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Santos JD, Dawson S, Conefrey C, Isaacs T, Khanum M, Faisal S, Paramasivan S. Most UK cardiovascular disease trial protocols feature criteria that exclude ethnic minority participants: a systematic review. J Clin Epidemiol 2024; 167:111259. [PMID: 38215800 DOI: 10.1016/j.jclinepi.2024.111259] [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: 07/05/2023] [Revised: 12/12/2023] [Accepted: 01/08/2024] [Indexed: 01/14/2024]
Abstract
OBJECTIVES We systematically reviewed UK cardiovascular disease (CVD) randomized controlled trial (RCT) protocols to identify the proportion featuring eligibility criteria that may disproportionately exclude ethnic minority (EM) participants. METHODS We searched MEDLINE, Embase, and Cochrane Library databases, January 2014-June 2022, to identify UK CVD RCT protocols. We extracted nonclinical eligibility criteria from trial protocols and inductively categorized the trials by their language, consent, and broad (ambiguous) criteria. Findings are narratively reported. RESULTS Of the seventy included RCT protocols, most (87.1%; 61/70) mentioned consent within the eligibility criteria, with more than two-thirds (68.9%; 42/61) indicating a requirement for 'written' consent. Alternative consent pathways that can aid EM participation were absent. English language requirement was present in 22.9% (16/70) of the studies and 37.1% (26/70) featured broad criteria that are open to interpretation and subject to recruiter bias. Only 4.3% (3/70) protocols mentioned the provision of translation services. CONCLUSION Most UK CVD trial protocols feature eligibility criteria that potentially exclude EM groups. Trial eligibility criteria must be situated within a larger inclusive recruitment framework, where ethnicity is considered alongside other intersecting and disadvantaging identities.
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Affiliation(s)
- Jhulia Dos Santos
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Shoba Dawson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Carmel Conefrey
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Talia Isaacs
- UCL Centre for Applied Linguistics, IOE, UCL's Faculty of Education and Society, University College London, London, UK
| | - Mahwar Khanum
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Saba Faisal
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sangeetha Paramasivan
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
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Patil T, Halsey E, Kaur A, Minchak J, Hobson J, Eppes D. CHAnges in Diuretic Medication Prescribing and Surrogate Laboratory Parameters After Initiating EmpagliflOziN in Veterans (CHAMPION Cohort Study). Clin Drug Investig 2023; 43:61-74. [PMID: 36515856 DOI: 10.1007/s40261-022-01226-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVES Sodium-glucose cotransporter type 2 inhibitors have evolved into a novel drug class utilized for reductions in cardiovascular risk and heart failure hospitalization. We aimed to describe the impact of sodium-glucose cotransporter type 2 inhibitors on diuretic prescribing patterns and intermediate laboratory outcomes in patients with and without diuretic use. METHODS This retrospective cohort study included patients taking empagliflozin as of 1 July, 2021. Patients were assigned to the intervention group if prescribed a diuretic concomitantly or a control group otherwise. The primary outcome was the impact of empagliflozin on diuretic prescribing (i.e., no change, discontinuation, decrease, increase). Secondary outcomes were change in weight, hemoglobin A1c, estimated glomerular filtration rate, hemoglobin, hematocrit, blood pressure, and electrolytes at 90 and 180 days. Mean differences were compared using the t-test between groups or the paired t-test within groups. Patients without diuretic use were matched 1:1 to patients taking diuretics using propensity scores. RESULTS This study included 1189 patients: 750 in the control group and 439 in the intervention group. After propensity score matching, baseline characteristics were well balanced. Of the 439 patients in the intervention group, 118 had changes in the diuretic regimen. There were 131 changes: 109 (83.2%) discontinuations, 13 (9.92%) decreases, and nine (6.87%) increases. The mean furosemide equivalent loop dose was reduced after empagliflozin initiation (50.62 mg vs 43.13 mg; p < 0.001). Among all patients, there was a decrease in weight (p = 0.01), estimated glomerular filtration rate (p < 0.001), and hemoglobin A1c (p < 0.001). There was an increase in hemoglobin (p < 0.001), hematocrit (p < 0.001), and magnesium (p < 0.001). In the propensity score-matched cohort, there was a significant reduction from baseline in mean weight in the intervention group compared with the control group (p < 0.001). CONCLUSIONS This hypothesis-generating study suggests that sodium-glucose cotransporter type 2 inhibitors may lower diuretic requirements, further supported by a reduction in weight in the intervention cohort.
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Affiliation(s)
- Tanvi Patil
- Salem Veterans Affairs Healthcare System, 1970 Roanoke Blvd, Salem, VA, 24153, USA.
| | - Emily Halsey
- Salem Veterans Affairs Healthcare System, 1970 Roanoke Blvd, Salem, VA, 24153, USA
| | - Alamdeep Kaur
- Salem Veterans Affairs Healthcare System, 1970 Roanoke Blvd, Salem, VA, 24153, USA
| | - John Minchak
- Salem Veterans Affairs Healthcare System, 1970 Roanoke Blvd, Salem, VA, 24153, USA
| | - Jesse Hobson
- Salem Veterans Affairs Healthcare System, 1970 Roanoke Blvd, Salem, VA, 24153, USA
| | - Davida Eppes
- Salem Veterans Affairs Healthcare System, 1970 Roanoke Blvd, Salem, VA, 24153, USA
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3
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Zhang X, Zhang Y, Hu Y. Knowledge domain and emerging trends in empagliflozin for heart failure: A bibliometric and visualized analysis. Front Cardiovasc Med 2022; 9:1039348. [DOI: 10.3389/fcvm.2022.1039348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022] Open
Abstract
ObjectiveEmpagliflozin (EMPA), a sodium-glucose cotransporter 2 inhibitor (SGLT2i), is recommended for all patients with Heart failure (HF) to reduce the risk of Cardiovascular death, hospitalization, and HF exacerbation. Qualitative and quantitative evaluation was conducted by searching relevant literatures of EMPA for Heart Failure from 2013 to 2022, and visual analysis in this field was conducted.MethodsThe data were from the Web of Science Core Collection database (WOSCC). The bibliometric tools, CiteSpace and VOSviewer, were used for econometric analysis to probe the evolvement of disciplines and research hotspots in the field of EMPA for Heart Failure.ResultsA total of 1461 literatures with 43861 references about EMPA for Heart Failure in the decade were extracted from WOSCC, and the number of manuscripts were on a rise. In the terms of co-authorship, USA leads the field in research maturity and exerts a crucial role in the field of EMPA for Heart Failure. Multidisciplinary research is conducive to future development. With regards to literatures, we obtained 9 hot paper, 93 highly cited literatures, and 10 co-cited references. The current research focuses on the following three aspects: EMPA improves left ventricular remodeling, exert renal protection, and increases heart rate variability.ConclusionBased on methods such as bibliometrics, citation analysis and knowledge graph, this study analyzed the current situation and trend of EMPA for Heart Failure, sorted out the knowledge context in this field, and provided reference for current and future prevention and scientific research.
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KAYA E, AKPINAR Ü, TAŞKIRAN TATAR B, KOCA N. Use of SGLT-2 Inhibitor in Decompensated Heart Failure Presenting with Bilateral Resistant Pleural Effusion. TURKISH JOURNAL OF INTERNAL MEDICINE 2022. [DOI: 10.46310/tjim.1078269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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5
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A Comparative Study of Safety Outcomes of Sodium Glucose Cotransporter-2 Inhibitors and Loop Diuretics Among Diabetic Patients Using Real-world Data. Curr Probl Cardiol 2021; 47:100995. [PMID: 34571107 DOI: 10.1016/j.cpcardiol.2021.100995] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 09/14/2021] [Indexed: 11/21/2022]
Abstract
Sodium glucose cotransporter-2 (SGLT2) inhibitors and loop diuretics can cause volume depletion. However, the long-term safety of the concurrent use of both agents has not been widely evaluated. We conducted a retrospective observational cohort study to evaluate the safety of SGLT2 inhibitors with loop diuretics vs SGLT2 inhibitors alone among diabetic patients. The primary endpoint was a composite of volume-depletion adverse events at 1 month and 12 months. Of the 400 patients included, 98 received SGLT2 inhibitors with a loop diuretic and 302 received SGLT2 inhibitors alone. The concurrent use of SGLT2 inhibitors and loop diuretics was tolerated at 1 month; however, it resulted in a significant increase in volume-depletion events at 12 months (10.2% vs 1.7%; aHR = 7.03, 95% CI (1.80-27.37), P-value = 0.005). In conclusion, the long-term concurrent use of SGLT2 inhibitors and loop diuretics increases the risk of volume depletion, warranting frequent monitoring.
