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Kawano R, Haze T, Fujiwara A, Haruna A, Ozawa M, Kobayashi Y, Saka S, Hirawa N, Tamura K. Favorable changes in the eGFR slope after dapagliflozin treatment and its association with the initial dip. Clin Exp Nephrol 2024:10.1007/s10157-024-02532-4. [PMID: 38970649 DOI: 10.1007/s10157-024-02532-4] [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: 01/31/2024] [Accepted: 06/19/2024] [Indexed: 07/08/2024]
Abstract
BACKGROUND Renoprotective effects of sodium glucose transporter 2 (SGLT2) inhibitors, including dapagliflozin, were observed in randomized controlled trials (RCTs). The suspected underlying mechanism is a correction of hyperfiltration, observed as an "initial dip". Whether SGLT2 inhibitors can attenuate the rate of decline in the estimated glomerular filtration rate (eGFR) in clinical settings, even when considering the pre-treatment decline rate, is unknown. Although several RCTs identified an association between the initial dip and long-term renal prognoses, a conclusion has not been reached. METHODS We collected the eGFR data of patients for whom dapagliflozin was initiated in our hospital and then calculated their eGFR slopes before and after the start of the treatment. We investigated the changes in the eGFR slopes (ΔeGFR slope) and the association between the ΔeGFR slope and the initial dip. Risks for rapid eGFR decliners (eGFR slope < - 3 mL/min/1.73 m2/year) were also examined. RESULTS The eGFR slope was significantly milder after dapagliflozin treatment (p < 0.01). A deeper initial dip was associated with a milder rate of eGFR decline (adjusted beta: - 0.29, p < 0.001). Dapagliflozin treatment reduced the proportion of rapid eGFR decliners from 52.9 to 14.7%, and a smaller initial dip was identified as a significant risk for post-treatment rapid eGFR decline (adjusted odds ratio: 1.73, p < 0.05). CONCLUSIONS Compared to before the administration of dapagliflozin, the rate of eGFR decline was significantly milder after its administration. The initial dip was significantly associated with long-term renoprotective effects and may be a useful predictor of treatment response.
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Affiliation(s)
- Rina Kawano
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
- Department of Nephrology and Hypertension, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan
| | - Tatsuya Haze
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
- Department of Nephrology and Hypertension, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan
- YCU Center for Novel and Exploratory Clinical Trials (Y-NEXT), Yokohama City University Hospital, Yokohama, Japan
| | - Akira Fujiwara
- Department of Nephrology and Hypertension, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan.
| | - Aiko Haruna
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
- Department of Nephrology and Hypertension, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan
| | - Moe Ozawa
- Department of Nephrology and Hypertension, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan
| | - Yusuke Kobayashi
- YCU Center for Novel and Exploratory Clinical Trials (Y-NEXT), Yokohama City University Hospital, Yokohama, Japan
| | - Sanae Saka
- Department of Nephrology and Hypertension, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan
| | - Nobuhito Hirawa
- Department of Nephrology and Hypertension, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan
| | - Kouichi Tamura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Kanaoka T, Wakui H, Yano Y, Nagasu H, Kanegae H, Nangaku M, Hirakawa Y, Nakagawa N, Wada J, Tsuruya K, Nakano T, Maruyama S, Wada T, Konishi M, Nagahiro T, Yamagata K, Narita I, Yanagita M, Terada Y, Araki S, Emoto M, Okada H, Isaka Y, Suzuki Y, Yokoo T, Kataoka H, Kanda E, Kashihara N, Tamura K. Factors affecting the sodium-glucose cotransporter 2 inhibitors-related initial decline in glomerular filtration rate and its possible effect on kidney outcome in chronic kidney disease with type 2 diabetes: The Japan Chronic Kidney Disease Database. Diabetes Obes Metab 2024; 26:2905-2914. [PMID: 38719436 DOI: 10.1111/dom.15611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 03/28/2024] [Accepted: 04/06/2024] [Indexed: 06/05/2024]
Abstract
AIM Sodium-glucose cotransporter 2 (SGLT2) inhibitors often cause a transient decrease in glomerular filtration rate (GFR) shortly after the initiation, referred to as the 'initial drop'. However, the clinical significance of this initial drop in real-world practice remains unclear. MATERIALS AND METHODS Using the nationwide Japan Chronic Kidney Disease Database, we examined factors that affected the initial drop, in patients with chronic kidney disease (CKD) and type 2 diabetes mellitus (T2DM). We also evaluated the effects of the initial drop on a composite kidney outcome (a decline in GFR of ≥50% or progression to end-stage kidney disease). RESULTS Data from 2053 patients with CKD and T2DM newly prescribed an SGLT2 inhibitor were analysed. The follow-up period after SGLT2 inhibitor administration was 1015 days (interquartile range: 532, 1678). Multivariate linear regression models revealed that the concomitant use of the renin-angiotensin system inhibitors and diuretics, urinary protein levels ≥2+, and changes in GFR before the initiation of the SGLT2 inhibitor were associated with a larger initial GFR decline (β = -0.609, p = .039; β = -2.298, p < .001; β = -0.936, p = .048; β = -0.079, p < .001, respectively). Patients in the quartile with the largest initial GFR decline experienced a higher incidence of the subsequent composite kidney outcome than those in the other quartiles (p < .001). CONCLUSIONS The concomitant use of renin-angiotensin system inhibitors and diuretics, higher urine protein levels and pre-treatment GFR changes were associated with a larger initial GFR decline. Of these factors, the use of a diuretic had the largest effect. Furthermore, patients with CKD and T2DM experiencing an excessive initial GFR drop might be at a higher risk of adverse kidney outcomes.
