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Marx N, Kolkailah AA, Rosenstock J, Johansen OE, Cooper ME, Alexander JH, Toto RD, Wanner C, Espeland MA, Mattheus M, Schnaidt S, Perkovic V, Gollop ND, McGuire DK. Hypoglycemia and Cardiovascular Outcomes in the CARMELINA and CAROLINA Trials of Linagliptin: A Secondary Analysis of Randomized Clinical Trials. JAMA Cardiol 2024; 9:134-143. [PMID: 38170502 PMCID: PMC10765314 DOI: 10.1001/jamacardio.2023.4602] [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: 02/27/2023] [Accepted: 10/06/2023] [Indexed: 01/05/2024]
Abstract
Importance Previous studies have reported an association between hypoglycemia and cardiovascular (CV) events in people with type 2 diabetes (T2D), but it is unclear if this association is causal or identifies a high-risk patient phenotype. Objective To evaluate the associations between hypoglycemia and CV outcomes. Design, Setting, and Participants This secondary analysis was a post hoc assessment of the multinational, double-blind CARMELINA (Cardiovascular and Renal Microvascular Outcome Study With Linagliptin; 2013-2016) and CAROLINA (Cardiovascular Outcome Trial of Linagliptin vs Glimepiride in Type 2 Diabetes; 2010-2018) randomized clinical trials of the antihyperglycemic drug, linagliptin, a dipeptidyl peptidase 4 inhibitor. Participants were adults with T2D at high CV risk with or without high kidney risk. By design, participants in the CARMELINA trial had longer duration of T2D and had a higher CV risk than participants in the CAROLINA trial. Data analyses were conducted between June 2021 and June 2023. Intervention Linagliptin or placebo in the CARMELINA trial, and linagliptin or glimepiride in the CAROLINA trial. Main Outcomes and Measures The primary outcome for both trials was CV death, myocardial infarction (MI), or stroke (3-point major adverse CV events [3P-MACE]). For the present analyses, hospitalization for heart failure (HF) was added. Hypoglycemia was defined as plasma glucose less than 54 mg/dL or severe hypoglycemia (episodes requiring the assistance of another person). Associations between the first hypoglycemic episode and subsequent CV events and between nonfatal CV events (MI, stroke, hospitalization for HF) and subsequent hypoglycemic episodes were assessed using multivariable Cox proportional hazards regression models. Sensitivity analyses explored the risk of CV events within 60 days after each hypoglycemic episode. Results In the CARMELINA trial (6979 patients; 4390 males [62.9%]; mean [SD] age, 65.9 [9.1] years), there was an association between hypoglycemia and subsequent 3P-MACE plus hospitalization for HF (hazard ratio [HR], 1.23; 95% CI, 1.04-1.46) as well as between nonfatal CV events and subsequent hypoglycemia (HR, 1.39; 95% CI, 1.06-1.83). In the CAROLINA trial (6033 patients; 3619 males (60.0%); mean [SD] age, 64.0 [9.5] years), there was no association between hypoglycemia and subsequent 3P-MACE plus hospitalization for HF (HR, 1.00; 95% CI, 0.76-1.32) and between nonfatal CV events and subsequent hypoglycemia (HR, 1.44; 95% CI, 0.96-2.16). In analyses of CV events occurring within 60 days after hypoglycemia, there was either no association or too few events to analyze. Conclusions and Relevance This study found bidirectional associations between hypoglycemia and CV outcomes in the CARMELINA trial but no associations in either direction in the CAROLINA trial, challenging the notion that hypoglycemia causes adverse CV events. The findings from the CARMELINA trial suggest that both hypoglycemia and CV events more likely identify patients at high risk for both. Trial Registration ClinicalTrials.gov Identifier: NCT01897532 (CARMELINA) and NCT01243424 (CAROLINA).