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Liu L, Ni YQ, Zhan JK, Liu YS. The Role of SGLT2 Inhibitors in Vascular Aging. Aging Dis 2021; 12:1323-1336. [PMID: 34341711 PMCID: PMC8279525 DOI: 10.14336/ad.2020.1229] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 12/29/2020] [Indexed: 12/19/2022] Open
Abstract
Vascular aging is defined as organic and functional changes in blood vessels, in which decline in autophagy levels, DNA damage, MicroRNA (miRNA), oxidative stress, sirtuin, and apoptosis signal-regulated kinase 1 (ASK1) are integral thereto. With regard to vascular morphology, the increase in arterial stiffness, atherosclerosis, vascular calcification and high amyloid beta levels are closely related to vascular aging. Further closely related thereto, at the cellular level, is the aging of vascular endothelial cells (ECs) and vascular smooth muscle cells (VSMCs). Vascular aging seriously affects the health, economy and life of patients, but can be delayed by SGLT2 inhibitors through the improvement of vascular function. In the present article, a review is conducted of recent domestic and international progress in research on SGLT2 inhibitors,vascular aging and diseases related thereto, thereby providing theoretical support and guidance for further revealing the relationship between SGLT2 inhibitors and diseases related to vascular aging.
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Affiliation(s)
- Le Liu
- 1Department of Geriatrics, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China.,2Institute of Aging and Age-related Disease Research, Central South University, Changsha, Hunan 410011, China
| | - Yu-Qing Ni
- 1Department of Geriatrics, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China.,2Institute of Aging and Age-related Disease Research, Central South University, Changsha, Hunan 410011, China
| | - Jun-Kun Zhan
- 1Department of Geriatrics, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China.,2Institute of Aging and Age-related Disease Research, Central South University, Changsha, Hunan 410011, China
| | - You-Shuo Liu
- 1Department of Geriatrics, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China.,2Institute of Aging and Age-related Disease Research, Central South University, Changsha, Hunan 410011, China
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7
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Hinton W, Feher MD, Munro N, Joy M, de Lusignan S. Prescribing sodium-glucose co-transporter-2 inhibitors for type 2 diabetes in primary care: influence of renal function and heart failure diagnosis. Cardiovasc Diabetol 2021; 20:130. [PMID: 34183018 PMCID: PMC8237469 DOI: 10.1186/s12933-021-01316-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 06/07/2021] [Indexed: 02/08/2023] Open
Abstract
Background Sodium-glucose co-transporter-2 inhibitors (SGLT-2is) are licenced for initiation for glucose lowering in people with type 2 diabetes (T2DM) with an estimated glomerular filtration rate (eGFR) ≥ 60 mL/min/1.73m2). However, recent trial data have shown that these medications have renal and cardio-protective effects, even for impaired kidney function. The extent to which trial evidence and updated guidelines have influenced real-world prescribing of SGLT-2is is not known, particularly with co-administration of diuretics. Methods We performed a cross-sectional analysis of people with T2DM registered with practices in the Oxford-Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) database on the 31st July 2019. We calculated the percentage of people prescribed SGLT-2is according to eGFR categories (< 45, 45–59, and ≥ 60 mL/min/1.73m2), with a heart failure diagnosis and stratified by body mass index categories (underweight, normal weight, overweight, obese), and with concomitant prescription of a diuretic. Multilevel logistic regression analysis was performed to determine whether heart failure diagnosis and renal function were associated with SGLT-2i prescribing. Results From a population of 242,624 people with T2DM across 419 practices, 11.0% (n = 26,700) had been prescribed SGLT-2is. The majority of people initiated SGLT-2is had an eGFR ≥ 60 mL/min/1.73m2 (93.2%), and 4.3% had a heart failure diagnosis. 9,226 (3.8%) people were prescribed SGLT-2is as an add-on to their diuretic prescription. People in the highest eGFR category (≥ 60 mL/min/1.73m2) were more likely to be prescribed SGLT-2is than those in eGFR lower categories. Overweight (OR 2.05, 95% CI 1.841–2.274) and obese people (OR 3.84, 95% CI 3.472–4.250) were also more likely to be prescribed these medications, whilst use of diuretics (OR 0.74, 95% CI 0.682–0.804) and heart failure (OR 0.81, 95% CI 0.653–0.998) were associated with lower odds of being prescribed SGLT-2is. Conclusions Prescribing patterns of SGLT-2is for glucose lowering in T2DM in primary care generally concur with licenced indications according to recommended renal thresholds. A small percentage of people with heart failure were prescribed SGLT-2is for T2DM. An updated analysis is merited should UK National Institute for Health Care and Excellence prescribing guidelines for T2DM be revised to incorporate new data on the benefits for those with reduced renal function or with heart failure. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-021-01316-4.
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Affiliation(s)
- William Hinton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.,Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Michael D Feher
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Neil Munro
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Mark Joy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK. .,Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC), London, UK.
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8
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Scholtes RA, van Baar MJB, Kok MD, Bjornstad P, Cherney DZI, Joles JA, van Raalte DH. Renal haemodynamic and protective effects of renoactive drugs in type 2 diabetes: Interaction with SGLT2 inhibitors. Nephrology (Carlton) 2021; 26:377-390. [PMID: 33283420 PMCID: PMC8026736 DOI: 10.1111/nep.13839] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/05/2020] [Accepted: 11/24/2020] [Indexed: 12/25/2022]
Abstract
Diabetic kidney disease remains the leading cause of end‐stage kidney disease and a major risk factor for cardiovascular disease. Large cardiovascular outcome trials and dedicated kidney trials have shown that sodium‐glucose cotransporter (SGLT)2 inhibitors reduce cardiovascular morbidity and mortality and attenuate hard renal outcomes in patients with type 2 diabetes (T2D). Underlying mechanisms explaining these renal benefits may be mediated by decreased glomerular hypertension, possibly by vasodilation of the post‐glomerular arteriole. People with T2D often receive several different drugs, some of which could also impact the renal vasculature, and could therefore modify both renal efficacy and safety of SGLT2 inhibition. The most commonly prescribed drugs that could interact with SGLT2 inhibitors on renal haemodynamic function include renin‐angiotensin system inhibitors, calcium channel blockers and diuretics. Herein, we review the effects of these drugs on renal haemodynamic function in people with T2D and focus on studies that measured glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) with gold‐standard techniques. In addition, we posit, based on these observations, potential interactions with SGLT2 inhibitors with an emphasis on efficacy and safety. This invited review describes the renal haemodynamic and protective effects of commonly prescribed drugs in people with type 2 diabetes and their interaction with SGLT2 inhibitors.