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Affiliation(s)
- Tomohiko Kanaoka
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Hiromichi Wakui
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yuichiro Yano
- Non-communicable Disease Epidemiology Research Centre, Shiga University of Medical Science, Otsu, Japan
| | - Hajime Nagasu
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| | | | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Yosuke Hirakawa
- Division of Nephrology and Endocrinology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Naoki Nakagawa
- Division of Cardiology, Nephrology, Pulmonology and Neurology, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Jun Wada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | | | - Toshiaki Nakano
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takashi Wada
- Department of Nephrology and Rheumatology, Kanazawa University, Kanazawa, Japan
| | - Masaaki Konishi
- Department of Cardiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Takanori Nagahiro
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kunihiro Yamagata
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Motoko Yanagita
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoshio Terada
- Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi University, Kochi, Japan
| | - Shinichi Araki
- Department of Nephrology, Wakayama Medical School, Wakayama, Japan
| | - Masanori Emoto
- Metabolism, Endocrinology, and Molecular Medicine, Nephrology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Hirokazu Okada
- Department of Nephrology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | - Yoshitaka Isaka
- Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yusuke Suzuki
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, Tokyo, Japan
| | - Hiromi Kataoka
- Faculty of Health Science and Technology, Kawasaki University of Medical Welfare, Okayama, Japan
| | - Eiichiro Kanda
- Department of Medical Science, Kawasaki Medical School, Kurashiki, Japan
| | - Naoki Kashihara
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| | - Kouichi Tamura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Bansal N, Zelnick L, Scherzer R, Estrella M, Shlipak M. Risk Factors and Outcomes Associated With Heart Failure With Preserved and Reduced Ejection Fraction in People With Chronic Kidney Disease. Circ Heart Fail 2024; 17:e011173. [PMID: 38742428 PMCID: PMC11108746 DOI: 10.1161/circheartfailure.123.011173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 02/12/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Heart failure (HF) is associated with poor outcomes in people with chronic kidney disease, yet it is unknown whether outcomes differ by HF subtype. This study aimed to examine associations of incident HF with preserved ejection fraction (HFpEF) versus HF with reduced ejection fraction (HFrEF) with progression to end-stage kidney disease (ESKD) and mortality. METHODS We studied individuals with chronic kidney disease in the CRIC study (Chronic Renal Insufficiency Cohort) who were free of HF at cohort entry. Incident HF hospitalizations were adjudicated and classified into HFpEF (ejection fraction, ≥50%) or HFrEF (ejection fraction, <50%) based on echocardiograms performed during the hospitalization or at a research study visit. ESKD was defined as need for chronic dialysis or kidney transplant. Cox proportional hazards were used to evaluate the association of time-updated HF subtype with risk of ESKD and mortality, adjusting for demographics, comorbidities, and medication use. RESULTS Among the 3557 study participants without HF at cohort entry, mean age was 57 years and mean estimated glomerular filtration rate was 45 mL/min per 1.73 m2. A total of 682 participants had incident HF. Incidence rates for HFpEF and HFrEF were 0.9 (95% CI, 0.8-1.0) and 0.7 (95% CI, 0.6-0.8) per 100 person-years, respectively (Pdifference=0.005). Associations of incident HF with progression to ESKD were not statistically different for HFpEF (hazard ratio, 2.06 [95% CI, 1.66-2.56]) and HFrEF (hazard ratio, 1.80 [95% CI, 1.36-2.38]; P=0.42). The associations with mortality were stronger for HFrEF (hazard ratio, 2.73 [95% CI, 2.24-3.33]) compared with HFpEF (hazard ratio, 1.99 [95% CI, 1.65-2.40]; P=0.0002). CONCLUSIONS In a chronic kidney disease population, the rates of HFpEF hospitalizations were greater than that of HFrEF. Risk of ESKD was high but not statically different across HF subtypes. There was a stronger association of HFrEF with mortality. Prevention and treatment of both HFpEF and HFrEF should be central priorities to improve outcomes in chronic kidney disease.
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Affiliation(s)
- Nisha Bansal
- Division of Nephrology, University of Washington
| | | | - Rebecca Scherzer
- Kidney Health Research Collaborative, University of California, San Francisco
| | - Michelle Estrella
- Kidney Health Research Collaborative, University of California, San Francisco
| | - Michael Shlipak
- Kidney Health Research Collaborative, University of California, San Francisco
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Mc Causland FR, Claggett BL, Vaduganathan M, Desai A, Jhund P, Vardeny O, Fang JC, de Boer RA, Docherty KF, Hernandez AF, Inzucchi SE, Kosiborod MN, Lam CSP, Martinez F, Saraiva JFK, McGrath MM, Shah SJ, Verma S, Langkilde AM, Petersson M, McMurray JJV, Solomon SD. Decline in Estimated Glomerular Filtration Rate After Dapagliflozin in Heart Failure With Mildly Reduced or Preserved Ejection Fraction: A Prespecified Secondary Analysis of the DELIVER Randomized Clinical Trial. JAMA Cardiol 2024; 9:144-152. [PMID: 37952176 PMCID: PMC10641768 DOI: 10.1001/jamacardio.2023.4664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 10/20/2023] [Indexed: 11/14/2023]
Abstract
Importance An initial decline in estimated glomerular filtration rate (eGFR) is expected after initiating a sodium-glucose cotransporter-2 inhibitor (SGLT2i) and has been observed across patients with diabetes, chronic kidney disease, and heart failure. Objective To examine the implications of initial changes in eGFR among patients with heart failure with mildly reduced ejection fraction (HFmrEF) or preserved ejection fraction (HFpEF) enrolled in the Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure (DELIVER) trial. Design, Setting, and Participants This was a prespecified analysis of the results of the DELIVER randomized clinical trial, which was an international multicenter study of patients with EF greater than 40% and eGFR greater than or equal to 25. The DELIVER trial took place from August 2018 to March 2022. Data for the current prespecified study were analyzed from February to October 2023. Intervention Dapagliflozin, 10 mg per day, or placebo. Main Outcomes and Measures In this prespecified analysis, the frequency of an initial eGFR decline (baseline to month 1) was compared between dapagliflozin and placebo. Cox models adjusted for baseline eGFR and established prognostic factors were fit to estimate the association of an initial eGFR decline with cardiovascular (cardiovascular death or heart failure event) and kidney (≥50% eGFR decline, eGFR<15 or dialysis, death from kidney causes) outcomes, landmarked at month 1, stratified by diabetes. Results Study data from 5788 participants (mean [SD] age, 72 [10] years; 3253 male [56%]) were analyzed. The median (IQR) change in eGFR level from baseline to month 1 was -1 (-6 to 5) with placebo and -4 (-9 to 1) with dapagliflozin (difference, -3; P < .001). A higher proportion of patients assigned to dapagliflozin developed an initial eGFR decline greater than 10% vs placebo (1144 of 2892 [40%] vs 737 of 2896 [25%]; odds ratio, 1.9; 95% CI, 1.7-2.1; P difference <.001). An initial eGFR decline of greater than 10% (vs ≤10%) was associated with a higher risk of the primary cardiovascular outcome among those randomized to placebo (adjusted hazard ratio [aHR], 1.33; 95% CI, 1.10-1.62) but not among those randomized to dapagliflozin (aHR, 0.90; 95% CI, 0.74-1.09; P for interaction = .01). Similar associations were observed when alternative thresholds of initial eGFR decline were considered and when analyzed as a continuous measure. An initial eGFR decline of greater than 10% was not associated with adverse subsequent kidney composite outcomes in dapagliflozin-treated patients (aHR, 0.94; 95% CI, 0.49-1.82). Conclusions and Relevance Among patients with HFmrEF or HFpEF treated with dapagliflozin, an initial eGFR decline was frequent but not associated with subsequent risk of cardiovascular or kidney events. These data reinforce clinical guidance that SGLT2is should not be interrupted or discontinued in response to an initial eGFR decline. Trial Registration ClinicalTrials.gov Identifier: NCT03619213.