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Affiliation(s)
- Nikolaus Marx
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Ahmed A. Kolkailah
- Division of Cardiology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas
| | | | - Odd Erik Johansen
- Therapeutic Area Cardiometabolism, Boehringer Ingelheim KS, Asker, Norway
| | - Mark E. Cooper
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - John H. Alexander
- Duke Clinical Research Institute, Duke Health, Durham, North Carolina
| | - Robert D. Toto
- Department of Internal Medicine, Division of Nephrology, The University of Texas Southwestern Medical Center, Dallas
| | - Christoph Wanner
- Division of Nephrology, Department of Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Mark A. Espeland
- Division of Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Michaela Mattheus
- Biostatistics and Data Sciences, Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim am Rhein, Germany
| | - Sven Schnaidt
- Biostatistics and Data Sciences, Boehringer Ingelheim Pharma GmbH & Co KG, Biberach an der Riß, Germany
| | - Vlado Perkovic
- Renal and Metabolic Division, The George Institute for Global Health, University of New South Wales Sydney, Newtown, New South Wales, Australia
| | - Nicholas D. Gollop
- Therapeutic Area Cardiometabolism, Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Darren K. McGuire
- Division of Cardiology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas
- Parkland Health, Dallas, Texas
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ElSayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Das SR, Ekhlaspour L, Hilliard ME, Johnson EL, Khunti K, Kosiborod MN, Lingvay I, Matfin G, McCoy RG, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Stanton RC, Gabbay RA. 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2024. Diabetes Care 2024; 47:S179-S218. [PMID: 38078592 PMCID: PMC10725811 DOI: 10.2337/dc24-s010] [Citation(s) in RCA: 44] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Rosenstock J, Kolkailah AA, McGuire DK, Espeland MA, Mattheus M, Pfarr E, Lund SS, Marx N. Incident and recurrent hypoglycaemia with linagliptin and glimepiride over a median of 6 years in the CAROLINA cardiovascular outcome trial. Diabetes Obes Metab 2023; 25:1453-1463. [PMID: 36700416 DOI: 10.1111/dom.14991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 01/12/2023] [Accepted: 01/23/2023] [Indexed: 01/27/2023]
Abstract
AIM The CAROLINA trial established non-inferiority of linagliptin versus glimepiride for major adverse cardiovascular events in patients with relatively early type 2 diabetes at increased cardiovascular risk. In pre-specified and post-hoc analyses, we investigated treatment effects on total hypoglycaemic burden in CAROLINA. MATERIALS AND METHODS Patients were randomized and treated with 5 mg linagliptin (n = 3014) or 1-4 mg glimepiride (n = 3000) once daily added to standard care. Hypoglycaemia captured from investigator-reported adverse events was analysed with Poisson and negative binomial regressions for the first and total (first plus recurrent) events, respectively. The influence of insulin initiation and glycated haemoglobin (HbA1c) change on the treatment effect for hypoglycaemia was also explored. RESULTS Over 6.3 years median follow-up, average HbA1c over time did not differ between linagliptin versus glimepiride (weighted mean difference [95% confidence interval]: 0.00%, [-0.05, 0.05]), nor did insulin initiation (18.6% vs. 19.2% of patients, respectively), whereas body weight was lower with linagliptin (-1.54 kg, [-1.80, -1.28]). Hypoglycaemia frequency was lower with linagliptin across all hypoglycaemia categories, including severe episodes. Rate ratios (95% confidence interval) for first and total events for investigator-reported hypoglycaemia were 0.21 (0.19-0.24) and 0.12 (0.10-0.14), respectively, with 8.7 first and 60.8 total estimated events prevented/100 patient-years with linagliptin versus glimepiride. These differences occurred during night-time and daytime, and in subgroup analyses of total events. Treatment differences in hypoglycaemia were neither impacted by HbA1c changes nor insulin initiation. CONCLUSIONS Across the severity spectrum, linagliptin substantially reduced the hypoglycaemic burden versus glimepiride in patients with relatively early type 2 diabetes at increased cardiovascular risk.