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Affiliation(s)
- Rosalie A Scholtes
- Amsterdam Diabetes Center, Department of Internal Medicine, Academic Medical Center, VU University Medical Center, Amsterdam, The Netherlands
| | - Michaël J B van Baar
- Amsterdam Diabetes Center, Department of Internal Medicine, Academic Medical Center, VU University Medical Center, Amsterdam, The Netherlands
| | - Megan D Kok
- Amsterdam Diabetes Center, Department of Internal Medicine, Academic Medical Center, VU University Medical Center, Amsterdam, The Netherlands
| | - Petter Bjornstad
- Department of Pediatrics, Division of Endocrinology, University of Colorado School of Medicine, Aurora, Colorado, USA.,Department of Medicine, Division of Nephrology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - David Z I Cherney
- Department of Medicine and Department of Physiology, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jaap A Joles
- Department of Nephrology and Hypertension, University Medical Center, Utrecht, The Netherlands
| | - Daniël H van Raalte
- Amsterdam Diabetes Center, Department of Internal Medicine, Academic Medical Center, VU University Medical Center, Amsterdam, The Netherlands.,Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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9
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Martin WP, Bauer J, Coleman J, Dellatorre‐Teixeira L, Reeve JL, Twomey PJ, Docherty NG, O'Riordan A, Watson AJ, le Roux CW, Holian J. Obesity is common in chronic kidney disease and associates with greater antihypertensive usage and proteinuria: evidence from a cross-sectional study in a tertiary nephrology centre. Clin Obes 2020; 10:e12402. [PMID: 32845571 PMCID: PMC7685118 DOI: 10.1111/cob.12402] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 07/09/2020] [Accepted: 08/03/2020] [Indexed: 12/18/2022]
Abstract
Obesity is a treatable risk factor for chronic kidney disease progression. We audited the reporting of body-mass index in nephrology outpatient clinics to establish the characteristics of individuals with obesity in nephrology practice. Body-mass index, clinical information and biochemical measures were recorded for patients attending clinics between 3rd August, 2018 and 18th January, 2019. Inferential statistics and Pearson correlations were used to investigate relationships between body-mass index, type 2 diabetes, hypertension and proteinuria. Mean ± SD BMI was 28.6 ± 5.8 kg/m2 (n = 374). Overweight and obesity class 1 were more common in males (P = .02). Amongst n = 123 individuals with obesity and chronic kidney disease, mean ± SD age, n (%) female and median[IQR] eGFR were 64.1 ± 14.2 years, 52 (42.3%) and 29.0[20.5] mL/min/BSA, respectively. A positive correlation between increasing body-mass index and proteinuria was observed in such patients (r = 0.21, P = .03), which was stronger in males and those with CKD stages 4 and 5. Mean body-mass index was 2.3 kg/m2 higher in those treated with 4-5 versus 0-1 antihypertensives (P = .03). Amongst n = 59 patients with obesity, chronic kidney disease and type 2 diabetes, 2 (3.5%) and 0 (0%) were prescribed a GLP-1 receptor analogue and SGLT2-inhibitor, respectively. Our data provides a strong rationale not only for measuring body-mass index but also for acting on the information in nephrology practice, although prospective studies are required to guide treatment decisions in people with obesity and chronic kidney disease.
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Affiliation(s)
- William P. Martin
- Diabetes Complications Research CentreConway Institute of Biomolecular and Biomedical Research, School of Medicine, University College DublinDublinIreland
- Department of NephrologySt. Vincent's University HospitalDublinIreland
| | - Jessica Bauer
- Diabetes Complications Research CentreConway Institute of Biomolecular and Biomedical Research, School of Medicine, University College DublinDublinIreland
| | - John Coleman
- Department of NephrologySt. Vincent's University HospitalDublinIreland
| | - Ludmilla Dellatorre‐Teixeira
- Diabetes Complications Research CentreConway Institute of Biomolecular and Biomedical Research, School of Medicine, University College DublinDublinIreland
| | - Janice L.V. Reeve
- Department of Clinical ChemistrySt. Vincent's University HospitalDublinIreland
| | - Patrick J. Twomey
- Department of Clinical ChemistrySt. Vincent's University HospitalDublinIreland
| | - Neil G. Docherty
- Diabetes Complications Research CentreConway Institute of Biomolecular and Biomedical Research, School of Medicine, University College DublinDublinIreland
- Institute of Clinical Sciences, Sahlgrenska Academy, University of GothenburgGothenburgSweden
| | - Aisling O'Riordan
- Department of NephrologySt. Vincent's University HospitalDublinIreland
| | - Alan J. Watson
- Department of NephrologySt. Vincent's University HospitalDublinIreland
| | - Carel W. le Roux
- Diabetes Complications Research CentreConway Institute of Biomolecular and Biomedical Research, School of Medicine, University College DublinDublinIreland
- Institute of Clinical Sciences, Sahlgrenska Academy, University of GothenburgGothenburgSweden
- Division of Investigative ScienceImperial College LondonLondonUK
| | - John Holian
- Department of NephrologySt. Vincent's University HospitalDublinIreland
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Kalra S, Aydin H, Sahay M, Ghosh S, Ruder S, Tiwaskar M, Kilov G, Kishor K, Nair T, Makkar V, Unnikrishnan AG, Dhanda D, Gupta N, Srinivasan B, Kumar A. Cardiorenal Syndrome in Type 2 Diabetes Mellitus - Rational Use of Sodium-glucose Cotransporter-2 Inhibitors. EUROPEAN ENDOCRINOLOGY 2020; 16:113-121. [PMID: 33117442 DOI: 10.17925/ee.2020.16.2.113] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 07/01/2020] [Indexed: 01/10/2023]
Abstract
Cardiorenal syndrome (CRS) in people with type 2 diabetes mellitus (T2DM) illustrates the bidirectional link between the heart and the kidneys, with acute or chronic dysfunction of one organ adversely impacting the function of the other. Of the five subtypes identified, type 1 and 2 CRS occur because of the adverse impact of cardiac conditions on the kidneys. Type 3 and 4 occur when renal conditions affect the heart, and in type 5, systemic conditions impact the heart and kidneys concurrently. The cardiovascular and renoprotective benefits evidenced with sodium-glucose cotransporter-2 (SGLT2) inhibitors make them a potential choice in the management of CRS. Cardiovascular protection is mediated by a reduction in cardiac workload, blood pressure, and body weight; with improvement in lipid profile, uric acid levels, and adaptive ketogenesis process. Renoprotection is facilitated by reduction in albuminuria and hypoxic stress, and restoration of tubuloglomerular feedback. The favourable effect on cardiovascular complications and death, as well as renal complications and progression to end-stage kidney disease, has been confirmed in clinical trials. Guidelines endorse first-line use of SGLT2 inhibitors after metformin in patients with T2DM with high cardiovascular risk, chronic kidney disease or both. Since most trials with SGLT2 inhibitors excluded subjects with acute illness, patients with CRS subtypes 1 and 3 have not been studied adequately, making SGLT2 initiation in clinical practice challenging. Ongoing trials may provide evidence for SGLT2 inhibitor use in CRS. This review aims to enhance understanding of CRS and provide guidance for judicious use of SGLT2 inhibitors in T2DM.
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Affiliation(s)
- Sanjay Kalra
- Bharti Hospital and Bharti Research Institute of Diabetes and Endocrinology (BRIDE), Karnal, India
| | - Hasan Aydin
- Department of Endocrinology and Metabolism, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Manisha Sahay
- Department of Nephrology, Osmania Medical College and General Hospital, Hyderabad, Telangana, India
| | | | - Sundeep Ruder
- Life Fourways Hospital, University of the Witwatersrand, Cape Town, South Africa
| | - Mangesh Tiwaskar
- Shilpa Medical Research Center, Dahisar East, Mumbai, Maharashtra, India
| | - Gary Kilov
- Department of General Practice, University of Melbourne, Melbourne, Australia
| | - Kamal Kishor
- Rama Superspeciality Hospital Karnal, Haryana, India
| | - Tiny Nair
- Department of Cardiology, PRS Hospital, Trivandrum, Kerala, India
| | - Vikas Makkar
- Dayanand Medical College and Hospital, Ludhiana, India
| | | | - Dinesh Dhanda
- Rama Superspeciality Hospital Karnal, Haryana, India
| | - Nikhil Gupta
- CanMed Multispeciality and Weight Management Clinics, Toronto, Canada
| | - Bharath Srinivasan
- Medical Affairs, AstraZeneca Pharma India Ltd, Bengaluru, Karnataka, India
| | - Amit Kumar
- Medical Affairs, AstraZeneca Pharma India Ltd, Bengaluru, Karnataka, India
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11
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Brito D, Bettencourt P, Carvalho D, Ferreira J, Fontes-Carvalho R, Franco F, Moura B, Silva-Cardoso JC, de Melo RT, Fonseca C. Sodium-Glucose Co-transporter 2 Inhibitors in the Failing Heart: a Growing Potential. Cardiovasc Drugs Ther 2020; 34:419-436. [PMID: 32350793 PMCID: PMC7242490 DOI: 10.1007/s10557-020-06973-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Sodium-glucose co-transporter 2 inhibitors (SGLT2i) are a new drug class designed to treat patients with type 2 diabetes (T2D). However, cardiovascular outcome trials showed that SGLT2i also offer protection against heart failure (HF)-related events and cardiovascular mortality. These benefits appear to be independent of glycaemic control and have recently been demonstrated in the HF population with reduced ejection fraction (HFrEF), with or without T2D. This comprehensive, evidence-based review focuses on the published studies concerning HF outcomes with SGLT2i, discussing issues that may underlie the different results, along with the impact of these new drugs in clinical practice. The potential translational mechanisms behind SGLT2i cardio-renal benefits and the information that ongoing studies may add to the already existing body of evidence are also reviewed. Finally, we focus on practical management issues regarding SGLT2i use in association with other T2D and HFrEF common pharmacological therapies. Safety considerations are also highlighted. Considering the paradigm shift in T2D management, from a focus on glycaemic control to a broader approach on cardiovascular protection and event reduction, including the potential for wide SGLT2i implementation in HF patients, with or without T2D, we are facing a promising time for major changes in the global management of cardiovascular disease.