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Affiliation(s)
- Finnian R. Mc Causland
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Brian L. Claggett
- Harvard Medical School, Boston, Massachusetts
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Muthiah Vaduganathan
- Harvard Medical School, Boston, Massachusetts
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Akshay Desai
- Harvard Medical School, Boston, Massachusetts
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Pardeep Jhund
- British Heart Foundation Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, Scotland
| | - Orly Vardeny
- Minneapolis VA Center for Care Delivery and Outcomes Research, University of Minnesota, Minneapolis
| | - James C. Fang
- University of Utah School of Medicine, Salt Lake City
| | - Rudolf A. de Boer
- Erasmus MC, Cardiovascular Institute, Thorax Center, Department of Cardiology, Rotterdam, the Netherlands
| | - Kieran F. Docherty
- British Heart Foundation Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, Scotland
| | | | | | | | - Carolyn S. P. Lam
- National Heart Center Singapore and Duke–National University of Singapore, Singapore
| | | | - Jose F. Kerr Saraiva
- Cardiovascular Division, Instituto de Pesquisa Clínica de Campinas, Campinas, Brazil
| | - Martina M. McGrath
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Sanjiv J. Shah
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Anna Maria Langkilde
- Late-Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden
| | - Magnus Petersson
- Late-Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden
| | - John J. V. McMurray
- British Heart Foundation Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, Scotland
| | - Scott D. Solomon
- Harvard Medical School, Boston, Massachusetts
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Moady G, Ben Avraham B, Aviv S, Itzhaki Ben Zadok O, Atar S, Abu Akel M, Ben Gal T. The safety of sodium-glucose co-transporter 2 inhibitors in patients with left ventricular assist device - a single center experience. J Cardiovasc Med (Hagerstown) 2023; 24:765-770. [PMID: 37577871 DOI: 10.2459/jcm.0000000000001531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
AIMS Sodium-glucose co-transporter 2 (SGLT2) inhibitors are used increasingly for patients with heart failure or chronic kidney disease to improve cardiac and renal outcomes. The use of these medications in patients with left ventricular assist devices (LVAD) is still limited and lacks evidence regarding the safety profile. In this study, we aimed to report our experience in treating 20 patients, supported by LVAD, with SGLT2 inhibitors. METHODS We studied the safety profile of SGLT2 inhibitors (dapagliflozin and empagliflozin) in 20 patients (mean age 64.7 ± 12.2 years, 75% male) supported by LVAD as destination therapy. All patients have diabetes mellitus and were prescribed SGLT2 inhibitors for glycemic control. RESULTS SGLT2 inhibitors were well tolerated with no major adverse events. Few suction events were reported in three patients without the need for pump speed adjustment. There was no change in mean arterial pressure (71.1 ± 5.6 vs. 70.1 ± 4.8 mmHg, P = 0.063). Modest decline in renal function was observed in six patients within the first weeks after drug initiation. There were no events of diabetic ketoacidosis or limb amputation. CONCLUSION SGLT2 inhibitors are safe in patients with LVAD and may potentially improve cardiovascular and renal outcomes in this special population.
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Affiliation(s)
- Gassan Moady
- Department of Cardiology, Galilee Medical Center, Nahariya
- Azrieli Faculty of Medicine, Bar Ilan University, Safed
| | - Binyamin Ben Avraham
- Heart Failure Unit, Cardiology Department, Rabin Medical Center
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shaul Aviv
- Heart Failure Unit, Cardiology Department, Rabin Medical Center
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Osnat Itzhaki Ben Zadok
- Heart Failure Unit, Cardiology Department, Rabin Medical Center
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shaul Atar
- Department of Cardiology, Galilee Medical Center, Nahariya
- Azrieli Faculty of Medicine, Bar Ilan University, Safed
| | | | - Tuvia Ben Gal
- Heart Failure Unit, Cardiology Department, Rabin Medical Center
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Song J, Li X, Ni J. A Role for Sodium-Glucose Cotransporter 2 Inhibitors in the Treatment of Chronic Kidney Disease: A Mini Review. Kidney Blood Press Res 2023; 48:599-610. [PMID: 37717569 PMCID: PMC10614480 DOI: 10.1159/000534174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 09/14/2023] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND Sodium-glucose cotransport protein 2 (SGLT2) inhibitors, a new type of glucose-lowering drug, have been well proved in several clinical studies for their glucose-lowering and nephroprotective effects, and the nephroprotective effects include both indirect effects of metabolic improvement and direct effects, independent of glucose-lowering effects. SUMMARY In patients with diabetic kidney disease (DKD), several studies have demonstrated the potential nephroprotective mechanisms of SGLT2 inhibitors, and evidence of nephroprotective mechanisms in the non-DKD population is accumulating. Although the nephroprotective mechanism of SGLT2 inhibitors has not been fully elucidated, several laboratory studies have illustrated the mechanism underlying the effects of SGLT2 inhibitors at various aspects. KEY MESSAGES The purpose of this article is to review the mechanism of nephroprotective effect of SGLT2 inhibitors and to look forward to promising research in the future.
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Affiliation(s)
- Jinfang Song
- Department of Clinical Pharmacy, Affiliated Hospital of Jiangnan University, Wuxi, China
- Jiangsu Key Laboratory of New Drug Research and Clinical Pharmacy, Xuzhou Medical University, Xuzhou, China
| | - Xia Li
- Department of Clinical Pharmacy, Affiliated Hospital of Jiangnan University, Wuxi, China
- Wuxi School of Medicine, Jiangnan University, Jiangsu Province, Wuxi, China
| | - Jiang Ni
- Department of Clinical Pharmacy, Affiliated Hospital of Jiangnan University, Wuxi, China
- Wuxi School of Medicine, Jiangnan University, Jiangsu Province, Wuxi, China
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7
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Mukai J, Okamura N, Saito Y, Kubota R. A systematic review of sodium-glucose cotransporter 2 inhibitors and renal profiles among Japanese patients with type 2 diabetes mellitus. J Pharm Health Care Sci 2023; 9:36. [PMID: 37715226 PMCID: PMC10504754 DOI: 10.1186/s40780-023-00305-x] [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: 06/30/2023] [Accepted: 09/12/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND We conducted a systematic review and meta-analysis to summarize the available literature and comprehensively appraise the renal profiles of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in Japanese patients with type 2 diabetes mellitus (T2DM). METHODS The electronic databases MEDLINE, Ichushi-web, and ClinicalTrials.gov were searched for studies without language restrictions from their inception until 20 July 2023 and CENTRAL until 21 September 2021. Studies were included if they were double-masked randomized controlled trials (RCTs) (1) including Japanese patients with T2DM aged > 18 years who received SGLT2i or a placebo, (2) reporting at least one renal outcome of serum creatinine or the estimated glomerular filtration rate (eGFR), and (3) with a follow-up of > 12 weeks. Cross-over and open label trials were excluded. The risk of bias based on the Cochrane risk-of-bias tool for randomized trials (RoB 2) was appraised. We computed the weighed mean difference with 95%CI for each renal outcome and used a random-effects model (inverse variance method). RESULTS We ultimately retrieved 13 RCTs including 2687 individuals in our review. The durations of RCTs ranged between 12 and 104 weeks. Only one trial had a longer duration of more than one year. Ten out of 13 RCTs reported serum creatinine, while nine included eGFR. Serum creatinine and eGFR were slightly worse with SGLT2i than with a placebo [mean difference 0.01 (95%CI 0.00 to 0.02) mg/dL, p = 0.002, mean difference - 1.30 (95%CI -2.23 to -0.37) mL/min/1.73 m2, p = 0.006, respectively]. Merged results revealed insignificant heterogeneity (I2 < 30%). CONCLUSION These results suggest that SGLT2i slightly worsens serum creatinine and eGFR in Japanese patients with T2DM. However, since the durations of most RCTs were short, the effects of eGFR in particular may be transient. Further evidence is needed from rigorous studies that focus on renal outcomes with a longer duration to confirm the present results.