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Affiliation(s)
| | - Ahmed A Kolkailah
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Parkland Health and Hospital System, Dallas, Texas, USA
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Parkland Health and Hospital System, Dallas, Texas, USA
| | - Mark A Espeland
- Departments of Internal Medicine and Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | | | - Egon Pfarr
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Søren S Lund
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
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4
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ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, Collins BS, Das SR, Hilliard ME, Isaacs D, Johnson EL, Kahan S, Khunti K, Kosiborod M, Leon J, Lyons SK, Perry ML, Prahalad P, Pratley RE, Seley JJ, Stanton RC, Gabbay RA, on behalf of the American Diabetes Association. 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2023. Diabetes Care 2023; 46:S158-S190. [PMID: 36507632 PMCID: PMC9810475 DOI: 10.2337/dc23-s010] [Citation(s) in RCA: 210] [Impact Index Per Article: 210.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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5
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He J, Xi Y, Lam H, Du K, Chen D, Dong Z, Xiao J. Effect of Intensive Glycemic Control on Myocardial Infarction Outcome in Patients with Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis. J Diabetes Res 2023; 2023:8818502. [PMID: 36873813 PMCID: PMC9984264 DOI: 10.1155/2023/8818502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 02/02/2023] [Accepted: 02/06/2023] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND The effect of intensive glucose-lowering treatment on the risk of cardiovascular events in type 2 diabetes remains uncertain, especially the effect on the occurrence of myocardial infarction in patients with type 2 diabetes is still unclear. The purpose of this study was to conduct a systematic review and meta-analysis of relevant RCTs. METHODS We performed a systematic review of randomized clinical trials (RCTS) and observational studies relevant to this study question. We searched the PubMed and Cochrane databases until June 2022. RESULTS We included data on 14 RCTs and 144,334 patients, all of whom had type 2 diabetes. When all studies were considered, intensive glucose-lowering treatment significantly reduced the incidence of MI compared with conventional therapy and the total OR value is 0.90 (CI 0.84, 0.97; P = 0.004) when considering all the studies. When the target value of intensive glucose-lowering treatment was considered as HbA1c decrease of more than 0.5%, there was no significant protective effect on MI, the total OR value is 0.88 (CI 0.81, 0.96; P = 0.003). When considering all available RCTS, the intensive glucose-lowering treatment group had a protective effect for MACE compared to the conventional treatment group, and the total OR value is 0.92 (CI 0.88, 0.96; P < 0.00001). In the available RCTs, for the patients with a history of prior CAD, the total OR value is 0.94 (CI 0.89, 0.99; P = 0.002). And there was no difference in the incidence of hypoglycemic events between the intensive and conservative treatment groups. CONCLUSION Our data support the positive protective effect of glucose-lowering therapy on MI in patients with T2DM, but there is no significant effect of intensive glucose-lowering. In addition, we found no greater protective effect of enhanced glucose control in the HbA1c reduction of more than 0.5%, and no difference in the incidence of adverse events compared with the HbA1c reduction of less than 0.5%.
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Affiliation(s)
- Jiading He
- Department of Cardiology, The Dongguan Affiliated Hospital of Jinan University, Binhaiwan Central Hospital of Dongguan, Dongguan, China
- Department of The First Clinical Medical College, Jinan University, Guangzhou, China
| | - Yangbo Xi
- Department of Cardiology, The Dongguan Affiliated Hospital of Jinan University, Binhaiwan Central Hospital of Dongguan, Dongguan, China
- Department of The First Clinical Medical College, Jinan University, Guangzhou, China
| | - Hingcheung Lam
- Department of Cardiology, The Dongguan Affiliated Hospital of Jinan University, Binhaiwan Central Hospital of Dongguan, Dongguan, China
- Department of The First Clinical Medical College, Jinan University, Guangzhou, China
| | - Keyi Du