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Affiliation(s)
- Dulce Brito
- Department of Cardiology, Centro Hospitalar Universitário Lisboa Norte, Av. Prof. Egas Moniz, 1649-035, Lisboa, Portugal. .,CCUL, Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, 1649-035, Lisboa, Portugal.
| | - Paulo Bettencourt
- Department of Internal Medicine, Hospital CUF Porto, Porto, Portugal.,Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Davide Carvalho
- Faculdade de Medicina, Universidade do Porto, Porto, Portugal.,Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar, Universitário de São João, Porto, Portugal.,Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
| | - Jorge Ferreira
- Department of Cardiology, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Ricardo Fontes-Carvalho
- Department of Cardiology, Centro Hospitalar Vila Nova de Gaia/Espinho, Espinho, Portugal.,Department of Surgery and Physiology, Cardiovascular Investigation Unit, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Fátima Franco
- Department of Cardiology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Brenda Moura
- Faculdade de Medicina, Universidade do Porto, Porto, Portugal.,Department of Cardiology, Hospital das Forças Armadas-Pólo do Porto, Porto, Portugal.,CINTESIS-Cardiocare, Center for Health Technology and Services Research, Porto, Portugal
| | - José Carlos Silva-Cardoso
- Faculdade de Medicina, Universidade do Porto, Porto, Portugal.,CINTESIS-Cardiocare, Center for Health Technology and Services Research, Porto, Portugal.,Department of Cardiology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | | | - Cândida Fonseca
- Heart Failure Clinic, Hospital São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal.,NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal
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12
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Mordi NA, Mordi IR, Singh JS, McCrimmon RJ, Struthers AD, Lang CC. Renal and Cardiovascular Effects of SGLT2 Inhibition in Combination With Loop Diuretics in Patients With Type 2 Diabetes and Chronic Heart Failure: The RECEDE-CHF Trial. Circulation 2020; 142:1713-1724. [PMID: 32865004 PMCID: PMC7594536 DOI: 10.1161/circulationaha.120.048739] [Citation(s) in RCA: 142] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Supplemental Digital Content is available in the text. Background: SGLT2 (sodium-glucose cotransporter-2) inhibitors improve heart failure–associated outcomes in patients with type 2 diabetes. In patients with heart failure, SGLT2 inhibitors will likely be coprescribed with a loop diuretic, but this combined effect is not well-defined. Our aim was to assess the diuretic and natriuretic effect of empagliflozin in combination with loop diuretics. Methods: The RECEDE-CHF trial (SGLT2 Inhibition in Combination With Diuretics in Heart Failure) was a randomized, double-blind, placebo-controlled, crossover trial of patients with type 2 diabetes and heart failure with reduced ejection fraction taking regular loop diuretic who were randomized to empagliflozin 25 mg once daily or placebo for 6 weeks with a 2-week washout period. The primary outcome was change in 24-hour urinary volume from baseline to week 6. Results: Twenty-three participants (mean age, 69.8 years; 73.9% male; mean furosemide dose, 49.6±31.3 mg/d; mean HbA1c, 7.9±3.8%) were recruited. Compared with placebo, empagliflozin caused a significant increase in 24-hour urinary volume at both day 3 (mean difference, 535 mL [95% CI, 133–936]; P=0.005) and week 6 (mean difference, 545 mL [95% CI, 136–954]; P=0.005) after adjustment for treatment order, baseline 24-hour urine volume, and percentage change in loop diuretic dose. At 6 weeks, empagliflozin did not cause a significant change in 24-hour urinary sodium (mean difference, −7.85 mmol/L [95% CI, −2.43 to 6.73]; P=0.57). Empagliflozin caused a nonsignificant increase in fractional excretion of sodium at day 3, which was absent at week 6 (mean difference day 3, 0.30% [95% CI, −0.03 to 0.63]; P=0.09; week 6, 0.11% [95% CI, −0.22 to 0.44]; P>0.99), and a significant increase in electrolyte-free water clearance at week 6 (mean difference, 312 mL [95% CI, 26–598]; P=0.026) compared with placebo. Empagliflozin also caused significant reductions in body weight and serum urate at week 6. Conclusions: Empagliflozin caused a significant increase in 24-hour urine volume without an increase in urinary sodium when used in combination with loop diuretic. Registration: URL: https://www.clinicaltrials.gov; Unique Identifier: NCT03226457.
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Affiliation(s)
- Natalie A Mordi
- Division of Molecular and Clinical Medicine, University of Dundee, Scotland, United Kingdom (N.A.M., I.R.M., R.J.M., A.D.S., C.C.L.)
| | - Ify R Mordi
- Division of Molecular and Clinical Medicine, University of Dundee, Scotland, United Kingdom (N.A.M., I.R.M., R.J.M., A.D.S., C.C.L.)
| | - Jagdeep S Singh
- Royal Infirmary of Edinburgh, Scotland, United Kingdom (J.D.S.)
| | - Rory J McCrimmon
- Division of Molecular and Clinical Medicine, University of Dundee, Scotland, United Kingdom (N.A.M., I.R.M., R.J.M., A.D.S., C.C.L.)
| | - Allan D Struthers
- Division of Molecular and Clinical Medicine, University of Dundee, Scotland, United Kingdom (N.A.M., I.R.M., R.J.M., A.D.S., C.C.L.)
| | - Chim C Lang
- Division of Molecular and Clinical Medicine, University of Dundee, Scotland, United Kingdom (N.A.M., I.R.M., R.J.M., A.D.S., C.C.L.)
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13
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Lo KB, Gul F, Ram P, Kluger AY, Tecson KM, McCullough PA, Rangaswami J. The Effects of SGLT2 Inhibitors on Cardiovascular and Renal Outcomes in Diabetic Patients: A Systematic Review and Meta-Analysis. Cardiorenal Med 2019; 10:1-10. [PMID: 31743918 DOI: 10.1159/000503919] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 10/02/2019] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Previous meta-analyses demonstrated the benefits of sodium-glucose cotransporter 2 inhibitors (SGLT2i) primarily on patients with established atherosclerotic cardiovascular disease (ASCVD), but with questionable efficacy on patients at risk of ASCVD. Additionally, evidence of beneficial cardiorenal outcomes in patients with estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 with the CV outcomes trials remains unclear. Canagliflozin, one of the SGLT2i, has recently been studied in a large randomized controlled trial in diabetic patients with chronic kidney disease. Thus, there is a need to understand the combined outcomes on the population targeted for treatment with SGLT2i as a whole, regardless of ASCVD status. This meta-analysis will therefore assess the efficacy of SGLT2i in cardiovascular and renal outcomes in general, and in patients with eGFR under 60 mL/min/1.73 m2 in particular. METHODS We searched PubMed and Cochrane databases for randomized, placebo-controlled studies involving SGLT2i. We examined composite cardiovascular outcomes of death from cardiovascular causes, nonfatal myocardial infarctions, nonfatal stroke, and heart failure hospitalizations. Renal composite outcomes and progression of albuminuria were also analyzed. Pooled relative risks (RR) and their 95% confidence intervals (CI) were calculated using a fixed-effects model. RESULTS The search yielded a total of 252 articles. Four studies were ultimately included in the meta-analysis after exclusion of other irrelevant studies. The pooled RR (95% CI) for the composite cardiovascular outcome was 0.93 (0.87-0.99) with a number needed to treat (NNT) of 167 in the general study population and 0.89 (0.77-1.02) in patients with eGFR <60 mL/min/1.73 m2. The pooled RR for all-cause mortality was 0.9 (0.84-0.97) with NNT = 143. The pooled RR for death from cardiovascular causes alone was 0.89 (0.81-0.99) in the general population and 0.82 (0.62-1.07) in patients with eGFR <60 mL/min/1.73 m2. The pooled RR for heart failure hospitalizations was 0.71 (0.63-0.79) with NNT = 91. With respect to renal outcomes, the pooled RR for the composite renal outcome was 0.63 (0.56-0.71) with NNT = 67; this was true even in patients with eGFR <60 mL/min/1.73 m2 0.67 (0.59-0.76). Lastly, the pooled RR for progression of albuminuria was 0.80 (0.76-0.84). CONCLUSION SGLT2i are associated with significantly lower major adverse cardiovascular events, heart failure hospitalizations, and all-cause mortality. The evidence is strongest in reducing heart failure hospitalizations. However, the evidence is weaker when it comes to the population subset with eGFR <60 mL/min/1.73 m2. SGLT2i are also associated with significantly lower adverse renal events, with these effects apparent even in the population with eGFR <60 mL/min/1.73 m2.