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Affiliation(s)
- Junichi Mukai
- Division of Clinical Pharmacy (Laboratory of Clinical Pharmacy Education) and Research and Education Center for Clinical Pharmacy, School of Pharmacy, Kitasato University, 5-9-1, Shirokane, Minato-ku, Tokyo, 108-8641, Japan.
| | - Nakaba Okamura
- Division of Clinical Pharmacy (Laboratory of Clinical Pharmacy Education) and Research and Education Center for Clinical Pharmacy, School of Pharmacy, Kitasato University, 5-9-1, Shirokane, Minato-ku, Tokyo, 108-8641, Japan
| | - Yuki Saito
- Division of Clinical Pharmacy (Laboratory of Clinical Pharmacy Education) and Research and Education Center for Clinical Pharmacy, School of Pharmacy, Kitasato University, 5-9-1, Shirokane, Minato-ku, Tokyo, 108-8641, Japan
| | - Rie Kubota
- Division of Clinical Pharmacy (Laboratory of Clinical Pharmacy Education) and Research and Education Center for Clinical Pharmacy, School of Pharmacy, Kitasato University, 5-9-1, Shirokane, Minato-ku, Tokyo, 108-8641, Japan
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8
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Xie Y, Bowe B, Xian H, Loux T, McGill JB, Al-Aly Z. Comparative effectiveness of SGLT2 inhibitors, GLP-1 receptor agonists, DPP-4 inhibitors, and sulfonylureas on risk of major adverse cardiovascular events: emulation of a randomised target trial using electronic health records. Lancet Diabetes Endocrinol 2023; 11:644-656. [PMID: 37499675 DOI: 10.1016/s2213-8587(23)00171-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 05/15/2023] [Accepted: 05/15/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Randomised clinical trials showed that compared with placebo, SGLT2 inhibitors and GLP-1 receptor agonists reduced risk of adverse cardiovascular events. The evidence base for the older antihyperglycaemic drug classes (DPP-4 inhibitors and sulfonylureas) is generally less well developed. Because most randomised trials evaluated one antihyperglycaemic medication versus placebo, a head-to-head comparative effectiveness analysis of the newer drug classes (SGLT2 inhibitors vs GLP-1 receptor agonists) or newer (SGLT2 inhibitors or GLP-1 receptor agonists) versus older (DPP-4 inhibitors or sulfonylureas) drug classes on risk of major adverse cardiovascular events (MACE) is not available. In this study, we aimed to evaluate the comparative effectiveness of incident use of SGLT2 inhibitors, GLP-1 receptor agonists, DPP-4 inhibitors, or sulfonylureas on risk of MACE. METHODS We first specified the protocol of a four-arm randomised pragmatic clinical trial and then emulated it using the health-care databases of the US Department of Veterans Affairs. We built a cohort of metformin users with incident use of SGLT2 inhibitors, GLP-1 receptor agonists, DPP-4 inhibitors, or sulfonylureas between Oct 1, 2016 and Sept 30, 2021, and followed up until Dec 31, 2022. We used the overlap weighting approach to balance the treatment groups using a battery of predefined variables and a set of algorithmically selected variables from high-dimensional data domains. Both intention-to-treat and per-protocol analyses (the latter estimated the effect of maintained use of the antihyperglycaemic throughout follow-up) were conducted to estimate risk of MACE-defined as a composite endpoint of stroke, myocardial infarction, and all-cause mortality. FINDINGS The final cohort consisted of 283 998 new users of SGLT2 inhibitors (n=46 516), GLP-1 receptor agonists (n=26 038), DPP-4 inhibitors (n=55 310), or sulfonylureas (n=156 134). In intention-to-treat analyses, compared with sulfonylureas, SGLT2 inhibitors, GLP-1 receptor agonists, and DPP-4 inhibitors were associated with lower risk of MACE (hazard ratio [HR] 0·77 [95% CI 0·74-0.80], 0·78 [0·74-0·81), and 0·90 [0·86-0.93], respectively). Both SGLT2 inhibitors and GLP-1 receptor agonists were associated with a lower risk of MACE when compared with DPP-4 inhibitors (HR 0·86 [0·82-0·89] and 0·86 [0·82-0·90], respectively). The risk of MACE between SGLT2 inhibitors and GLP-1 receptor agonists yielded an HR of 0·99 (0·94-1·04). In per-protocol analyses, compared with sulfonylureas, SGLT2 inhibitors, GLP1 receptor agonists, and DPP-4 inhibitors were associated with reduced risk of MACE (HR 0·77 [95% CI 0·73-0·82], 0·77 [0·72-0·82], and 0·88 [0·83-0·93], respectively). Both SGLT2 inhibitors and GLP-1 receptor agonists were associated with a lower risk of MACE when compared with DPP-4 inhibitors (HR 0·88 [0·83-0·93] and 0·88 [0·82-0·93], respectively). The risk of MACE between SGLT2 inhibitors and GLP-1 receptor agonists yielded an HR of 1·01 (0·94-1·07). INTERPRETATION Both SGLT2 inhibitors and GLP-1 receptor agonists were associated with reduced risk of MACE compared with DPP-4 inhibitors or sulfonylureas. DPP-4 inhibitors were associated with reduced risk of MACE compared with sulfonylureas. There was no statistically significant difference in risk of MACE between SGLT2 inhibitors and GLP-1 receptor agonists. The results provide evidence of the real-world comparative effectiveness of the four most commonly used second-line antihyperglycaemics and could guide choice of antihyperglycaemic therapy. FUNDING US Department of Veterans Affairs and the American Society of Nephrology.
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Affiliation(s)
- Yan Xie
- Clinical Epidemiology Center, Research and Development Service, VA Saint Louis Health Care System, Saint Louis, MO, USA; Division of Pharmacoepidemiology, Clinical Epidemiology Center, VA Saint Louis Health Care System, Saint Louis, MO, USA; Veterans Research and Education Foundation of Saint Louis, Saint Louis, MO, USA; Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, Saint Louis, MO, USA
| | - Benjamin Bowe
- Clinical Epidemiology Center, Research and Development Service, VA Saint Louis Health Care System, Saint Louis, MO, USA; Veterans Research and Education Foundation of Saint Louis, Saint Louis, MO, USA
| | - Hong Xian
- Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, Saint Louis, MO, USA
| | - Travis Loux
- Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, Saint Louis, MO, USA
| | - Janet B McGill
- Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Ziyad Al-Aly
- Clinical Epidemiology Center, Research and Development Service, VA Saint Louis Health Care System, Saint Louis, MO, USA; Veterans Research and Education Foundation of Saint Louis, Saint Louis, MO, USA; Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA; Nephrology Section, Medicine Service, VA Saint Louis Health Care System, Saint Louis, MO, USA; Institute for Public Health, Washington University in Saint Louis, Saint Louis, MO, USA.