- Department of Cardiology, The Dongguan Affiliated Hospital of Jinan University, Binhaiwan Central Hospital of Dongguan, Dongguan, China
- Department of The First Clinical Medical College, Jinan University, Guangzhou, China
| | - Dongping Chen
- Central Laboratory, The Dongguan Affiliated Hospital of Jinan University, Binhaiwan Central Hospital of Dongguan, Dongguan, China
| | - Zhihui Dong
- Central Laboratory, The Dongguan Affiliated Hospital of Jinan University, Binhaiwan Central Hospital of Dongguan, Dongguan, China
| | - Jianmin Xiao
- Department of Cardiology, The Dongguan Affiliated Hospital of Jinan University, Binhaiwan Central Hospital of Dongguan, Dongguan, China
- Central Laboratory, The Dongguan Affiliated Hospital of Jinan University, Binhaiwan Central Hospital of Dongguan, Dongguan, China
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6
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Dinges SMT, Krotz J, Gass F, Treitschke J, Fegers-Wustrow I, Geisberger M, Esefeld K, von Korn P, Duvinage A, Edelmann F, Wolfram O, Brandts J, Winzer EB, Wolfarth B, Freigang F, Neubauer S, Nebling T, Hackenberg B, Amelung V, Mueller S, Halle M. Cardiovascular risk factors, exercise capacity and health literacy in patients with chronic ischaemic heart disease and type 2 diabetes mellitus in Germany: Baseline characteristics of the Lifestyle Intervention in Chronic Ischaemic Heart Disease and Type 2 Diabetes study. Diab Vasc Dis Res 2022; 19:14791641221113781. [PMID: 35953083 PMCID: PMC9379969 DOI: 10.1177/14791641221113781] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Lifestyle interventions are a cornerstone in the treatment of chronic ischaemic heart disease (CIHD) and type 2 diabetes mellitus (T2DM). This study aimed at identifying differences in clinical characteristics between categories of the common lifestyle intervention targets BMI, exercise capacity (peak V̇O2) and health literacy (HL). METHODS Cross-sectional baseline characteristics of patients enrolled in the LeIKD trial (Clinicaltrials.gov NCT03835923) are presented in total, grouped by BMI, %-predicted peak V̇O2 and HL (HLS-EU-Q16), and compared to other clinical trials with similar populations. RESULTS Among 499 patients (68.3±7.7 years; 16.2% female; HbA1c, 6.9±0.9%), baseline characteristics were similar to other trials and revealed insufficient treatment of several risk factors (LDL-C 92±34 mg/dl; BMI, 30.1±4.8 kg/m2; 69.6% with peak V̇O2<90% predicted). Patients with lower peak V̇O2 showed significantly higher (p < 0.05) CIHD and T2DM disease severity (HbA1c, CIHD symptoms, coronary artery bypass graft). Obese patients had a significantly higher prevalence of hypertension and higher triglyceride levels, whereas in patients with low HL both quality of life components (physical, mental) were significantly reduced. CONCLUSIONS In patients with CIHD and T2DM, peak V̇O2, BMI and HL are important indicators of disease severity, risk factor burden and quality of life, which reinforces the relevance of lifestyle interventions.
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Affiliation(s)
- Sophia MT Dinges
- Department of Prevention and Sports
Medicine, University Hospital Klinikum Rechts
der Isar, Technical University of
Munich, Munich, Germany
- DZHK (German Centre for
Cardiovascular Research), Partner Site Munich Heart
Alliance, Munich, Germany
| | - Janosch Krotz
- Institute for Applied Healthcare
Research GmbH (inav), Berlin, Germany
| | - Felix Gass
- Department of Prevention and Sports
Medicine, University Hospital Klinikum Rechts
der Isar, Technical University of
Munich, Munich, Germany
- DZHK (German Centre for
Cardiovascular Research), Partner Site Munich Heart
Alliance, Munich, Germany
| | - Julian Treitschke
- Department of Prevention and Sports
Medicine, University Hospital Klinikum Rechts
der Isar, Technical University of
Munich, Munich, Germany
| | - Isabel Fegers-Wustrow
- Department of Prevention and Sports
Medicine, University Hospital Klinikum Rechts
der Isar, Technical University of
Munich, Munich, Germany
- DZHK (German Centre for
Cardiovascular Research), Partner Site Munich Heart
Alliance, Munich, Germany
| | - Marisa Geisberger
- Department of Prevention and Sports
Medicine, University Hospital Klinikum Rechts
der Isar, Technical University of
Munich, Munich, Germany
| | - Katrin Esefeld
- Department of Prevention and Sports
Medicine, University Hospital Klinikum Rechts
der Isar, Technical University of
Munich, Munich, Germany
- DZHK (German Centre for
