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Imai T, Kato N, Kanda N, Hashimoto H, Yamana H, Hatakeyama S. Risk of Urogenital Bacterial Infection with Sodium-Glucose Cotransporter-2 Inhibitors: A Retrospective Cohort Study Using a Claims Database. Diabetes Ther 2024; 15:1821-1830. [PMID: 38958909 PMCID: PMC11263449 DOI: 10.1007/s13300-024-01613-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 06/18/2024] [Indexed: 07/04/2024] Open
Abstract
INTRODUCTION The association between sodium-glucose cotransporter-2 (SGLT2) inhibitors and the risk of urogenital infections remains controversial. This study aimed to investigate the association between SGLT2 inhibitors and the incidence of perineal soft tissue infections, including Fournier's gangrene (FG), genital bacterial infections, and urinary tract infections (UTIs), using administrative claims data in Japan. METHODS In this retrospective cohort study, we utilized the JMDC Claims Database. The study included patients aged 18 years or older diagnosed with type 2 diabetes mellitus, identified by a diagnostic code, who received new prescriptions for SGLT2 inhibitors or dipeptidyl peptidase 4 (DPP-4) inhibitors between April 2014 and August 2020. Using one-to-one propensity score (PS) matching, we compared the incidence of perineal soft tissue infections, including FG, genital bacterial infection, and UTIs between groups treated with SGLT2 and DPP-4 inhibitors. Hazard ratios (HR) and their 95% confidence intervals (CI) were estimated using the Cox proportional hazards model. RESULTS We identified 34,897 patients in the SGLT2 inhibitor group and 135,311 patients in the DPP-4 inhibitor group. After one-to-one PS matching, 31,665 pairs were generated. The mean age of the patients was 51 years, with approximately 70% being male. The use of SGLT2 inhibitors was associated with a decreased risk of UTI (HR 0.90, 95% CI 0.83-0.98) and an increased risk of genital bacterial infection (HR 1.23, 95% CI 1.03-1.46) compared to DPP-4 inhibitors. However, no significant association was observed with perineal soft tissue infection (HR 1.05, 95% CI 0.61-1.81). CONCLUSIONS SGLT2 inhibitors were associated with a reduced risk of UTI and an increased risk of genital bacterial infection. They showed no significant association with perineal soft tissue infection when compared to DPP-4 inhibitors. Future research should explore broader demographics, focusing on the elderly and achieving gender balance, to gain a comprehensive understanding of infection risks.
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Affiliation(s)
- Takanori Imai
- Division of General Internal Medicine, Jichi Medical University Hospital, 3311-1 Yakushiji, Shimotsuke-Shi, Tochigi, 329-0498, Japan
| | - Naoto Kato
- Division of General Internal Medicine, Jichi Medical University Hospital, 3311-1 Yakushiji, Shimotsuke-Shi, Tochigi, 329-0498, Japan
- Yamagata Prefectural Central Hospital, 1800 Aoyagi, Yamagata-Shi, Yamagata, 990-2292, Japan
| | - Naoki Kanda
- Division of General Internal Medicine, Jichi Medical University Hospital, 3311-1 Yakushiji, Shimotsuke-Shi, Tochigi, 329-0498, Japan
| | - Hideki Hashimoto
- Division of General Internal Medicine, Jichi Medical University Hospital, 3311-1 Yakushiji, Shimotsuke-Shi, Tochigi, 329-0498, Japan
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1, Jonan-Cho, Hitachi-Shi, Ibaraki, 317-0077, Japan
| | - Hayato Yamana
- Data Science Center, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-Shi, Tochigi, 329-0498, Japan
| | - Shuji Hatakeyama
- Division of General Internal Medicine, Jichi Medical University Hospital, 3311-1 Yakushiji, Shimotsuke-Shi, Tochigi, 329-0498, Japan.
- Division of Infectious Diseases, Department of Infection and Immunity, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-Shi, Tochigi, 329-0498, Japan.