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9
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Xu E, Xie Y, Al-Aly Z. Risks and burdens of incident dyslipidaemia in long COVID: a cohort study. Lancet Diabetes Endocrinol 2023; 11:120-128. [PMID: 36623520 PMCID: PMC9873268 DOI: 10.1016/s2213-8587(22)00355-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/14/2022] [Accepted: 11/25/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Non-clinical evidence and a few human studies with short follow-ups suggest increased risk of dyslipidaemia in the post-acute phase of COVID-19 (ie, >30 days after SARS-CoV-2 infection). However, detailed large-scale controlled studies with longer follow-ups and in-depth assessment of the risks and burdens of incident dyslipidaemia in the post-acute phase of COVID-19 are not yet available. We, therefore, aimed to examine the risks and 1-year burdens of incident dyslipidaemia in the post-acute phase of COVID-19 among people who survive the first 30 days of SARS-CoV-2 infection. METHODS In this cohort study, we used the national health-care databases of the US Department of Veterans Affairs to build a cohort of 51 919 participants who had a positive COVID-19 test and survived the first 30 days of infection between March 1, 2020, and Jan 15, 2021; a non-infected contemporary control group (n=2 647 654) that enrolled patients between March 1, 2020, and Jan 15, 2021; and a historical control group (n=2 539 941) that enrolled patients between March 1, 2018, and Jan 15, 2019. Control groups had no evidence of SARS-CoV-2 infection, and participants in all three cohorts were free of dyslipidaemia before cohort enrolment. We then used inverse probability weighting using predefined and algorithmically-selected high dimensional variables to estimate the risks and 1-year burdens of incident dyslipidaemia, lipid-lowering medications use, and a composite of these outcomes. We reported two measures of risk: hazard ratios (HRs) and burden per 1000 people at 12 months. Additionally, we estimated the risks and burdens of incident dyslipidaemia outcomes in mutually exclusive groups based on the care setting of the acute infection (ie, participants who were non-hospitalised, hospitalised, or admitted to intensive care during the acute phase of SARS-CoV-2 infection). FINDINGS In the post-acute phase of the SARS-CoV-2 infection, compared with the non-infected contemporary control group, those in the COVID-19 group had higher risks and burdens of incident dyslipidaemia, including total cholesterol greater than 200 mg/dL (hazard ratio [HR] 1·26, 95% CI 1·22-1·29; burden 22·46, 95% CI 19·14-25·87 per 1000 people at 1 year), triglycerides greater than 150 mg/dL (1·27, 1·23-1·31; 22·03, 18·85-25·30), LDL cholesterol greater than 130 mg/dL (1·24, 1·20-1·29; 18·00, 14·98-21·11), and HDL cholesterol lower than 40 mg/dL (1·20, 1·16-1·25; 15·58, 12·52-18·73). The risk and burden of a composite of these abnormal lipid laboratory outcomes were 1·24 (95% CI 1·21-1·27) and 39·19 (95% CI 34·71-43·73), respectively. There was also increased risk and burden of incident lipid-lowering medications use (HR 1·54, 95% CI 1·48-1·61; burden 25·50, 95% CI 22·61-28·50). A composite of any dyslipidaemia outcome (laboratory abnormality or lipid-lowering medications use) yielded an HR of 1·31 (95% CI 1·28-1·34) and a burden of 54·03 (95% CI 49·21-58·92). The risks and burdens of these post-acute outcomes increased in a graded fashion corresponding to the severity of the acute phase of COVID-19 infection (ie, whether patients were non-hospitalised, hospitalised, or admitted to intensive care). The results were consistent in analyses comparing the COVID-19 group to the non-infected historical control group. INTERPRETATION Our findings suggest increased risks and 1-year burdens of incident dyslipidaemia and incident lipid-lowering medications use in the post-acute phase of COVID-19 infection. Post-acute care for those with COVID-19 should involve attention to dyslipidaemia as a potential post-acute sequela of SARS-CoV-2 infection. FUNDING US Department of Veterans Affairs.
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Affiliation(s)
- Evan Xu
- Clinical Epidemiology Center, Research and Development Service, VA Saint Louis Health Care System, Saint Louis, MO, USA; Veterans Research and Education Foundation of Saint Louis, Saint Louis, MO, USA
| | - Yan Xie
- Clinical Epidemiology Center, Research and Development Service, VA Saint Louis Health Care System, Saint Louis, MO, USA; Veterans Research and Education Foundation of Saint Louis, Saint Louis, MO, USA
| | - Ziyad Al-Aly
- Clinical Epidemiology Center, Research and Development Service, VA Saint Louis Health Care System, Saint Louis, MO, USA; Nephrology Section, Medicine Service, VA Saint Louis Health Care System, Saint Louis, MO, USA; Veterans Research and Education Foundation of Saint Louis, Saint Louis, MO, USA; Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA; Institute for Public Health, Washington University in Saint Louis, Saint Louis, MO, USA.
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Gohda T, Murakoshi M. Sodium-Glucose Cotransporter-2 Inhibitors-Miracle Drugs for the Treatment of Chronic Kidney Disease Irrespective of the Diabetes Status: Lessons from the Dedicated Kidney Disease-Focused CREDENCE and DAPA-CKD Trials. Int J Mol Sci 2022; 23:ijms232213749. [PMID: 36430228 PMCID: PMC9696577 DOI: 10.3390/ijms232213749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/04/2022] [Accepted: 11/07/2022] [Indexed: 11/11/2022] Open
Abstract
Diabetic kidney disease (DKD) is the leading cause of chronic kidney disease (CKD) and end-stage kidney disease worldwide. In Japan, the proportion of new patients requiring dialysis due to DKD has remained unchanged over the past five years. Early diagnosis and treatment are extremely important for the prevention of DKD progression. Albuminuria is the most promising biomarker currently available for diagnosing DKD and predicting its prognosis at an early stage; however, it has relatively poor specificity and sensitivity for DKD. Measuring the serum levels of tumor necrosis factor receptors (TNFRs; TNFR1 and TNFR2) is an alternative for predicting the prognosis of patients with CKD, irrespective of their diabetes status. Cardiorenal risk factor management and renin-angiotensin system inhibitor usage are effective in slowing the DKD progression, although the residual risk remains high in patients with DKD. Recently, two classes of antihyperglycemic agents, sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists, in addition to nonsteroidal selective mineralocorticoid receptor antagonists, which are less potent blood pressure-lowering and potassium-sparing agents, have emerged as cardiorenal disease-modifying therapies for preventing the DKD progression. This review focused on the SGLT2 inhibitor-based therapeutic strategies that have demonstrated cardiorenal benefits in patients with type 2 diabetes.
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Shikuma J, Sakakura K, Sugiyama-Takahashi M, Nakamura Y, Nagai Y, Suwanai H, Ito R, Miwa T, Suzuki R. Hematocrit elevation after SGLT2 inhibitor administration may be associated with the degree of proximal tubular damage. Medicine (Baltimore) 2022; 101:e31122. [PMID: 36281104 PMCID: PMC9592340 DOI: 10.1097/md.0000000000031122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The renal protective effects of SGLT2 inhibitors are known to be due to the elimination of glomerular hypertension and improvement of hypoxia and oxidative stress in the proximal tubule. Therefore, this increased hematocrit (ΔHct) level has been hypothesized to indicate restored tubular function and improved renal prognosis. To analyze the relationship between ΔHct and decreased estimated glomerular filtration rate (eGFR) after SGLT2 inhibitor administration backward from medical record data. Data from 206 patients who continued SGLT2 inhibitors for >3 years were analyzed. The decreased eGFR after administration of SGLT2 inhibitors was defined as Slope B. Factors statistically significantly associated with Slope B in multiple regression analysis were systolic blood pressure (sBP) (β -.211, P = .03), short-term decreased eGFR after SGLT2 inhibitor administration (initial dip) (β -.235, P = .003), ΔHct (β -.185, P = .026), and urine protein (β -.204, P = .015). These findings were the opposite of our hypothesis. ΔHct was not a marker indicating improved renal prognosis and may reflect the extent of the proximal tubular disorder before administering SGLT2 inhibitors.