Cardiovascular Research), Partner Site Munich Heart
Alliance, Munich, Germany
| | - Pia von Korn
- Department of Prevention and Sports
Medicine, University Hospital Klinikum Rechts
der Isar, Technical University of
Munich, Munich, Germany
- DZHK (German Centre for
Cardiovascular Research), Partner Site Munich Heart
Alliance, Munich, Germany
| | - André Duvinage
- Department of Prevention and Sports
Medicine, University Hospital Klinikum Rechts
der Isar, Technical University of
Munich, Munich, Germany
- DZHK (German Centre for
Cardiovascular Research), Partner Site Munich Heart
Alliance, Munich, Germany
| | - Frank Edelmann
- Department of Internal Medicine and
Cardiology, Campus Virchow Klinikum, Charité Universitätsmedizin
Berlin, Berlin, Germany
- German Centre for Cardiovascular
Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Oliver Wolfram
- Department of Cardiology and
Angiology, University Hospital
Magdeburg, Magdeburg, Germany
| | - Julia Brandts
- Department of Medicine I, University Hospital
Aachen, Aachen, Germany
| | - Ephraim B Winzer
- Heart Centre Dresden, University
Hospital, Technische Universität
Dresden, Dresden, Germany
| | - Bernd Wolfarth
- Department of Sports Medicine, Humboldt University and Charité
University School of Medicine, Berlin, Germany
| | - Felix Freigang
- Institute for Applied Healthcare
Research GmbH (inav), Berlin, Germany
| | | | | | | | - Volker Amelung
- Institute for Applied Healthcare
Research GmbH (inav), Berlin, Germany
| | - Stephan Mueller
- Department of Prevention and Sports
Medicine, University Hospital Klinikum Rechts
der Isar, Technical University of
Munich, Munich, Germany
- DZHK (German Centre for
Cardiovascular Research), Partner Site Munich Heart
Alliance, Munich, Germany
| | - Martin Halle
- Department of Prevention and Sports
Medicine, University Hospital Klinikum Rechts
der Isar, Technical University of
Munich, Munich, Germany
- DZHK (German Centre for
Cardiovascular Research), Partner Site Munich Heart
Alliance, Munich, Germany
- Martin Halle, Department of Prevention and
Sports Medicine, Centre for Sports Cardiology/EAPC, Klinikum rechts der Isar,
Technical University of Munich, Georg-Brauchle-Ring 56/58, Munich D-80992,
Germany.
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Islam N, Ayele HT, Yu OHY, Douros A, Filion KB. Sulfonylureas and the Risk of Ventricular Arrhythmias Among People with Type 2 Diabetes: A Systematic Review of Observational Studies. Clin Pharmacol Ther 2022; 111:1248-1257. [PMID: 35238022 DOI: 10.1002/cpt.2570] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 02/14/2022] [Indexed: 01/01/2023]
Abstract
Previous studies have suggested an association between sulfonylureas and an increased risk of cardiovascular death among patients with type 2 diabetes. A potential mechanism involves sulfonylurea-induced ventricular arrhythmias (VAs). We conducted a systematic review of observational studies to determine whether the use of sulfonylureas, compared with the use of other antihyperglycemic drugs, is associated with the risk of VA (ventricular tachycardia, ventricular fibrillation, and premature ventricular complexes), cardiac arrest, and sudden cardiac death among patients with type 2 diabetes. Two independent reviewers searched MEDLINE, EMBASE, CINAHL Plus, CENTRAL, and ClinicalTrials.gov from inception to July 2021 for observational studies comparing sulfonylureas vs. other antihyperglycemic therapies or intraclass comparisons of sulfonylureas. Our systematic review included 17 studies (1,607,612 patients). Per Risk Of Bias In Non-randomized Studies of Interventions (ROBINS)-I, there were few high-quality studies (2 studies at moderate risk of bias; 4 at serious risk; and 11 at critical risk). All studies at a moderate or serious risk of bias reporting comparisons with other therapies were consistent with an increased risk of VA. Sulfonylureas were associated with a higher risk of arrhythmia vs. dipeptidyl peptidase-4 inhibitors (adjusted hazard ratio (aHR): 1.52, 95% confidence interval (CI): 1.27-1.80) and of VA vs. metformin (aHR: 1.52, 95% CI: 1.10-2.13). One moderate quality study reported inconsistent results for a composite of cardiac arrest/VA in analyses of US Medicaid claims and Optum claims data. Our systematic review suggests that, among higher-quality observational studies, sulfonylureas are associated with an increased risk of VA. However, we identified few methodologically rigorous studies, underscoring the need for additional real-world studies.