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Landgraf R, Aberle J, Birkenfeld AL, Gallwitz B, Kellerer M, Klein HH, Müller-Wieland D, Nauck MA, Wiesner T, Siegel E. Therapy of Type 2 Diabetes. Exp Clin Endocrinol Diabetes 2024; 132:340-388. [PMID: 38599610 DOI: 10.1055/a-2166-6755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Affiliation(s)
| | - Jens Aberle
- Division of Endocrinology and Diabetology, University Obesity Centre Hamburg, University Hospital Hamburg-Eppendorf, Germany
| | | | - Baptist Gallwitz
- Department of Internal Medicine IV, Diabetology, Endocrinology, Nephrology, University Hospital Tübingen, Germany
| | - Monika Kellerer
- Department of Internal Medicine I, Marienhospital, Stuttgart, Germany
| | - Harald H Klein
- MVZ for Diagnostics and Therapy Bochum, Bergstraße 26, 44791 Bochum, Germany
| | - Dirk Müller-Wieland
- Department of Internal Medicine I, Aachen University Hospital RWTH, Aachen, Germany
| | - Michael A Nauck
- Diabetology, Endocrinology and Metabolism Section, Department of Internal Medicine I, St. Josef Hospital, Ruhr University, Bochum, Germany
| | | | - Erhard Siegel
- Department of Internal Medicine - Gastroenterology, Diabetology/Endocrinology and Nutritional Medicine, St. Josefkrankenhaus Heidelberg GmbH, Heidelberg, Germany
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Suciu IM, Greluș A, Cozlac AR, Suciu BS, Stoica S, Luca S, Luca CT, Gaiță DI. Fournier's Gangrene as an Adverse Event Following Treatment with Sodium Glucose Cotransporter 2 Inhibitors. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:837. [PMID: 38793020 PMCID: PMC11122753 DOI: 10.3390/medicina60050837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/13/2024] [Accepted: 05/17/2024] [Indexed: 05/26/2024]
Abstract
We present the case of a 51-year-old male with known congestive heart failure and acute myocarditis who presented to the emergency department (ED) with swollen testicles and urinary symptoms two weeks after the initiation of sodium glucose cotransporter 2 (SGLT2) inhibitor treatment. Abdominal and pelvic computed tomography (CT) scan was consistent with the diagnosis of Fournier's gangrene (FG). Intravenous antibiotics were administered and surgical exploratory intervention and excision of necrotic tissue were performed, stopping the evolution of necrotizing fasciitis. FG, a reported adverse event, may rarely occur when SGLT2 inhibitors are administered in patients with diabetes. To our knowledge, there have been no reported cases of FG in Romania since SLGT2 inhibitors were approved. The distinguishing feature of this case is that the patient was not diabetic, which emphasizes that patients without diabetes who are treated for heart failure with SGLT2 inhibitors may also be at risk of developing genitourinary infections. The association of predisposing factors may have contributed to the development of FG in this case and even though the benefits of SGLT2 inhibitors outweigh the risks, serious adverse events need to be voluntarily reported in order to intervene promptly, verify the relationship, and minimize the risk of bias.
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Affiliation(s)
- Ioana-Maria Suciu
- Institute of Cardiovascular Diseases Timișoara, 13A Gheorghe Adam Street, 300310 Timișoara, Romania
| | - Alin Greluș
- Institute of Life Sciences, “Vasile Goldiș” Western University of Arad, Str. Liviu Rebreanu 86, 310045 Arad, Romania
- Arad County Emergency Clinical Hospital, Str. Andreny Karoly nr. 2–4, 310037 Arad, Romania
| | - Alina-Ramona Cozlac
- Institute of Cardiovascular Diseases Timișoara, 13A Gheorghe Adam Street, 300310 Timișoara, Romania
- Cardiology Department, “Victor Babeș” University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timișoara, Romania
- Research Center of the Institute of Cardiovascular Diseases Timișoara—IBCV-TIM, 13A Gheorghe Adam Street, 300310 Timișoara, Romania
| | - Bogdan-Simion Suciu
- Institute of Cardiovascular Diseases Timișoara, 13A Gheorghe Adam Street, 300310 Timișoara, Romania
| | - Svetlana Stoica
- Institute of Cardiovascular Diseases Timișoara, 13A Gheorghe Adam Street, 300310 Timișoara, Romania
- Cardiology Department, “Victor Babeș” University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timișoara, Romania
- Research Center of the Institute of Cardiovascular Diseases Timișoara—IBCV-TIM, 13A Gheorghe Adam Street, 300310 Timișoara, Romania
| | - Silvia Luca
- Institute of Cardiovascular Diseases Timișoara, 13A Gheorghe Adam Street, 300310 Timișoara, Romania
- Cardiology Department, “Victor Babeș” University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timișoara, Romania
| | - Constantin-Tudor Luca
- Institute of Cardiovascular Diseases Timișoara, 13A Gheorghe Adam Street, 300310 Timișoara, Romania
- Cardiology Department, “Victor Babeș” University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timișoara, Romania
- Research Center of the Institute of Cardiovascular Diseases Timișoara—IBCV-TIM, 13A Gheorghe Adam Street, 300310 Timișoara, Romania
| | - Dan-Ion Gaiță
- Institute of Cardiovascular Diseases Timișoara, 13A Gheorghe Adam Street, 300310 Timișoara, Romania
- Cardiology Department, “Victor Babeș” University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timișoara, Romania
- Research Center of the Institute of Cardiovascular Diseases Timișoara—IBCV-TIM, 13A Gheorghe Adam Street, 300310 Timișoara, Romania
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Seidu S, Alabraba V, Davies S, Newland-Jones P, Fernando K, Bain SC, Diggle J, Evans M, James J, Kanumilli N, Milne N, Viljoen A, Wheeler DC, Wilding JPH. SGLT2 Inhibitors - The New Standard of Care for Cardiovascular, Renal and Metabolic Protection in Type 2 Diabetes: A Narrative Review. Diabetes Ther 2024; 15:1099-1124. [PMID: 38578397 PMCID: PMC11043288 DOI: 10.1007/s13300-024-01550-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/06/2024] [Indexed: 04/06/2024] Open
Abstract
A substantial evidence base supports the use of sodium-glucose cotransporter-2 inhibitors (SGLT2is) in the treatment of type 2 diabetes mellitus (T2DM). This class of medicines has demonstrated important benefits that extend beyond glucose-lowering efficacy to protective mechanisms capable of slowing or preventing the onset of long-term cardiovascular, renal and metabolic (CVRM) complications, making their use highly applicable for organ protection and the maintenance of long-term health outcomes. SGLT2is have shown cost-effectiveness in T2DM management and economic savings over other glucose-lowering therapies due to reduced incidence of cardiovascular and renal events. National and international guidelines advocate SGLT2i use early in the T2DM management pathway, based upon a plethora of supporting data from large-scale cardiovascular outcome trials, renal outcomes trials and real-world studies. While most people with T2DM would benefit from CVRM protection through SGLT2i use, prescribing hesitancy remains, potentially due to confusion concerning their place in the complex therapeutic paradigm, variation in licensed indications or safety perceptions/misunderstandings associated with historical data that have since been superseded by robust clinical evidence and long-term pharmacovigilance reporting. This latest narrative review developed by the Improving Diabetes Steering Committee (IDSC) outlines the place of SGLT2is within current evidence-informed guidelines, examines their potential as the standard of care for the majority of newly diagnosed people with T2DM and sets into context the perceived risks and proven advantages of SGLT2is in terms of sustained health outcomes. The authors discuss the cost-effectiveness case for SGLT2is and provide user-friendly tools to support healthcare professionals in the correct application of these medicines in T2DM management. The previously published IDSC SGLT2i Prescribing Tool for T2DM Management has undergone updates and reformatting and is now available as a Decision Tool in an interactive pdf format as well as an abbreviated printable A4 poster/wall chart.
