00128, Rome, Italy
- Department of Movement, Human and Health Sciences, University of Rome, Foro Italico, Rome, Italy
| | - Gian Paolo Ussia
- Department of Cardiovascular Science, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 21, 00128, Rome, Italy
| | - Francesco Grigioni
- Department of Cardiovascular Science, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 21, 00128, Rome, Italy
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Scheen AJ. The current role of SGLT2 inhibitors in type 2 diabetes and beyond: a narrative review. Expert Rev Endocrinol Metab 2023; 18:271-282. [PMID: 37154218 DOI: 10.1080/17446651.2023.2210673] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 05/02/2023] [Indexed: 05/10/2023]
Abstract
INTRODUCTION Sodium-glucose cotransporter 2 inhibitors (SGLT2is, gliflozins), the most recent oral antihyperglycaemic agents, provide a cardiorenal protection, an effect independent of their glucose-lowering potency. AREAS COVERED The antihyperglycaemic potency of SGLT2is was compared with that of dipeptidyl peptidase-4 inhibitors and glucagon-like peptide-1 receptor agonists, especially when added to metformin monotherapy. Main results of cardiovascular/renal outcome trials with SGLT2is were summarized in different populations: patients with type 2 diabetes mellitus (T2DM) with or without established cardiovascular disease, patients (with or without T2DM) with heart failure (with reduced or preserved left ventricular ejection fraction) and in patients (with or without T2DM) with chronic kidney disease (CKD, including stage 4). Original papers and meta-analyses of these different trials have consistently reported a reduction in hospitalization for heart failure (alone or combined with cardiovascular mortality) and a reduced progression of CKD, with an overall good safety profile. EXPERT OPINION Global use of SGLT2is has increased over time but remains suboptimal despite clinically relevant cardiovascular and renal protection, particularly in patients most likely to benefit. SGLT2is has proven both positive benefit-risk balance and cost-effectiveness in at risk patients. New prospects are expected in other complications, i.e. metabolic-associated fatty liver disease and neurodegenerative disorders.
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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, Centre for Interdisciplinary Research on Medicines (CIRM), Liège University, Liège, Belgium
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