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Affiliation(s)
- Nehal Islam
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada.,Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montréal, Québec, Canada
| | - Henok T Ayele
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada.,Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montréal, Québec, Canada
| | - Oriana H Y Yu
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montréal, Québec, Canada.,Division of Endocrinology, Jewish General Hospital, Montréal, Québec, Canada
| | - Antonios Douros
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada.,Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montréal, Québec, Canada.,Department of Medicine, McGill University, Montréal, Québec, Canada.,Institute of Clinical Pharmacology and Toxicology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Kristian B Filion
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada.,Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montréal, Québec, Canada.,Department of Medicine, McGill University, Montréal, Québec, Canada
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Abhyankar M, Das A, Wangnoo S, Chawla R, Shaikh A, Bantwal G, Kalra P, Jaggi S, Prasad A, Sarda P. Expert consensus on triple combination of glimepiride, metformin, and voglibose usage in patients with type 2 diabetes mellitus in Indian settings. JOURNAL OF DIABETOLOGY 2022. [DOI: 10.4103/jod.jod_118_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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9
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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10
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Kang SM, Park JH. Pleiotropic Benefits of DPP-4 Inhibitors Beyond Glycemic Control. CLINICAL MEDICINE INSIGHTS-ENDOCRINOLOGY AND DIABETES 2021; 14:11795514211051698. [PMID: 34733107 PMCID: PMC8558587 DOI: 10.1177/11795514211051698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 09/20/2021] [Indexed: 12/14/2022]
Abstract
Dipeptidyl peptidase (DPP)-4 inhibitors are oral anti-diabetic medications that block the activity of the ubiquitous enzyme DPP-4. Inhibition of this enzyme increases the level of circulating active glucagon-like peptide (GLP)-1 secreted from L-cells in the small intestine. GLP-1 increases the glucose level, dependent on insulin secretion from pancreatic β-cells; it also decreases the abnormally increased level of glucagon, eventually decreasing the blood glucose level in patients with type 2 diabetes. DPP-4 is involved in many physiological processes other than the degradation of GLP-1. Therefore, the inhibition of DPP-4 may have numerous effects beyond glucose control. In this article, we review the pleiotropic effects of DPP-4 inhibitors beyond glucose control, including their strong beneficial effects on the stress induced accelerated senescence of vascular cells, and the possible clinical implications of these effects.