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Affiliation(s)
- Samuel Seidu
- Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, UK
| | - Vicki Alabraba
- Leicester Diabetes Centre, University Hospitals Leicester NHS Trust, Leicester, UK
| | | | | | | | - Stephen C Bain
- Diabetes Research Group, Swansea University Medical School, Swansea University, Swansea, UK
- Department of Diabetes and Endocrinology, Singleton Hospital, Swansea Bay University Health Board, Swansea, UK
| | - Jane Diggle
- College Lane Surgery, Ackworth, West Yorkshire, UK
| | - Marc Evans
- University Hospital Llandough, Cardiff, UK
| | - June James
- Leicester Diabetes Centre, University Hospitals Leicester NHS Trust, Leicester, UK
| | - Naresh Kanumilli
- Brooklands Northenden Primary Care Network, Manchester, UK
- Manchester University Foundation Trust, Manchester, UK
| | - Nicola Milne
- Brooklands Northenden Primary Care Network, Manchester, UK
| | - Adie Viljoen
- Borthwick Diabetes Research Unit, Lister Hospital, Stevenage, UK
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, Clinical Sciences Centre, Aintree University Hospital, University of Liverpool, Liverpool, UK.
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Patil T, Cook M, Hobson J, Kaur A, Lee A. Evaluating the Safety of Sodium-Glucose Cotransporter-2 Inhibitors in a Nationwide Veterans Health Administration Observational Cohort Study. Am J Cardiol 2023; 201:281-293. [PMID: 37393731 DOI: 10.1016/j.amjcard.2023.06.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 05/30/2023] [Accepted: 06/05/2023] [Indexed: 07/04/2023]
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT-2is) are indicated in patients with or without type 2 diabetes mellitus atherosclerotic cardiovascular disease, chronic kidney disease, or heart failure. Postmarket surveillance data have identified many safety signals which warrants further investigation. We aimed to compare the safety of SGLT-2i and glucagon-like peptide-1 receptor agonists (GLP-1RA). Using the Veterans Health Administration nationwide database, patients with type 2 diabetes mellitus who were newly initiated on a SGLT-2i or GLP-1RA between April 1, 2013 and September 1, 2020 were identified. The primary outcome was the incidence of any amputation, below-knee amputation (BKA), all clinical fractures, hip fracture, Fournier gangrene, acute pancreatitis, diabetic ketoacidosis (DKA), serious urinary tract infections (UTIs), and venous thromboembolism (VTE). All outcomes were compared between the treatment groups. Cox proportional hazard models were used to estimate adjusted hazard ratios (aHRs) for the comparative analysis. A total of 70,694 propensity-matched new users of SGLT-2i and GLP-1RA were identified. The use of SGLT-2 inhibitors, compared with GLP-1RA, was not associated with an increased rate of any amputation (aHR 1.02, 95% confidence interval [CI] 0.82 to 1.27), BKA (aHR 1.05, 95% CI 0.84 to 1.32), all clinical fractures (aHR 0.94, 95% CI 0.86 to 1.03), hip fractures (aHR 0.82, 95% CI 0.50 to 1.32), DKA (aHR 1.66, 95% CI 0.97 to 2.85), VTE (aHR 1.02, 95% CI 0.80 to 1.30), acute pancreatitis (aHR 1.02, 95% CI 0.80 to 1.30), and Fournier gangrene (aHR 0.92 95% CI 0.61 to 1.38). Lower rates of serious UTIs were observed in the SGLT-2i group than in the GLP-1RA group (aHR 0.74, 95% CI 0.64 to 0.84). This real-world study found that SGLT-2i use compared with GLP-1RA did not increase the rate of amputation, BKA, clinical fractures, hip fracture, Fournier gangrene, acute pancreatitis, DKA, serious UTIs, and VTE in veteran patients.