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Affiliation(s)
- Kevin Bryan Lo
- Department of Medicine, Einstein Medical Center, Philadelphia, Pennsylvania, USA,
| | - Fahad Gul
- Department of Medicine, Einstein Medical Center, Philadelphia, Pennsylvania, USA
| | - Pradhum Ram
- Department of Cardiology, Emory University, Atlanta, Georgia, USA
| | - Aaron Y Kluger
- Baylor Heart and Vascular Institute, Dallas, Texas, USA.,Baylor Scott and White Research Institute, Dallas, Texas, USA
| | - Kristen M Tecson
- Baylor Heart and Vascular Institute, Dallas, Texas, USA.,Baylor Scott and White Research Institute, Dallas, Texas, USA.,Texas A&M College of Medicine Health Science Center, Dallas, Texas, USA
| | - Peter A McCullough
- Baylor Heart and Vascular Institute, Dallas, Texas, USA.,Texas A&M College of Medicine Health Science Center, Dallas, Texas, USA.,Baylor University Medical Center, Dallas, Texas, USA.,Baylor Heart and Vascular Hospital, Dallas, Texas, USA
| | - Janani Rangaswami
- Department of Medicine, Einstein Medical Center, Philadelphia, Pennsylvania, USA.,Sidney Kimmel College of Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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14
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Abstract
PURPOSE OF REVIEW To address common concerns regarding sodium-glucose cotransporter 2 (SGLT2) inhibitor use for patients with type 2 diabetes mellitus (T2DM) in cardiovascular practice. RECENT FINDINGS SGLT2 inhibitors provide glycemic control and improve cardiovascular and renal endpoints in T2DM. Cardiovascular outcome trials have demonstrated sustained cardiovascular, heart failure and renal benefits independent of glycemic control, which persist down to an eGFR of 30 ml/min/1.73 m. SGLT2 inhibitors can be safely administered alongside common diuretics, and routine monitoring of renal function is advised at initiation of therapy, particularly for patients on loop diuretics. Mild initial reductions in eGFR are expected, usually stabilizing over time. The most common adverse effect noted with SGLT2 inhibitors is genital mycotic infections, primarily in women. Less common, but concerning effects associated with canagliflozin include increased risk of fractures and lower limb amputations, particularly in patients with previous amputation history. Overall, SGLT2 inhibitors are well tolerated and effective adjuncts to diabetic treatment, for which the benefits seem to outweigh the risks. SUMMARY The care of patients with T2DM requires an interdisciplinary team approach, within which the role of cardiologists is expanding. SGLT2 inhibitors are an encouraging treatment option for achieving glycemic control, whilst also improving cardiovascular and renal outcomes.
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15
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Ali A, Bain S, Hicks D, Newland Jones P, Patel DC, Evans M, Fernando K, James J, Milne N, Viljoen A, Wilding J. SGLT2 Inhibitors: Cardiovascular Benefits Beyond HbA1c-Translating Evidence into Practice. Diabetes Ther 2019; 10:1595-1622. [PMID: 31290126 PMCID: PMC6778582 DOI: 10.1007/s13300-019-0657-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Indexed: 02/07/2023] Open
Abstract
Cardiovascular disease (CVD), including heart failure (HF), is a leading cause of morbidity and mortality in people with type 2 diabetes mellitus (T2DM). CVD and T2DM share common risk factors for development and progression, and there is significant overlap between the conditions in terms of worsening outcomes. In assessing the cardiovascular (CV) safety profiles of anti-diabetic drugs, sodium-glucose co-transporter-2 inhibitor (SGLT2i) therapies have emerged with robust evidence for reducing the risk of adverse CVD outcomes in people with T2DM who have either established CVD or are at risk of developing CVD. A previous consensus document from the Improving Diabetes Steering Committee has examined the potential role of SGLT2is in T2DM management and considered the risk-benefit profile of the class and the appropriate place for these medicines within the T2DM pathway. This paper builds on these findings and presents practical guidance for maximising the pleiotropic benefits of this class of medicines in people with T2DM in terms of reducing adverse CVD outcomes. The Improving Diabetes Steering Committee aims to offer evidence-based practical guidance for the use of SGLT2i therapies in people with T2DM stratified by CVD risk. This is of particular importance currently because some treatment guidelines have not been updated to reflect recent evidence from cardiovascular outcomes trials (CVOTs) and real-world studies that complement the CVOTs. The Improving Diabetes Steering Committee seeks to support healthcare professionals (HCPs) in appropriate treatment selection for people with T2DM who are at risk of developing or have established CVD and examines the role of SGLT2i therapy for these people.Funding: Napp Pharmaceuticals Limited.
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Affiliation(s)
- Amar Ali
- Oakenhurst Medical Practice, Blackburn, UK
| | - Steve Bain
- Diabetes Research Unit Cymru, Swansea University, Swansea, UK
| | | | | | - Dipesh C Patel
- Department of Diabetes and Endocrinology, Division of Medicine, University College London, London, UK
| | - Marc Evans
- Department of Diabetes, University Hospital Llandough, Llandough, UK
| | | | - June James
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Nicola Milne
- CODES (Community Diabetes Education and Support), Manchester University NHS Foundation Trust, Manchester, UK
| | - Adie Viljoen
- Department of Metabolic Medicine/Chemical Pathology, Lister Hospital, Stevenage, UK
| | - John Wilding
- Obesity and Endocrinology Research, University of Liverpool, Liverpool, UK.
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16
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Li J, Fagbote CO, Zhuo M, Hawley CE, Paik JM. Sodium-glucose cotransporter 2 inhibitors for diabetic kidney disease: a primer for deprescribing. Clin Kidney J 2019; 12:620-628. [PMID: 31583087 PMCID: PMC6768299 DOI: 10.1093/ckj/sfz100] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Indexed: 02/06/2023] Open
Abstract
Chronic kidney disease (CKD) is a critical global public health problem associated with high morbidity and mortality, poorer quality of life and increased health care expenditures. CKD and its associated comorbidities are one of the most complex clinical constellations to manage. Treatments for CKD and its comorbidities lead to polypharmacy, which exponentiates the morbidity and mortality. Sodium-glucose cotransporter 2 inhibitors (SGLT2is) have shown remarkable benefits in cardiovascular and renal protection in patients with type 2 diabetes mellitus (T2DM). The pleiotropic effects of SGLT2is beyond glycosuria suggest a promising role in reducing polypharmacy in diabetic CKD, but the potential adverse effects of SGLT2is should also be considered. In this review, we present a typical case of a patient with multiple comorbidities seen in a CKD clinic, highlighting the polypharmacy and complexity in the management of proteinuria, hyperkalemia, volume overload, hyperuricemia, hypoglycemia and obesity. We review the cardiovascular and renal protection effects of SGLT2is in the context of clinical trials and current guidelines. We then discuss the roles of SGLT2is in the management of associated comorbidities and review the adverse effects and controversies of SGLT2is. We conclude with a proposal for deprescribing principles when initiating SGLT2is in patients with diabetic CKD.