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Affiliation(s)
- Jumpei Shikuma
- Department of Diabetes, Metabolism and Endocrinology, Tokyo Medical University, Nishishinjuku Shinjuku-ku, Tokyo, Japan
- *Correspondence: Jumpei Shikuma, Department of Diabetes, Metabolism and Endocrinology, Tokyo Medical University, 6-7-1 Nishishinjuku Shinjuku-ku, Tokyo 160-0023, Japan (e-mail: ) and Ryo Suzuki, Department of Diabetes, Metabolism and Endocrinology, Tokyo Medical University, 6-7-1 Nishishinjuku Shinjuku-ku, Tokyo 160-0023, Japan (e-mail: )
| | - Keiichi Sakakura
- Department of Pharmacy, Tokyo Medical University Hospital, Nishishinjuku Shinjuku-ku, Tokyo, Japan
| | - Miyu Sugiyama-Takahashi
- Department of Pharmacy, Tokyo Medical University Hospital, Nishishinjuku Shinjuku-ku, Tokyo, Japan
| | - Yukiko Nakamura
- Department of Diabetes, Metabolism and Endocrinology, Tokyo Medical University, Nishishinjuku Shinjuku-ku, Tokyo, Japan
| | - Yoshiyuki Nagai
- Department of Diabetes, Metabolism and Endocrinology, Tokyo Medical University, Nishishinjuku Shinjuku-ku, Tokyo, Japan
| | - Hirotsugu Suwanai
- Department of Diabetes, Metabolism and Endocrinology, Tokyo Medical University, Nishishinjuku Shinjuku-ku, Tokyo, Japan
| | - Rokuro Ito
- Department of Diabetes, Metabolism and Endocrinology, Tokyo Medical University, Nishishinjuku Shinjuku-ku, Tokyo, Japan
| | - Takashi Miwa
- Department of Diabetes, Metabolism and Endocrinology, Tokyo Medical University, Nishishinjuku Shinjuku-ku, Tokyo, Japan
| | - Ryo Suzuki
- Department of Diabetes, Metabolism and Endocrinology, Tokyo Medical University, Nishishinjuku Shinjuku-ku, Tokyo, Japan
- *Correspondence: Jumpei Shikuma, Department of Diabetes, Metabolism and Endocrinology, Tokyo Medical University, 6-7-1 Nishishinjuku Shinjuku-ku, Tokyo 160-0023, Japan (e-mail: ) and Ryo Suzuki, Department of Diabetes, Metabolism and Endocrinology, Tokyo Medical University, 6-7-1 Nishishinjuku Shinjuku-ku, Tokyo 160-0023, Japan (e-mail: )
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12
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Jabbour SA, Ibrahim NE, Argyropoulos CP. Physicians' Considerations and Practice Recommendations Regarding the Use of Sodium-Glucose Cotransporter-2 Inhibitors. J Clin Med 2022; 11:6051. [PMID: 36294370 PMCID: PMC9604628 DOI: 10.3390/jcm11206051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 10/07/2022] [Accepted: 10/10/2022] [Indexed: 11/16/2022] Open
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT-2is) (canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin), although initially developed as glucose-lowering drugs, provide significant beneficial effects on cardiorenal outcomes, including heart failure, regardless of type 2 diabetes status. Integration of SGLT-2is into clinical practice requires practical guidance for physicians about their use. To overcome physicians' clinical inertia for SGLT-2i use, including addressing safety, potentially a barrier to their use, a roundtable discussion with physicians from three specialties (cardiology, endocrinology, and nephrology) was conducted. This review summarizes the physicians' clinical experience and recommendations about SGLT-2i use across different patient populations, taking into consideration the beneficial effects of SGLT-2is and their safety. The key aspects discussed regarding SGLT-2i safety include acute effects on kidney function (estimated glomerular filtration rate acute dip upon SGLT-2i initiation and acute kidney injury), volume depletion, diabetic ketoacidosis, genitourinary infections, hyperkalemia, and hypoglycemia. To mitigate any potential risks related to SGLT-2i safety, physicians can make minor adjustments to an individual patient's treatment plan, while retaining the SGLT-2i cardiorenal benefits for effective disease management. Recognition by physicians that the benefits of SGLT-2i use on clinical outcomes outweigh the risks will result in the integration of SGLT-2is into clinical practice and lead to improved patient care and outcomes.
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Affiliation(s)
- Serge A. Jabbour
- Division of Endocrinology, Diabetes & Metabolic Diseases, Sidney Kimmel Medical College, Thomas Jefferson University, 211 S Ninth Street, Suite 600, Philadelphia, PA 19107, USA
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Harrington J, Petrie MC, Anker SD, Bhatt DL, Jones SW, Udell JA, Hernandez AF, Butler J. Evaluating the Application of Chronic Heart Failure Therapies and Developing Treatments in Individuals With Recent Myocardial Infarction: A Review. JAMA Cardiol 2022; 7:1067-1075. [PMID: 36044233 DOI: 10.1001/jamacardio.2022.2847] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Despite advances in cardiac care, patients remain at a high risk of death and the development of heart failure (HF) following myocardial infarction (MI). These risks are highest in patients with reduced ejection fraction (EF) or signs of HF immediately after MI. Drugs to mitigate these risks have been identified through the systematic evaluation of therapies with proven efficacy in patients with HF and reduced EF (HFrEF). Observations Although landmark studies in patients with HFrEF consistently exclude patients with recent MI, dedicated post-MI trials of these drugs have led to multiple therapies with proven benefit in these patients. However, not all therapies with proven efficacy in patients with chronic HF have been shown to provide benefit in the post-MI population, as recently evidenced by the discrepant results between chronic HF and post-MI trials of sacubitril-valsartan. Similarly, multiple trials of early and aggressive use of therapies effective in chronic heart failure immediately post-MI failed to demonstrate benefit or were associated with harm, emphasizing the vulnerability of the post-MI population. Conclusions and Relevance Trials of patients at high risk of HF following MI have emphasized the differences between the post-MI and HFrEF populations and the necessity for dedicated trials in the post-MI population. This review summarizes trials studying the use of these therapies for at-risk patients following MI from therapies used in patients with HFrEF and exploring new potential therapies for this high-risk population.