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Affiliation(s)
- Tanvi Patil
- Pharmacy Department, Salem Veterans Affair Health Care Center, Salem, Virginia.
| | - Morgan Cook
- Pharmacy Department, Salem Veterans Affair Health Care Center, Salem, Virginia
| | - Jesse Hobson
- Pharmacy Department, Salem Veterans Affair Health Care Center, Salem, Virginia
| | - Alamdeep Kaur
- Pharmacy Department, Salem Veterans Affair Health Care Center, Salem, Virginia
| | - Aliza Lee
- Department of Podiatry and Surgery, Salem Veterans Affair Health Care Center, Salem, Virginia
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Breidung D, Malsagova AT, Loukas A, Billner M, Aurnhammer F, Reichert B, Megas IF. Causative Micro-Organisms in Necrotizing Fasciitis and their Influence on Inflammatory Parameters and Clinical Outcome. Surg Infect (Larchmt) 2023; 24:46-51. [PMID: 36521174 DOI: 10.1089/sur.2022.317] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background: Necrotizing fasciitis (NF) is a potentially fatal soft tissue infection. Four types of pathogens can be distinguished in the pathogen spectrum, although there are strong regional differences with regard to the most common pathogens. Patients and Methods: All cases of NF between 2003 and 2021 with an identified causative agent were analyzed retrospectively. The cases were divided into three groups: polymicrobial, gram-positive and gram-negative. Demographic factors, localization of infection, inflammatory parameters, and clinical outcome were compared between the three groups. Results: A total of 95 cases were analyzed, 41% of which were caused by multiple pathogens. A gram-positive pathogen was reported in 40% of cases and a gram-negative pathogen in 19%. There were significant differences between the three groups with respect to age (with patients in the gram-negative group being on average the oldest) and intensive care unit admissions (which was most frequent in the polymicrobial group). Conclusions: The pathogen spectrum of NF has rarely been studied in a large patient population. Gram-positive pathogens account for the majority of monomicrobial infections in our study. Nevertheless, we recommend calculated broad-spectrum antibiotic therapy given the high number of polymicrobial infections and gram-negative infections. Gram-negative infections may be associated with increased mortality, elevated procalcitonin levels, and are relatively frequent in NF of the lower extremities.
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Affiliation(s)
- David Breidung
- Department of Plastic, Reconstructive, and Hand Surgery, Center for Severe Burn Injuries, Medical Microbiology and Infectiology, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
| | - Asja T Malsagova
- Department of Plastic, Reconstructive, and Hand Surgery, Center for Severe Burn Injuries, Medical Microbiology and Infectiology, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
| | - Alexios Loukas
- Department of Genetics, Development, and Molecular Biology, School of Biology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Moritz Billner
- Department of Plastic, Reconstructive, and Hand Surgery, Center for Severe Burn Injuries, Medical Microbiology and Infectiology, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
| | - Felix Aurnhammer
- Institute of Clinical Hygiene, Medical Microbiology and Infectiology, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
| | - Bert Reichert
- Department of Plastic, Reconstructive, and Hand Surgery, Center for Severe Burn Injuries, Medical Microbiology and Infectiology, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
| | - Ioannis-Fivos Megas
- Department of Plastic, Reconstructive, and Hand Surgery, Center for Severe Burn Injuries, Medical Microbiology and Infectiology, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
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Practice Patterns in Fournier's Gangrene in Europe and Implications for a Prospective Registry Study. Antibiotics (Basel) 2023; 12:antibiotics12020197. [PMID: 36830108 PMCID: PMC9952046 DOI: 10.3390/antibiotics12020197] [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: 12/30/2022] [Revised: 01/13/2023] [Accepted: 01/16/2023] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Fournier's gangrene (FG) is a life-threatening, necrotizing infection. Due to the rareness of the disease, it is challenging to plan robust prospective studies. This study aims to describe current practice patterns of FG in Europe and identify implications for planning a prospective FG registry. METHODS Online non-validated 17-items survey among urologists treating FG in in European hospitals. Questionnaires were analyzed with LimeSurvey (LimeSurvey GmbH Hamburg, Germany). RESULTS 229 responses from ten different European countries were submitted, and 117 (51.1%) urologists completed the questionnaire. The departments treat a mean of 4.2 (SD 3.11) patients per year. The urology department mostly takes the lead in treating FG patients (n = 113; 96.6%). The practice in FG is very heterogenic and mostly case-based all over Europe, e.g., vacuum-assisted wound closure (VAC) is mostly used (n = 50; 42.7%) as adjunct wound. The biggest challenges in FG are the short time to diagnosis and treatment, standardization and establishment of guidelines, and disease awareness. Additionally, participants stated that an international registry is an outstanding initiative, and predictive models are needed. CONCLUSIONS There is no standard of care in the diagnosis, treatment, and long-term care of FG all over Europe. Further research could be conducted with a prospective registry.