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Affiliation(s)
- Jiahua Li
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Renal Section, VA Boston Healthcare System, Boston, MA, USA
| | | | - Min Zhuo
- Renal Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Chelsea E Hawley
- Department of Pharmacy, VA Boston Healthcare System, Boston, MA, USA.,New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, MA, USA
| | - Julie M Paik
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Renal Section, VA Boston Healthcare System, Boston, MA, USA.,New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, MA, USA
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17
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Katsiki N, Triposkiadis F. Resistance to Diuretics in Heart Failure: Any Role for Empagliflozin? Curr Vasc Pharmacol 2019; 17:421-424. [DOI: 10.2174/1570161116666180831124717] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Niki Katsiki
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, Thessaloniki, Greece
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18
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Diuretic treatment of the patient with diabetes and heart failure. Role of SGLT2 inhibitors and similarities with carbonic anhydrase inhibitors. Rev Clin Esp 2019. [DOI: 10.1016/j.rceng.2019.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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19
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Davidson JA. SGLT2 inhibitors in patients with type 2 diabetes and renal disease: overview of current evidence. Postgrad Med 2019; 131:251-260. [PMID: 30929540 DOI: 10.1080/00325481.2019.1601404] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Chronic kidney disease (CKD) is a frequent complication of type 2 diabetes mellitus (T2DM) and is associated with poor clinical outcomes, including an increased risk of all-cause and cardiovascular mortality, as well as adverse economic and social effects. Slowing the development and progression of CKD remains an unmet clinical need in patients with T2DM. Sodium-glucose co-transporter 2 (SGLT2) inhibitors are widely used for the management of T2DM and have effects beyond glucose lowering that include cardiovascular benefits and potential renoprotective effects. Although the glucose-lowering efficacy of these agents is dependent on renal function, the cardiovascular and renal benefits of SGLT2 inhibition appear to be maintained to estimated glomerular filtration levels as low as 30 mL/min/1.73 m2. Clinical evidence has indicated that these agents can reduce the risk of development or worsening of albuminuria, a marker of renal damage, through a range of mechanisms. These include blood pressure lowering, reduction of intraglomerular pressure and hyperfiltration, modification of inflammatory processes, reduction of ischemia-related renal injury, and increases in glucagon levels. The blood pressure-lowering effect of SGLT2 inhibitors is maintained in people with CKD and could further contribute to reduced renal burden, as well as potentially offering synergistic effects with antihypertensive therapies in these patients. Several cardiovascular outcomes trials (CVOTs) have included renal endpoints, adding to the growing evidence of the potential renoprotective effects of these agents in patients with T2DM. Several ongoing dedicated renal outcomes trials will provide further guidance on the potential clinical role of SGLT2 inhibitors in slowing the development and progression of renal impairment in individuals with T2DM.
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Affiliation(s)
- Jaime A Davidson
- a The University of Texas Southwestern Medical Center, Touchstone Diabetes Center , Dallas , TX , USA
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20
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Puga AM, Lopez-Oliva S, Trives C, Partearroyo T, Varela-Moreiras G. Effects of Drugs and Excipients on Hydration Status. Nutrients 2019; 11:nu11030669. [PMID: 30897748 PMCID: PMC6470661 DOI: 10.3390/nu11030669] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 03/14/2019] [Accepted: 03/15/2019] [Indexed: 12/17/2022] Open
Abstract
Despite being the most essential nutrient, water is commonly forgotten in the fields of pharmacy and nutrition. Hydration status is determined by water balance (the difference between water input and output). Hypohydration or negative water balance is affected by numerous factors, either internal (i.e., a lack of thirst sensation) or external (e.g., polypharmacy or chronic consumption of certain drugs). However, to date, research on the interaction between hydration status and drugs/excipients has been scarce. Drugs may trigger the appearance of hypohydration by means of the increase of water elimination through either diarrhea, urine or sweat; a decrease in thirst sensation or appetite; or the alteration of central thermoregulation. On the other hand, pharmaceutical excipients induce alterations in hydration status by decreasing the gastrointestinal transit time or increasing the gastrointestinal tract rate or intestinal permeability. In the present review, we evaluate studies that focus on the effects of drugs/excipients on hydration status. These studies support the aim of monitoring the hydration status in patients, mainly in those population segments with a higher risk, to avoid complications and associated pathologies, which are key axes in both pharmaceutical care and the field of nutrition.
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Affiliation(s)
- Ana M Puga
- Department of Pharmaceutical and Health Sciences, Faculty of Pharmacy, CEU San Pablo University, 28668 Madrid, Spain.
| | - Sara Lopez-Oliva
- Department of Pharmaceutical and Health Sciences, Faculty of Pharmacy, CEU San Pablo University, 28668 Madrid, Spain.
| | - Carmen Trives
- Department of Pharmaceutical and Health Sciences, Faculty of Pharmacy, CEU San Pablo University, 28668 Madrid, Spain.
| | - Teresa Partearroyo
- Department of Pharmaceutical and Health Sciences, Faculty of Pharmacy, CEU San Pablo University, 28668 Madrid, Spain.
| | - Gregorio Varela-Moreiras
- Department of Pharmaceutical and Health Sciences, Faculty of Pharmacy, CEU San Pablo University, 28668 Madrid, Spain.
- Spanish Nutrition Foundation (FEN), 28010 Madrid, Spain.
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21
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Cefalo CMA, Cinti F, Moffa S, Impronta F, Sorice GP, Mezza T, Pontecorvi A, Giaccari A. Sotagliflozin, the first dual SGLT inhibitor: current outlook and perspectives. Cardiovasc Diabetol 2019; 18:20. [PMID: 30819210 PMCID: PMC6393994 DOI: 10.1186/s12933-019-0828-y] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 02/19/2019] [Indexed: 12/12/2022] Open
Abstract
Sotagliflozin is a dual sodium-glucose co-transporter-2 and 1 (SGLT2/1) inhibitor for the treatment of both type 1 (T1D) and type 2 diabetes (T2D). Sotagliflozin inhibits renal sodium-glucose co-transporter 2 (determining significant excretion of glucose in the urine, in the same way as other, already available SGLT-2 selective inhibitors) and intestinal SGLT-1, delaying glucose absorption and therefore reducing post prandial glucose. Well-designed clinical trials, have shown that sotagliflozin (as monotherapy or add-on therapy to other anti-hyperglycemic agents) improves glycated hemoglobin in adults with T2D, with beneficial effects on bodyweight and blood pressure. Similar results have been obtained in adults with T1D treated with either continuous subcutaneous insulin infusion or multiple daily insulin injections, even after insulin optimization. A still ongoing phase 3 study is currently evaluating the effect of sotagliflozin on cardiovascular outcomes (ClinicalTrials.gov NCT03315143). In this review we illustrate the advantages and disadvantages of dual SGLT 2/1 inhibition, in order to better characterize and investigate its mechanisms of action and potentialities.
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Affiliation(s)
- Chiara Maria Assunta Cefalo
- Center for Endocrine and Metabolic Diseases, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Istituto di Patologia Speciale Medica e Semeiotica Clinica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesca Cinti
- Center for Endocrine and Metabolic Diseases, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Istituto di Patologia Speciale Medica e Semeiotica Clinica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Simona Moffa
- Center for Endocrine and Metabolic Diseases, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Istituto di Patologia Speciale Medica e Semeiotica Clinica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Flavia Impronta
- Center for Endocrine and Metabolic Diseases, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Istituto di Patologia Speciale Medica e Semeiotica Clinica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gian Pio Sorice
- Center for Endocrine and Metabolic Diseases, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Istituto di Patologia Speciale Medica e Semeiotica Clinica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Teresa Mezza
- Center for Endocrine and Metabolic Diseases, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Istituto di Patologia Speciale Medica e Semeiotica Clinica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alfredo Pontecorvi
- Center for Endocrine and Metabolic Diseases, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Istituto di Patologia Speciale Medica e Semeiotica Clinica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Giaccari
- Center for Endocrine and Metabolic Diseases, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy. .,Istituto di Patologia Speciale Medica e Semeiotica Clinica, Università Cattolica del Sacro Cuore, Rome, Italy.