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Affiliation(s)
- Josephine Harrington
- Department of Medicine, Division of Cardiology, Duke University, Durham, North Carolina.,Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Mark C Petrie
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Stefan D Anker
- Department of Cardiology, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany.,Institute of Heart Disease, Wroclaw Medical University, Wroclaw, Poland.,Berlin Institute of Health Center for Regenerative Therapies, Charité Universitätsmedizin Berlin, Berlin, Germany.,German Centre for Cardiovascular Research partner site Berlin, Berlin, Germany
| | - Deepak L Bhatt
- Heart and Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Schuyler W Jones
- Department of Medicine, Division of Cardiology, Duke University, Durham, North Carolina.,Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Jacob A Udell
- Women's College Hospital and Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Adrian F Hernandez
- Department of Medicine, Division of Cardiology, Duke University, Durham, North Carolina.,Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas.,Department of Medicine, University of Mississippi, Jackson
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Chan YH, Chao TF, Chen SW, Kao YW, Huang CY, Chu PH. Association of acute increases in serum creatinine with subsequent outcomes in patients with type 2 diabetes mellitus treated with sodium-glucose cotransporter 2 inhibitor or dipeptidyl peptidase-4 inhibitor. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2022:qcac040. [PMID: 35797996 DOI: 10.1093/ehjqcco/qcac040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
AIMS The frequency of an acute increase in serum creatinine (sCr) of >30%, following treatment of sodium-glucose cotransporter-2 inhibitors (SGLT2i) and its clinical implications in patients with type 2 diabetes remains unclear. METHODS AND RESULTS We used medical data from a multicenter health care provider in Taiwan and recruited 11,657 and 8,117 diabetic patients with baseline/follow-up sCr data available within 12 weeks of SGLT2i and dipeptidyl peptidase-4 inhibitor (DPP4i) treatment from June 1, 2016, to December 31, 2018. Participants receiving SGLT2i or DPP4i were categorized by initial sCr change into three groups:>30% sCr increase, 0-30% increase, or no-sCr increase. Participants receiving SGLT2i was associated with a higher proportion of sCr increase of 0-30% (52.7% vs. 42.6%) but a lower proportion of sCr increase of >30% (5.9% vs. 9.6%) when compared with DPP4i. In contrast to DPP4i, the mean estimated glomerular filtration rate over time became stable after 24 weeks in three categories of sCr increase following SGLT2i initiation. Compared with no sCr increase, an initial sCr increase of >30% was associated with a higher risk of major adverse cardiovascular events (adjusted hazard ratio [aHR]:2.91, [95% confidence interval [CI]:1.37-6.17]), heart failure hospitalization (HHF) (aHR:1.91,[95%CI:1.08-3.40]), and composite renal outcome (aHR:1.53,[95%CI:1.05-2.25]) in SGLT2i group; an initial sCr increase of >30% associated with a higher risk of HHF and composite renal outcome in DPP4i group after multivariate adjustment. Overall, participants receiving SGLT2i was associated with a lower risk of HHF (aHR:0.64,[95%CI:0.48-0.85]) and composite renal outcomes (aHR:0.40,[95%CI:0.34-0.48]) compared with DPP4i after multivariate adjustment, and the treatment benefit was persistent across three categories of sCr increase (P interaction>.05). CONCLUSIONS A modest increase in serum creatinine (<30%) was common following SGLT2i initiation, and was not associated with worse clinical outcomes, therefore should not stop therapy prematurely, but a larger increase in creatinine following drug therapy was not typical and should raise concern and review of the patient.
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Affiliation(s)
- Yi-Hsin Chan
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- School of Traditional Chinese Medicine, College of Medicine, Chang-Gung University, Taoyuan City 33302, Taiwan
- Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taiwan
- Institute of Clinical Medicine, Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shao-Wei Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yi-Wei Kao
- Graduate Institute of Business Administration, College of Management, Fu Jen Catholic University, Taipei, Taiwan
| | - Chien-Ying Huang
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Pao-Hsien Chu
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
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15
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Xie Y, Al-Aly Z. Risks and burdens of incident diabetes in long COVID: a cohort study. Lancet Diabetes Endocrinol 2022; 10:311-321. [PMID: 35325624 PMCID: PMC8937253 DOI: 10.1016/s2213-8587(22)00044-4] [Citation(s) in RCA: 262] [Impact Index Per Article: 131.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 01/07/2022] [Accepted: 01/28/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND There is growing evidence suggesting that beyond the acute phase of SARS-CoV-2 infection, people with COVID-19 could experience a wide range of post-acute sequelae, including diabetes. However, the risks and burdens of diabetes in the post-acute phase of the disease have not yet been comprehensively characterised. To address this knowledge gap, we aimed to examine the post-acute risk and burden of incident diabetes in people who survived the first 30 days of SARS-CoV-2 infection. METHODS In this cohort study, we used the national databases of the US Department of Veterans Affairs to build a cohort of 181 280 participants who had a positive COVID-19 test between March 1, 2020, and Sept 30, 2021, and survived the first 30 days of COVID-19; a contemporary control (n=4 118 441) that enrolled participants between March 1, 2020, and Sept 30, 2021; and a historical control (n=4 286 911) that enrolled participants between March 1, 2018, and Sept 30, 2019. Both control groups had no evidence of SARS-CoV-2 infection. Participants in all three comparison groups were free of diabetes before cohort entry and were followed up for a median of 352 days (IQR 245-406). We used inverse probability weighted survival analyses, including predefined and algorithmically selected high dimensional variables, to estimate post-acute COVID-19 risks of incident diabetes, antihyperglycaemic use, and a composite of the two outcomes. We reported two measures of risk: hazard ratio (HR) and burden per 1000 people at 12 months. FINDINGS In the post-acute phase of the disease, compared with the contemporary control group, people with COVID-19 exhibited an increased risk (HR 1·40, 95% CI 1·36-1·44) and excess burden (13·46, 95% CI 12·11-14·84, per 1000 people at 12 months) of incident diabetes; and an increased risk (1·85, 1·78-1·92) and excess burden (12·35, 11·36-13·38) of incident antihyperglycaemic use. Additionally, analyses to estimate the risk of a composite endpoint of incident diabetes or antihyperglycaemic use yielded a HR of 1·46 (95% CI 1·43-1·50) and an excess burden of 18·03 (95% CI 16·59-19·51) per 1000 people at 12 months. Risks and burdens of post-acute outcomes increased in a graded fashion according to the severity of the acute phase of COVID-19 (whether patients were non-hospitalised, hospitalised, or admitted to intensive care). All the results were consistent in analyses using the historical control as the reference category. INTERPRETATION In the post-acute phase, we report increased risks and 12-month burdens of incident diabetes and antihyperglycaemic use in people with COVID-19 compared with a contemporary control group of people who were enrolled during the same period and had not contracted SARS-CoV-2, and a historical control group from a pre-pandemic era. Post-acute COVID-19 care should involve identification and management of diabetes. FUNDING US Department of Veterans Affairs and the American Society of Nephrology.
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Affiliation(s)
- Yan Xie
- Clinical Epidemiology Center, Research and Development Service, VA Saint Louis Health Care System, Saint Louis, MO, USA; Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, Saint Louis, MO, USA; Veterans Research and Education Foundation of Saint Louis, Saint Louis, MO, USA
| | - Ziyad Al-Aly
- Clinical Epidemiology Center, Research and Development Service, VA Saint Louis Health Care System, Saint Louis, MO, USA; Nephrology Section, Medicine Service, VA Saint Louis Health Care System, Saint Louis, MO, USA; Veterans Research and Education Foundation of Saint Louis, Saint Louis, MO, USA; Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA; Institute for Public Health, Washington University in Saint Louis, Saint Louis, MO, USA.
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Somaili M, Oraibi O, Mohrag M, Hommadi A, Moafa E, Kulaybi A, Shobayli S, Moafa R, Mhgfory G, Jaafari A, Shami A, Majrashi K. Baseline Characteristics Associated With Sodium-Glucose Cotransporter Inhibitor Prescriptions in Type 2 Diabetic Patients in Jazan, Saudi Arabia. Cureus 2022; 14:e24284. [PMID: 35602773 PMCID: PMC9119415 DOI: 10.7759/cureus.24284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2022] [Indexed: 12/24/2022] Open
Abstract
Background: Sodium-glucose cotransporter inhibitors are promising medications for improving cardiovascular outcomes in diabetic and non-diabetic patients. The baseline characteristics associated with its prescription in Jazan, Saudi Arabia, are still lacking. Objectives: This study aims to determine the baseline characteristics associated with its prescription among type 2 diabetic patients in the Jazan region. Methods: A retrospective cohort study of adult patients with type 2 diabetes mellitus (T2DM) in Jazan region, Saudi Arabia, who received a prescription of sodium-glucose cotransporter 2 inhibitors (SGLT2i) from June 2016 to December 2021 was conducted. Categorical baseline characteristics are reported as frequencies, and proportion and continuous variables are reported as means (SD). The crude odds and adjusted ratio (OR) (95% CI) for SGLT2i prescription were then calculated using univariate and multivariate logistic regression analysis. Results: A total of 370 patients who satisfied the inclusion criteria were included in this study. There were 133 patients (36%) who had been prescribed SGLT2i over a median follow-up of five years. Characteristics associated with the prescription were female gender (adjusted odds ratio [aOR]: 2.2, 95% Cl: 1.3-3.9), endocrinologist doctors (aOR: 2.4, 95% Cl: 1.3-4.5), patients who had visited the center four times or more (aOR: 10.9, 95% Cl: 4.6-25.9), patients who have evidence of DM retinopathy (aOR: 9.7, 95% Cl: 2.9-31.7), or patients who are morbidly obese (aOR: 4.1, 95% Cl: 1.1-14.8). Conclusion: The sodium-glucose cotransporter inhibitors are under-prescribed among type 2 diabetic patients in the Jazan region despite their availability. Further studies are warranted to address the potential barriers to prescriptions among different medical specialties.