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Zhang JY, Xiao CF, Wang C, Yao YB. Bibliometric insights in fournier's gangrene: Research landscapes, turning points, and global trends. Front Surg 2023; 10:1057486. [PMID: 36874468 PMCID: PMC9978006 DOI: 10.3389/fsurg.2023.1057486] [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: 09/29/2022] [Accepted: 01/24/2023] [Indexed: 02/18/2023] Open
Abstract
Study Design Bibliometric and visualization analysis. Objective To analyze the research landscapes and hotspots of Fournier's gangrene, and reveal the dynamic changes and development trend of research hotspots for the purpose of providing ideas and a basis for clinical and basic research in this field. Methods Research datasets were acquired from the Web of Science. The publication years were limited from January 1, 1900 to August 5, 2022. The bibliometric tools CiteSpace (v5.8) and VOSviewer (v1.6) were used to analyze the data and generate visualization knowledge maps. Trends in annual publications, distribution, H-index status, coauthorships status and research hotspots were analyzed. Results According to the search strategy, we identified and enrolled 688 publications regarding to Fournier's gangrene. The number of published papers showed an overall upwards trend. The USA was the largest contributor, ranking first in total publications, citations and the H-index. The top 10 most productive institutions were all from the USA. De Simone B and Sartelli M were the most productive authors. There was close cooperation among countries, but the cooperation among institutions and authors had little contact and poor interactivity. The research hotspots included the pathogenesis factors and treatment. All the identified keywords were divided into 14 clusters, and the label of the latest cluster was "empagliflozin". Prognosis and risk factors, emerging treatment methods, and pathogenesis were at the forefront of the Fournier's gangrene field and were predicted to be the next hot topics. Conclusion The research of Fournier's gangrene has made some achievements, but the overall research level is still in the primary stage. The academic cooperation between different institutions and authors needs to be strengthened. At the early stage, the mainstream of research was the infected tissue and site, pathogenesis, and diagnosis of disease, while research on newly discovered sodium-glucose cotransporter 2 inhibitor, adjuvant therapy and prognostic factors may be the main directions in the future.
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Affiliation(s)
- Jia-Yuan Zhang
- Department of Anorectal Surgery, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Chang-Fang Xiao
- Department of Anorectal Surgery, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Chen Wang
- Department of Anorectal Surgery, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yi-Bo Yao
- Department of Anorectal Surgery, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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Brust-Sisti L, Rudawsky N, Gonzalez J, Brunetti L. The Role of Sodium-Glucose Cotransporter-2 Inhibition in Heart Failure with Preserved Ejection Fraction. PHARMACY 2022; 10:pharmacy10060166. [PMID: 36548322 PMCID: PMC9788031 DOI: 10.3390/pharmacy10060166] [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: 09/11/2022] [Revised: 11/19/2022] [Accepted: 11/23/2022] [Indexed: 12/03/2022] Open
Abstract
Sodium-glucose cotransporter-2 (SGLT2) inhibitors are a novel class of antidiabetic mediations found to also reduce cardiovascular morbidity and mortality and hospitalization for heart failure. Positive results from the EMPEROR-Preserved (empagliflozin) and PRESERVED-HF (dapagliflozin) studies led to recommendations for SGLT2 inhibitors in HFpEF within major international heart failure guidelines. However, studies of ipragliflozin and luseogliflozin, agents approved outside the United States (U.S.), reported different outcomes relative to pivotal trials and failed to realize benefits in the HFpEF population. Varying definitions of HFpEF and outcomes studied complicate the interpretation of study results. SGLT2 inhibitors may cause common adverse events (genital mycotic infections, volume depletion) in addition to rare but severe sequela, including euglycemic diabetic ketoacidosis, Fournier's gangrene, and lower limb amputation. While evidence of CV benefits grows, SGLT2 inhibitor prescribing has lagged, particularly among patients without diabetes. In the U.S., high cost and administrative hurdles may contribute to decreased patient and clinician uptake of this drug class. Future trial results and clinical experience with SGLT2 inhibitors may lead to expanded use and greater uptake among patients with heart failure.
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Affiliation(s)
- Lindsay Brust-Sisti
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA
| | - Nicole Rudawsky
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA
| | - Jimmy Gonzalez
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA
| | - Luigi Brunetti
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA
- Correspondence: ; Tel.: +1-848-445-6815
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Pozo Garcia L, Thomas SS, Rajesh H, Navaneethan SD. Progress in the management of patients with diabetes and chronic kidney disease. Curr Opin Nephrol Hypertens 2022; 31:456-463. [PMID: 35894280 PMCID: PMC9377049 DOI: 10.1097/mnh.0000000000000811] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Diabetic kidney disease is the most common cause of chronic kidney disease (CKD) and end-stage kidney disease in the world. Risk factor modification, glucose control, and renin-angiotensin-aldosterone system blockade have remained the standard of care for 2 decades. New therapeutic agents have emerged in recent years, demonstrating kidney and cardiovascular benefits, and herein we review recent clinical trials on this topic. RECENT FINDINGS After the publication of several cardiovascular outcome trials for sodium-glucose cotransporter 2 inhibitors (SGLT-2i), new trials have focused ON primary kidney-specific outcomes demonstrating safety and benefits among patients with proteinuric CKD; patients with or without diabetes, and heart failure with preserved ejection fraction (HFpEF) respectively. Similarly, nonsteroidal mineralocorticoid receptor antagonists (ns-MRAs) and glucagon-like-peptide 1 receptor agonists (GLP-1 RAs) have improved cardiovascular and kidney outcomes. Recently, clinical practice guidelines have also been updated to reflect this new evidence. SUMMARY In summary, SGLT-2i, GLP-1 RAs, and ns-MRAs have demonstrated cardiovascular and kidney benefits, including all-cause and cardiovascular mortality, progression to end-stage kidney disease, and hospitalizations for heart failure exacerbation among diverse patient population.