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22
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Yang J, Zhang LJ, Wang F, Hong T, Liu Z. Molecular imaging of diabetes and diabetic complications: Beyond pancreatic β-cell targeting. Adv Drug Deliv Rev 2019; 139:32-50. [PMID: 30529307 DOI: 10.1016/j.addr.2018.11.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 09/28/2018] [Accepted: 11/27/2018] [Indexed: 12/13/2022]
Abstract
Diabetes is a chronic non-communicable disease affecting over 400 million people worldwide. Diabetic patients are at a high risk of various complications, such as cardiovascular, renal, and other diseases. The pathogenesis of diabetes (both type 1 and type 2 diabetes) is associated with a functional impairment of pancreatic β-cells. Consequently, most efforts to manage and prevent diabetes have focused on preserving β-cells and their function. Advances in imaging techniques, such as magnetic resonance imaging, magnetic resonance spectroscopy, positron emission tomography, and single-photon-emission computed tomography, have enabled noninvasive and quantitative detection and characterization of the population and function of β-cells in vivo. These advantages aid in defining and monitoring the progress of diabetes and determining the efficacy of anti-diabetic therapies. Beyond β-cell targeting, molecular imaging of biomarkers associated with the development of diabetes, e.g., lymphocyte infiltration, insulitis, and metabolic changes, may also be a promising strategy for early detection of diabetes, monitoring its progression, and occurrence of complications, as well as facilitating exploration of new therapeutic interventions. Moreover, molecular imaging of glucose uptake, production and excretion in specified tissues is critical for understanding the pathogenesis of diabetes. In the current review, we summarize and discuss recent advances in noninvasive imaging technologies for imaging of biomarkers beyond β-cells for early diagnosis of diabetes, investigation of glucose metabolism, and precise diagnosis and monitoring of diabetic complications for better management of diabetic patients.
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Affiliation(s)
- Jichun Yang
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences Peking University Health Science Center, Key Laboratory of Cardiovascular Science of the Ministry of Education, Center for Non-coding RNA Medicine, Beijing 100191, China.
| | - Long Jiang Zhang
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China
| | - Fan Wang
- Medical Isotopes Research Center and Department of Radiation Medicine, School of Basic Medical Sciences, Peking University Health Science Center, Beijing 100191, China
| | - Tianpei Hong
- Department of Endocrinology and Metabolism, Peking University Third Hospital, Beijing 100191, China.
| | - Zhaofei Liu
- Medical Isotopes Research Center and Department of Radiation Medicine, School of Basic Medical Sciences, Peking University Health Science Center, Beijing 100191, China.
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23
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Simes BC, MacGregor GG. Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitors: A Clinician's Guide. Diabetes Metab Syndr Obes 2019; 12:2125-2136. [PMID: 31686884 PMCID: PMC6799898 DOI: 10.2147/dmso.s212003] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 09/11/2019] [Indexed: 12/13/2022] Open
Abstract
This comprehensive review covers the historical background, physiology, application in type 2 diabetes, novel uses, cardiovascular benefits, side effects and contraindications of sodium-glucose cotransporter-2 (SGLT2) inhibitors. SGLT2 inhibitors are an insulin-independent class of oral antihyperglycemic medication that clinicians use in the treatment of type 2 diabetes. Multiple landmark clinical trials support the effectiveness of SGLT2 inhibitors in reducing blood glucose levels, but it is important to understand when to properly utilize them. SGLT2 inhibitors are the most beneficial as an adjunct medication in addition to metformin in patients with a history of cardiovascular or renal disease who need further hemoglobin A1c reduction. The novel mechanism of action also demands clinicians be aware of the side effects not typically experienced with other oral antihyperglycemic drugs, such as genital tract infections, lower leg amputations, electrolyte disturbances and bone fractures. On top of their benefits in type 2 diabetes, novel uses for SGLT2 inhibitors are being uncovered. Diabetic patients with non-alcoholic fatty liver disease, who are at an increased risk of cirrhosis and hepatocellular carcinoma, experience a clinically significant reduction in serum alanine aminotransferase levels. SGLT2 inhibitors are also effective at lowering body weight in obese individuals and decreasing systolic blood pressure. Dual SGLT1/SGLT2 inhibitors are currently being investigated as possibly the first oral medication for type 1 diabetes.
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Affiliation(s)
- Bryce C Simes
- Alabama College of Osteopathic Medicine, Dothan, AL, USA
- Correspondence: Bryce C Simes Alabama College of Osteopathic Medicine, 445 Health Sciences Blvd., Dothan, AL36303, USATel +1 205 904-504-8897Fax +1 205 334-699-2268 Email
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León Jiménez D, Gómez Huelgas R, Fernández Romero AJ, López Chozas JM, Pérez de Isla L, Miramontes González JP. Diuretic treatment of the patient with diabetes and heart failure. Role of SGLT2 inhibitors and similarities with carbonic anhydrase inhibitors. Rev Clin Esp 2018; 219:208-217. [PMID: 30553441 DOI: 10.1016/j.rce.2018.09.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 09/25/2018] [Accepted: 09/28/2018] [Indexed: 12/28/2022]
Abstract
Sodium-glucose cotransporter-2 inhibitors have changed the concept of the effects that hypoglycemic drugs have on hearth failure (HF). For the first time, a therapeutic group has modified the evolution of HF. Its effect goes beyond glycemic control, and different theories have been postulated to justify this benefit. In the article we sent, we analyze the influence of the different pharmacological groups used in type 2 diabetes mellitus on HF, and we present the theory of the mechanism of action associated with the benefit of these drugs. In our opinion, this benefit in HF is secondary to its diuretic effect, specifically an effect very similar to carbon dioxide inhibitors. We think that our theory is novel, explains the mechanism of action and we have not found in the literature any article that explains the mechanism of action in such a precise way.
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Affiliation(s)
- D León Jiménez
- Unidad de Riesgo Vascular, Medicina Interna, Hospital Universitario Virgen Macarena, Sevilla, España.
| | - R Gómez Huelgas
- Unidad de Gestión Clínica de Medicina Interna, Hospital Regional Universitario, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, España
| | | | - J M López Chozas
- Unidad de Gestión Clínica de Medicina Interna, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - L Pérez de Isla
- Departamento de Cardiología, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos (IDISSC), Universidad Complutense, Madrid, España
| | - J P Miramontes González
- Medicina Interna, Instituto de Investigación Biomédica de Salamanca (IBSAL), Hospital Universitario de Salamanca, Salamanca, España
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León Jiménez D, Cherney DZI, Bjornstad P, Castilla-Guerra L, Miramontes González JP. Antihyperglycemic agents as novel natriuretic therapies in diabetic kidney disease. Am J Physiol Renal Physiol 2018; 315:F1406-F1415. [PMID: 30066584 DOI: 10.1152/ajprenal.00384.2017] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
While sodium-glucose cotransporter-2 (SGLT2) inhibitors have been used for the routine management of type 2 diabetes for several years, it is perhaps their natriuretic effects that are most important clinically. This natriuresis activates tubuloglomerular feedback, resulting in reduced glomerular hypertension and proteinuria, leading to renal protective effects in the EMPA-REG OUTCOME and CANVAS Program trials. In the cardiovascular system, it is likely that plasma volume contraction due to natriuresis in response to SGLT2 inhibition is at least in part responsible for the reduction in the risk of heart failure observed in these trials. We compare this mechanism of action with other antidiabetics. Importantly, other diuretic classes, including thiazide and loop diuretics, have not resulted in such robust clinical benefits in patients with type 2 diabetes, possibly because these older agents do not influence intraglomerular pressure directly. In contrast, SGLT2 inhibitors do have important physiological similarities with carbonic anhydrase inhibitors, which also act proximally, and have been shown to activate tubuloglomerular feedback.