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Giaccari A, Pontremoli R, Perrone Filardi P. SGLT-2 inhibitors for treatment of heart failure in patients with and without type 2 diabetes: A practical approach for routine clinical practice. Int J Cardiol 2022; 351:66-70. [PMID: 34979145 DOI: 10.1016/j.ijcard.2021.12.050] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 12/23/2021] [Accepted: 12/28/2021] [Indexed: 12/14/2022]
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT-2i), initially studied and approved for the treatment of diabetes, are now becoming a promising class of agents to treat heart failure (HF) and chronic kidney disease (CKD), even in patients without diabetes. While the potential benefits in several diseases (usually treated by different medical specialties) is amplifying the interest in these drugs, their use in frail patients with multiple pathologies and on polypharmacy can be complex, requiring a composite multidisciplinary approach. Following a brief overview of the evidence supporting the benefits of SGLT-2i in patients with HF or CKD, we herein provide guidance for prescribing SGLT-2i in daily practice using a multidisciplinary approach. A shared treatment algorithm is presented for initiating an SGLT-2i in patients already being treated for diabetes and HF. Tools to prevent hypoglycemia, blood pressure drop, genital infections, euglycemic diabetic ketoacidosis and eGFR dip are also provided. It is hoped that this practical, multidisciplinary guidance for initiating SGLT-2i in patients with HF and/or CKD, whatever therapy they are currently on, can help to offer SGLT-2i to the largest population of patients possible to provide the most therapeutic benefit.
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Affiliation(s)
- Andrea Giaccari
- Center for Endocrine and Metabolic Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS and Università Cattolica del Sacro Cuore, Rome, Italy
| | - Roberto Pontremoli
- University of Genoa and IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
| | - Pasquale Perrone Filardi
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy, Mediterranea Cardiocentro, Naples, Italy
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Fadini GP, Del Prato S, Avogaro A, Solini A. Challenges and opportunities in real-world evidence on the renal effects of sodium-glucose cotransporter-2 inhibitors. Diabetes Obes Metab 2022; 24:177-186. [PMID: 34747123 PMCID: PMC9298781 DOI: 10.1111/dom.14599] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/27/2021] [Accepted: 11/04/2021] [Indexed: 12/25/2022]
Abstract
With increasing population aging and prevalence of type 2 diabetes (T2D) worldwide, prevention of diabetic complications remains a major unmet need. While cardiovascular outcomes of diabetes are improving over time, diabetic kidney disease (DKD) still leads to an exceedingly high rate of end-stage kidney disease (ESKD). A game-changing opportunity is offered by treatment with sodium-glucose cotransporter-2 (SGLT2) inhibitors. Randomized controlled trials (RCTs) have indisputably shown that SGLT2 inhibitors reduce the rate of DKD progression, the decline in estimated glomerular filtration rate (eGFR), and the development of ESKD. In parallel, SGLT2 inhibitors improve cardiovascular outcomes, especially the risk of hospitalization for heart failure. Real-world studies (RWSs) have largely confirmed the findings of RCTs in broader populations of subjects with T2D followed under routine care. In the present paper, we review RWSs exploring the renal effects of SGLT2 inhibitors and highlight the most critical challenges that can be encountered in designing and conducting such studies. Channelling bias (confounding by indication), time-lag bias, conditioning on the future, database heterogeneity, linearity of eGFR change over time, and duration of observation are critical issues that may undermine the robustness of RWS findings. We then elaborate on the new opportunities to overcome such limitations by describing the design and objectives of the DARWIN (DApagliflozin Real-World evIdeNce)-Renal study, a new RWS promoted by the Italian Diabetes Society. Fine-tuning of methods for comparative observational research will improve evidence derived from RWSs on the renal effects of SGLT2 inhibitors, aiding the evolving discussion regarding the place of SGLT2 inhibitors in T2D treatment algorithms in different stages of DKD.
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Affiliation(s)
| | - Stefano Del Prato
- Department of Clinical and Experimental Medicine, Section of Metabolic Diseases and DiabetesUniversity of PisaPisaItaly
| | | | - Anna Solini
- Department of Surgical, Medical, Molecular and Critical Area PathologyUniversity of PisaPisaItaly
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19
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Xie Y, Bowe B, Al-Aly Z. Burdens of post-acute sequelae of COVID-19 by severity of acute infection, demographics and health status. Nat Commun 2021; 12:6571. [PMID: 34772922 PMCID: PMC8589966 DOI: 10.1038/s41467-021-26513-3] [Citation(s) in RCA: 184] [Impact Index Per Article: 61.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 10/12/2021] [Indexed: 01/30/2023] Open
Abstract
The Post-Acute Sequelae of SARS-CoV-2 infection (PASC) have been characterized; however, the burden of PASC remains unknown. Here we used the healthcare databases of the US Department of Veterans Affairs to build a cohort of 181,384 people with COVID-19 and 4,397,509 non-infected controls and estimated that burden of PASC-defined as the presence of at least one sequela in excess of non-infected controls-was 73.43 (72.10, 74.72) per 1000 persons at 6 months. Burdens of individual sequelae varied by demographic groups (age, race, and sex) but were consistently higher in people with poorer baseline health and in those with more severe acute infection. In sum, the burden of PASC is substantial; PASC is non-monolithic with sequelae that are differentially expressed in various population groups. Collectively, our results may be useful in informing health systems capacity planning and care strategies of people with PASC.
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Affiliation(s)
- Yan Xie
- Clinical Epidemiology Center, Research and Development Service, VA Saint Louis Health Care System, Saint Louis, MO, USA
- Veterans Research and Education Foundation of Saint Louis, Saint Louis, MO, USA
- Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, Saint Louis, MO, USA
| | - Benjamin Bowe
- Clinical Epidemiology Center, Research and Development Service, VA Saint Louis Health Care System, Saint Louis, MO, USA
- Veterans Research and Education Foundation of Saint Louis, Saint Louis, MO, USA
- Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, Saint Louis, MO, USA
| | - Ziyad Al-Aly
- Clinical Epidemiology Center, Research and Development Service, VA Saint Louis Health Care System, Saint Louis, MO, USA.
- Veterans Research and Education Foundation of Saint Louis, Saint Louis, MO, USA.
- Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA.
- Institute for Public Health, Washington University in Saint Louis, Saint Louis, MO, USA.
- Nephrology Section, Medicine Service, VA Saint Louis Health Care System, Saint Louis, MO, USA.
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