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Affiliation(s)
- Leonardo Pozo Garcia
- Section of Nephrology, Department of Medicine, Selzman Institute for Kidney Health, Baylor College of Medicine
| | - Sandhya S Thomas
- Section of Nephrology, Department of Medicine, Selzman Institute for Kidney Health, Baylor College of Medicine
- Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center
| | | | - Sankar D Navaneethan
- Section of Nephrology, Department of Medicine, Selzman Institute for Kidney Health, Baylor College of Medicine
- Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center
- Veterans Affairs Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety, Houston
- Institute of Clinical and Translational Research Baylor College of Medicine, Houston, Texas, USA
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11
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Erickson BA, Flynn KJ. Management of Necrotizing Soft Tissue Infections (Fournier’s Gangrene) and Surgical Reconstruction of Debridement Wound Defects. Urol Clin North Am 2022; 49:467-478. [DOI: 10.1016/j.ucl.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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12
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Chowdhury T, Gousy N, Bellamkonda A, Dutta J, Zaman CF, Zakia UB, Tasha T, Dutta P, Deb Roy P, Gomez AM, Mainali A. Fournier's Gangrene: A Coexistence or Consanguinity of SGLT-2 Inhibitor Therapy. Cureus 2022; 14:e27773. [PMID: 36106208 PMCID: PMC9450557 DOI: 10.7759/cureus.27773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Sodium-glucose cotransporter-2 inhibitors (SGLT2 inhibitors) are a relatively new class of medications used for the management of type II diabetes mellitus targeting the kidneys. Within the last decade, several warnings have been issued regarding the development of severe genitourinary infections, including necrotizing fasciitis, or Fournier's gangrene, in those with pre-existing type II diabetes and concomitant use of this drug class. OBJECTIVE The purpose of this review is to highlight and discuss the factors contributing to the development of Fournier's gangrene, its pathogenesis, and a review of existing literature describing patient outcomes, treatment, and future directions regarding early detection of this complication. METHODS Articles and studies addressing effective treatment adherence and key factors contributing to Fournier's gangrene with SGLT2 inhibitors were identified by effective keyword searches in PubMed Central, Google Scholar, and Cochrane, as well as the references found within these articles. RESULTS Using the keywords provided, 55 case reports, review articles, and meta-analysis reports written within the last 20 years were utilized as the source of the data presented in this systematic review article.
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Affiliation(s)
- Tutul Chowdhury
- Internal Medicine, One Brooklyn Health System, Brooklyn, USA
| | - Nicole Gousy
- Medicine, American University of Antigua, New York, USA
| | | | - Jui Dutta
- Medicine, Comilla Medical College, Cumilla, BGD
| | - Chowdhury F Zaman
- Internal Medicine, Jahurul Islam Medical College and Hospital, Cedar Lake, USA
| | - Ummul B Zakia
- Internal Medicine, Sir Salimullah Medical College, Dhaka, BGD
| | - Tasniem Tasha
- Internal Medicine, Rajshahi Medical College, Rajshahi, BGD
| | - Priyata Dutta
- Internal Medicine, Trinity Health, St Joseph Mercy Ann Arbor, Ann Arbor, USA
| | | | - Adriana M Gomez
- Internal Medicine/Endocrinology, One Brooklyn Health System, Brooklyn, USA
| | - Arjun Mainali
- Internal Medicine, One Brooklyn Health System, Brooklyn, USA
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13
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Landgraf R, Aberle J, Birkenfeld AL, Gallwitz B, Kellerer M, Klein H, Müller-Wieland D, Nauck MA, Wiesner T, Siegel E. Therapy of Type 2 Diabetes. Exp Clin Endocrinol Diabetes 2022; 130:S80-S112. [PMID: 35839797 DOI: 10.1055/a-1624-3449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
| | - Jens Aberle
- Division of Endocrinology and Diabetology, University Obesity Centre Hamburg, University Hospital Hamburg-Eppendorf, Germany
| | | | - Baptist Gallwitz
- Department of Internal Medicine IV, Diabetology, Endocrinology, Nephrology, University Hospital Tübingen, Germany
| | - Monika Kellerer
- Department of Internal Medicine I, Marienhospital, Stuttgart, Germany
| | - Harald Klein
- Department of Internal Medicine I, University Hospital Bergmannsheil, Bochum, Germany
| | - Dirk Müller-Wieland
- Department of Internal Medicine I, University Hospital RWTH, Aachen, Germany
| | - Michael A Nauck
- Diabetes Centre Bochum-Hattingen, St.-Josef-Hospital, Ruhr-University, Bochum, Germany
| | | | - Erhard Siegel
- Department of Internal Medicine - Gastroenterology, Diabetology/Endocrinology and Nutritional Medicine, St. Josefkrankenhaus Heidelberg GmbH, Heidelberg, Germany
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14
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Therapie des Typ-2-Diabetes. DIE DIABETOLOGIE 2022. [PMCID: PMC9191539 DOI: 10.1007/s11428-022-00921-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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15
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Kranz J, Dräger DL, Schneidewind L. [New aspects in Fournier's gangrene - a rapid review]. Aktuelle Urol 2021; 52:360-366. [PMID: 33882584 DOI: 10.1055/a-1472-5553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Fournier's gangrene (FG) is a sporadic, life-threatening, necrotising infection affecting the perineum, perineal region and genitals. Published literature provides hints that the outcome of this disease has failed to improve in recent years. We have therefore performed a rapid evidence synthesis by searching the database MEDLINE. The literature from 2020 was studied to identify new aspects to improve the care of FG patients and plan further therapeutic research. 18 publications were chosen for this review, 15 of these were original research and three systematic reviews. 12 were retrospective case series, 2 epidemiological studies, with one prospective clinical study, one systematic review and 2 systematic reviews, together with a meta-analysis. Most of the authors of the studies concluded that FG is still a severe disease with unacceptable mortality rates, so that there is urgent need for therapy improvement. New risk factors for higher mortality in FG have been identified in these studies, namely dyslipoproteinemia, diabetes mellitus, heart disease, as well as both acute and chronic kidney failure. Furthermore, 4 of the included studies investigated the association of SGLT2- and DDP4-inhibitors, which are drugs used in diabetes mellitus, and the incidence of FG. No studies reported a significant association between these drugs and FG, especially not a meta-analysis with 84 included studies. New promising concepts for wound conditioning are hyperbaric oxygenation (HBO), vacuum-assisted wound closure (VAC) and Maggot therapy (blowfly larvae). In summary, FG is still a severe disease, the prognosis has not improved in recent years and so there is an urgent need for improved therapy. This could only be achieved with further research in FG. In our opinion and due to the rarity of FG, this would be possible with a national registry study. For example, it might be possible to calculate risk stratification from this registry to identify patients who would benefit from treatment in a centre or with special wound conditioning.