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Affiliation(s)
- David León Jiménez
- Vascular Risk Unit, Internal Medicine Clinical Management Unit, Hospital Universitario Virgen Macarena , Seville , Spain
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology. Toronto General Hospital, University of Toronto , Toronto , Ontario, Canada
| | - Petter Bjornstad
- Department of Pediatrics, Division of Endocrinology and Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado , Aurora, Colorado
| | - Luis Castilla-Guerra
- Vascular Risk Unit, Internal Medicine Clinical Management Unit, Hospital Universitario Virgen Macarena , Seville , Spain
| | - José Pablo Miramontes González
- Service of Internal Medicine, Institute of Biomedical Research of Salamanca (IBSAL), Hospital Universitario de Salamanca , Salamanca , Spain
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Rådholm K, Figtree G, Perkovic V, Solomon SD, Mahaffey KW, de Zeeuw D, Fulcher G, Barrett TD, Shaw W, Desai M, Matthews DR, Neal B. Canagliflozin and Heart Failure in Type 2 Diabetes Mellitus: Results From the CANVAS Program. Circulation 2018; 138:458-468. [PMID: 29526832 PMCID: PMC6075881 DOI: 10.1161/circulationaha.118.034222] [Citation(s) in RCA: 333] [Impact Index Per Article: 55.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 02/22/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Canagliflozin is a sodium glucose cotransporter 2 inhibitor that reduces the risk of cardiovascular events. We report the effects on heart failure (HF) and cardiovascular death overall, in those with and without a baseline history of HF, and in other participant subgroups. METHODS The CANVAS Program (Canagliflozin Cardiovascular Assessment Study) enrolled 10 142 participants with type 2 diabetes mellitus and high cardiovascular risk. Participants were randomly assigned to canagliflozin or placebo and followed for a mean of 188 weeks. The primary end point for these analyses was adjudicated cardiovascular death or hospitalized HF. RESULTS Participants with a history of HF at baseline (14.4%) were more frequently women, white, and hypertensive and had a history of prior cardiovascular disease (all P<0.001). Greater proportions of these patients were using therapies such as blockers of the renin angiotensin aldosterone system, diuretics, and β-blockers at baseline (all P<0.001). Overall, cardiovascular death or hospitalized HF was reduced in those treated with canagliflozin compared with placebo (16.3 versus 20.8 per 1000 patient-years; hazard ratio [HR], 0.78; 95% confidence interval [CI], 0.67-0.91), as was fatal or hospitalized HF (HR, 0.70; 95% CI, 0.55-0.89) and hospitalized HF alone (HR, 0.67; 95% CI, 0.52-0.87). The benefit on cardiovascular death or hospitalized HF may be greater in patients with a prior history of HF (HR, 0.61; 95% CI, 0.46-0.80) compared with those without HF at baseline (HR, 0.87; 95% CI, 0.72-1.06; P interaction =0.021). The effects of canagliflozin compared with placebo on other cardiovascular outcomes and key safety outcomes were similar in participants with and without HF at baseline (all interaction P values >0.130), except for a possibly reduced absolute rate of events attributable to osmotic diuresis among those with a prior history of HF ( P=0.03). CONCLUSIONS In patients with type 2 diabetes mellitus and an elevated risk of cardiovascular disease, canagliflozin reduced the risk of cardiovascular death or hospitalized HF across a broad range of different patient subgroups. Benefits may be greater in those with a history of HF at baseline. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifiers: NCT01032629 and NCT01989754.
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Affiliation(s)
- Karin Rådholm
- Department of Medicine and Health Sciences, Division of Community Medicine, Primary Care, Faculty of Health Sciences, Department of Local Care West, County Council of Ötergötland, Linköping University, Sweden (K.R.)
- The George Institute for Global Health (K.R., V.P., B.N.)
| | | | - Vlado Perkovic
- The George Institute for Global Health (K.R., V.P., B.N.)
- University of New South Wales, Sydney, Australia. Royal North Shore Hospital (G.F., V.P., G.F.)
| | - Scott D. Solomon
- University of Sydney, Australia. Harvard Medical School and Brigham and Women’s Hospital, Boston, MA (S.D.S.)
| | - Kenneth W. Mahaffey
- Department of Medicine, Stanford Center for Clinical Research, Stanford University School of Medicine, CA (K.W.M.)
| | - Dick de Zeeuw
- University of Groningen, University Medical Center Groningen, The Netherlands (D.d.Z.)
| | - Greg Fulcher
- University of New South Wales, Sydney, Australia. Royal North Shore Hospital (G.F., V.P., G.F.)
| | | | - Wayne Shaw
- Janssen Research & Development, LLC, Raritan, NJ (T.D.B., W.S., M.D.)
| | - Mehul Desai
- Janssen Research & Development, LLC, Raritan, NJ (T.D.B., W.S., M.D.)
| | - David R. Matthews
- Oxford Centre for Diabetes, Endocrinology, and Metabolism, University of Oxford, United Kingdom (D.R.M)
| | - Bruce Neal
- The George Institute for Global Health (K.R., V.P., B.N.)
- Faculty of Medicine (B.N.)
- Charles Perkins Centre (B.N.)
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Lahnwong C, Chattipakorn SC, Chattipakorn N. Potential mechanisms responsible for cardioprotective effects of sodium-glucose co-transporter 2 inhibitors. Cardiovasc Diabetol 2018; 17:101. [PMID: 29991346 PMCID: PMC6038192 DOI: 10.1186/s12933-018-0745-5] [Citation(s) in RCA: 102] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 07/06/2018] [Indexed: 02/07/2023] Open
Abstract
Diabetes mellitus currently affects over 350 million patients worldwide and is associated with many deaths from cardiovascular complications. Sodium-glucose co-transporter 2 (SGLT-2) inhibitors are a novel class of antidiabetic drugs with cardiovascular benefits beyond other antidiabetic drugs. In the EMPA-REG OUTCOME trial, empagliflozin significantly decreases the mortality rate from cardiovascular causes [38% relative risk reduction (RRR)], the mortality rate from all-causes (32% RRR) and the rate of heart failure hospitalization (35% RRR) in diabetic patients with established cardiovascular diseases. The possible mechanisms of SGLT-2 inhibitors are proposed to be systemic effects by hemodynamic and metabolic actions. However, the direct mechanisms are not fully understood. In this review, reports concerning the effects of SGLT-2 inhibitors in models of diabetic cardiomyopathy, heart failure and myocardial ischemia from in vitro, in vivo as well as clinical reports are comprehensively summarized and discussed. By current evidences, it may be concluded that the direct effects of SGLT-2 inhibitors are potentially mediated through their ability to reduce cardiac inflammation, oxidative stress, apoptosis, mitochondrial dysfunction and ionic dyshomeostasis.
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Affiliation(s)
- Charshawn Lahnwong
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Department of Pharmacology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Siriporn C Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Department of Oral Biology and Diagnostic Sciences, Faculty of Dentistry, Chiang Mai University, Chiang Mai, 50200, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Nipon Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai, 50200, Thailand.
- Cardiac Electrophysiology Unit, Department of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
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Abstract
PURPOSE OF REVIEW In addition to their effects on glycemic control, two specific classes of relatively new anti-diabetic drugs, namely the sodium glucose co-transporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) have demonstrated reduced rates of major adverse cardiovascular events (MACE) in subjects with type 2 diabetes (T2D) at high risk for cardiovascular disease (CVD). This review summarizes recent experimental results that inform putative molecular mechanisms underlying these benefits. RECENT FINDINGS SGLT2i and GLP-1RA exert cardiovascular effects by targeting in both common and distinctive ways (A) several mediators of macro- and microvascular pathophysiology: namely (A1) inflammation and atherogenesis, (A2) oxidative stress-induced endothelial dysfunction, (A3) vascular smooth muscle cell reactive oxygen species (ROS) production and proliferation, and (A4) thrombosis. These agents also exhibit (B) hemodynamic effects through modulation of (B1) natriuresis/diuresis and (B2) the renin-angiotensin-aldosterone system. This review highlights that while GLP-1RA exert direct effects on vascular (endothelial and smooth muscle) cells, the effects of SGLT2i appear to include the activation of signaling pathways that prevent adverse vascular remodeling. Both SGLT2i and GLP-1RA confer hemodynamic effects that counter adverse cardiac remodeling.
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Affiliation(s)
- Dorrin Zarrin Khat
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
| | - Mansoor Husain
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada.
- Department of Medicine, University of Toronto, Toronto, Canada.
- Toronto General Hospital Research Institute, University Health Network, Toronto, Canada.
- Heart and Stroke Richard Lewar Centre of Excellence, University of Toronto, Toronto, Canada.
- Ted Rogers Centre for Heart Research, University Health Network, Toronto, Canada.
- Peter Munk Cardiac Centre, University Health Network, Toronto, Canada.
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Arrieta F, Iglesias P, Pedro-Botet J, Becerra A, Ortega E, Obaya JC, Nubiola A, Maldonado GF, Campos MDM, Petrecca R, Pardo JL, Sánchez-Margalet V, Alemán JJ, Navarro J, Duran S, Tébar FJ, Aguilar M, Escobar F. Diabetes mellitus y riesgo cardiovascular. Actualización de las recomendaciones del Grupo de Trabajo de Diabetes y Riesgo Cardiovascular de la Sociedad Española de Diabetes (SED, 2018). CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS 2018; 30:137-153. [DOI: 10.1016/j.arteri.2018.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 02/28/2018] [Accepted: 03/09/2018] [Indexed: 12/24/2022]
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