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Affiliation(s)
- Jennifer Kranz
- St-Antonius-Hospital gGmbH, Klinik für Urologie und Kinderurologie, Eschweiler
- Universitätsklinik und Poliklinik für Urologie, Universitätsklinikum Halle (Saale), Halle (Saale)
| | - Desiree L. Dräger
- Universitätsmedizin Rostock, Urologische Klinik und Poliklinik, Rostock
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16
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Auerbach J, Bornstein K, Ramzy M, Cabrera J, Montrief T, Long B. Fournier Gangrene in the Emergency Department: Diagnostic Dilemmas, Treatments and Current Perspectives. Open Access Emerg Med 2020; 12:353-364. [PMID: 33204184 PMCID: PMC7665443 DOI: 10.2147/oaem.s238699] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 10/07/2020] [Indexed: 12/11/2022] Open
Abstract
Fournier gangrene (FG) is a rare and life-threatening urosurgical emergency characterized most often by a polymicrobial infection of the perineal, genital, or perianal region. FG has an increased incidence in male patients, patients with alcoholism, and patients with immunocompromise including human immunodeficiency virus (HIV) and uncontrolled diabetes. FG often begins as a simple abscess or cellulitis with progression to necrotizing soft tissue infection (NSTI). Delays in diagnosis and treatment confer high mortality. Early recognition and high clinical suspicion are important in making a timely diagnosis, as early manifestations are often subtle. The most significant modifiable risk factor associated with NSTI mortality is delay to surgical intervention. Coordination of both inpatient medical and surgical teams to implement appropriate therapy is vital to successful outcomes. The emergency medicine clinician must be vigilant for this condition and be aware of risk factors, prognostic indicators, and proper treatment protocols to recognize FG early and initiate appropriate management. The objective of this review is to provide updated and relevant information regarding recognition, diagnosis, and management of FG for the emergency medicine provider.
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Affiliation(s)
- Jonathan Auerbach
- Department of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Kasha Bornstein
- Department of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Mark Ramzy
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jorge Cabrera
- Department of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Tim Montrief
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, TX, USA
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17
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Landgraf R, Aberle J, Birkenfeld AL, Gallwitz B, Kellerer M, Klein HH, Müller-Wieland D, Nauck MA, Reuter HM, Siegel E. Therapie des Typ-2-Diabetes. DIABETOL STOFFWECHS 2020. [DOI: 10.1055/a-1193-3793] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
| | - Jens Aberle
- Sektion Endokrinologie und Diabetologie, Universitäres Adipositas-Zentrum Hamburg, Universitätsklinikum Hamburg-Eppendorf
| | - Andreas L. Birkenfeld
- Deutsches Zentrum für Diabetesforschung (DZD e. V.), Neuherberg
- Medizinische Klinik IV, Diabetologie, Endokrinologie, Nephrologie, Universitätsklinikum Tübingen
| | - Baptist Gallwitz
- Medizinische Klinik IV, Diabetologie, Endokrinologie, Nephrologie, Universitätsklinikum Tübingen
| | | | - Harald H. Klein
- Medizinische Klinik I, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum
| | | | - Michael A. Nauck
- Diabeteszentrum Bochum-Hattingen, St.-Josef-Hospital, Ruhr-Universität, Bochum
| | | | - Erhard Siegel
- Abteilung für Innere Medizin – Gastroenterologie, Diabetologie/Endokrinologie und Ernährungsmedizin, St. Josefkrankenhaus Heidelberg GmbH, Heidelberg
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18
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Das SR, Everett BM, Birtcher KK, Brown JM, Januzzi JL, Kalyani RR, Kosiborod M, Magwire M, Morris PB, Neumiller JJ, Sperling LS. 2020 Expert Consensus Decision Pathway on Novel Therapies for Cardiovascular Risk Reduction in Patients With Type 2 Diabetes: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2020; 76:1117-1145. [PMID: 32771263 PMCID: PMC7545583 DOI: 10.1016/j.jacc.2020.05.037] [Citation(s) in RCA: 253] [Impact Index Per Article: 63.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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19
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Chiang CE, Ueng KC, Chao TH, Lin TH, Wu YJ, Wang KL, Sung SH, Yeh HI, Li YH, Liu PY, Chang KC, Shyu KG, Huang JL, Tsai CD, Hung HF, Liu ME, Chao TF, Cheng SM, Cheng HM, Chu PH, Yin WH, Wu YW, Chen WJ, Lai WT, Lin SJ, Yeh SJ, Hwang JJ. 2020 Consensus of Taiwan Society of Cardiology on the pharmacological management of patients with type 2 diabetes and cardiovascular diseases. J Chin Med Assoc 2020; 83:587-621. [PMID: 32628427 DOI: 10.1097/jcma.0000000000000359] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
The global incidence and prevalence of type 2 diabetes have been escalating in recent decades. The total diabetic population is expected to increase from 415 million in 2015 to 642 million by 2040. Patients with type 2 diabetes have an increased risk of atherosclerotic cardiovascular disease (ASCVD). About two-thirds of patients with type 2 diabetes died of ASCVD. The association between hyperglycemia and elevated cardiovascular (CV) risk has been demonstrated in multiple cohort studies. However, clinical trials of intensive glucose reduction by conventional antidiabetic agents did not significantly reduce macrovascular outcomes.In December 2008, U.S. Food and Drug Administration issued a mandate that every new antidiabetic agent requires rigorous assessments of its CV safety. Thereafter, more than 200,000 patients have been enrolled in a number of randomized controlled trials (RCTs). These trials were initially designed to prove noninferiority. It turned out that some of these trials demonstrated superiority of some new antidiabetic agents versus placebo in reducing CV endpoints, including macrovascular events, renal events, and heart failure. These results are important in clinical practice and also provide an opportunity for academic society to formulate treatment guidelines or consensus to provide specific recommendations for glucose control in various CV diseases.In 2018, the Taiwan Society of Cardiology (TSOC) and the Diabetes Association of Republic of China (DAROC) published the first joint consensus on the "Pharmacological Management of Patients with Type 2 Diabetes and Cardiovascular Diseases." In 2020, TSOC appointed a new consensus group to revise the previous version. The updated 2020 consensus was comprised of 5 major parts: (1) treatment of diabetes in patients with multiple risk factors, (2) treatment of diabetes in patients with coronary heart disease, (3) treatment of diabetes in patients with stage 3 chronic kidney disease, (4) treatment of diabetes in patients with a history of stroke, and (5) treatment of diabetes in patients with heart failure. The members of the consensus group thoroughly reviewed all the evidence, mainly RCTs, and also included meta-analyses and real-world evidence. The treatment targets of HbA1c were finalized. The antidiabetic agents were ranked according to their clinical evidence. The consensus is not mandatory. The final decision may need to be individualized and based on clinicians' discretion.
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Affiliation(s)
- Chern-En Chiang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Kwo-Chang Ueng
- Chung-Shan Medical University Hospital, Taichung, Taiwan, ROC
| | - Ting-Hsing Chao
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan, ROC
| | - Tsung-Hsien Lin
- Department of Internal Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC
| | - Yih-Jer Wu
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan, ROC
- Cardiovascular Center, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan, ROC
| | - Kang-Ling Wang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Shih-Hsien Sung
- Department of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Public Health and Community Medicine Research Center, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Hung-I Yeh
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan, ROC
- Cardiovascular Center, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan, ROC
| | - Yi-Heng Li
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan, ROC
| | - Ping-Yen Liu
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan, ROC
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan, ROC
| | - Kuan-Cheng Chang
- Division of Cardiovascular Medicine, China Medical University Hospital, Taichung, Taiwan, ROC
- School of Medicine, China Medical University, Taichung, Taiwan, ROC
| | - Kou-Gi Shyu
- Division of Cardiology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan, ROC
| | - Jin-Long Huang
- Cardiovascular center, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Cheng-Dao Tsai
- Department of Medicine, Changhua Christian Hospital, Changhua, Taiwan, ROC
| | - Huei-Fong Hung
- Division of Cardiology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan, ROC
| | - Ming-En Liu
- Division of Cardiology, Department of Internal Medicine, Hsinchu Mackay Memorial Hospital, Hsinchu, Taiwan, ROC
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Shu-Meng Cheng
- Division of Cardiology, Department of Medicine, Tri-Service General Hospital, Taipei, Taiwan, ROC
| | - Hao-Min Cheng
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan, ROC
- Institute of Health and Welfare Policy, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Cardiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan, ROC
| | - Pao-Hsien Chu
- Department of Cardiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan, ROC
- School of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC
| | - Wei-Hsian Yin
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan, ROC
| | - Yen-Wen Wu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Division of Cardiology, Cardiovascular Medical Center, and Department of Nuclear, ROC Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan, ROC
- Department of Internal Medicine and Nuclear Medicine, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - Wen-Jone Chen
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - Wen-Ter Lai
- Department of Internal Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC
| | - Shing-Jong Lin
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan, ROC
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - San-Jou Yeh
- Department of Cardiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan, ROC
| | - Juey-Jen Hwang
- Cardiovascular Division, Department of Internal Medicine, National Taiwan, ROC, University College of Medicine and Hospital, Taipei, Taiwan, ROC
- Cardiovascular Center, National Taiwan University Hospital Yunlin Branch, Yunlin, Taiwan, ROC
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