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Affiliation(s)
- Seon Mee Kang
- Department of Internal Medicine, College of Medicine, Inje University, Busan, Republic of Korea.,Paik Institute for Clinical Research, Inje University, Busan, Republic of Korea
| | - Jeong Hyun Park
- Department of Internal Medicine, College of Medicine, Inje University, Busan, Republic of Korea.,Paik Institute for Clinical Research, Inje University, Busan, Republic of Korea
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Kanie T, Mizuno A, Takaoka Y, Suzuki T, Yoneoka D, Nishikawa Y, Tam WWS, Morze J, Rynkiewicz A, Xin Y, Wu O, Providencia R, Kwong JS. Dipeptidyl peptidase-4 inhibitors, glucagon-like peptide 1 receptor agonists and sodium-glucose co-transporter-2 inhibitors for people with cardiovascular disease: a network meta-analysis. Cochrane Database Syst Rev 2021; 10:CD013650. [PMID: 34693515 PMCID: PMC8812344 DOI: 10.1002/14651858.cd013650.pub2] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cardiovascular disease (CVD) is a leading cause of death globally. Recently, dipeptidyl peptidase-4 inhibitors (DPP4i), glucagon-like peptide-1 receptor agonists (GLP-1RA) and sodium-glucose co-transporter-2 inhibitors (SGLT2i) were approved for treating people with type 2 diabetes mellitus. Although metformin remains the first-line pharmacotherapy for people with type 2 diabetes mellitus, a body of evidence has recently emerged indicating that DPP4i, GLP-1RA and SGLT2i may exert positive effects on patients with known CVD. OBJECTIVES To systematically review the available evidence on the benefits and harms of DPP4i, GLP-1RA, and SGLT2i in people with established CVD, using network meta-analysis. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and the Conference Proceedings Citation Index on 16 July 2020. We also searched clinical trials registers on 22 August 2020. We did not restrict by language or publication status. SELECTION CRITERIA We searched for randomised controlled trials (RCTs) investigating DPP4i, GLP-1RA, or SGLT2i that included participants with established CVD. Outcome measures of interest were CVD mortality, fatal and non-fatal myocardial infarction, fatal and non-fatal stroke, all-cause mortality, hospitalisation for heart failure (HF), and safety outcomes. DATA COLLECTION AND ANALYSIS Three review authors independently screened the results of searches to identify eligible studies and extracted study data. We used the GRADE approach to assess the certainty of the evidence. We conducted standard pairwise meta-analyses and network meta-analyses by pooling studies that we assessed to be of substantial homogeneity; subgroup and sensitivity analyses were also pursued to explore how study characteristics and potential effect modifiers could affect the robustness of our review findings. We analysed study data using the odds ratios (ORs) and log odds ratios (LORs) with their respective 95% confidence intervals (CIs) and credible intervals (Crls), where appropriate. We also performed narrative synthesis for included studies that were of substantial heterogeneity and that did not report quantitative data in a usable format, in order to discuss their individual findings and relevance to our review scope. MAIN RESULTS We included 31 studies (287 records), of which we pooled data from 20 studies (129,465 participants) for our meta-analysis. The majority of the included studies were at low risk of bias, using Cochrane's tool for assessing risk of bias. Among the 20 pooled studies, six investigated DPP4i, seven studied GLP-1RA, and the remaining seven trials evaluated SGLT2i. All outcome data described below were reported at the longest follow-up duration. 1. DPP4i versus placebo Our review suggests that DPP4i do not reduce any risk of efficacy outcomes: CVD mortality (OR 1.00, 95% CI 0.91 to 1.09; high-certainty evidence), myocardial infarction (OR 0.97, 95% CI 0.88 to 1.08; high-certainty evidence), stroke (OR 1.00, 95% CI 0.87 to 1.14; high-certainty evidence), and all-cause mortality (OR 1.03, 95% CI 0.96 to 1.11; high-certainty evidence). DPP4i probably do not reduce hospitalisation for HF (OR 0.99, 95% CI 0.80 to 1.23; moderate-certainty evidence). DPP4i may not increase the likelihood of worsening renal function (OR 1.08, 95% CI 0.88 to 1.33; low-certainty evidence) and probably do not increase the risk of bone fracture (OR 1.00, 95% CI 0.83 to 1.19; moderate-certainty evidence) or hypoglycaemia (OR 1.11, 95% CI 0.95 to 1.29; moderate-certainty evidence). They are likely to increase the risk of pancreatitis (OR 1.63, 95% CI 1.12 to 2.37; moderate-certainty evidence). 2. GLP-1RA versus placebo Our findings indicate that GLP-1RA reduce the risk of CV mortality (OR 0.87, 95% CI 0.79 to 0.95; high-certainty evidence), all-cause mortality (OR 0.88, 95% CI 0.82 to 0.95; high-certainty evidence), and stroke (OR 0.87, 95% CI 0.77 to 0.98; high-certainty evidence). GLP-1RA probably do not reduce the risk of myocardial infarction (OR 0.89, 95% CI 0.78 to 1.01; moderate-certainty evidence), and hospitalisation for HF (OR 0.95, 95% CI 0.85 to 1.06; high-certainty evidence). GLP-1RA may reduce the risk of worsening renal function (OR 0.61, 95% CI 0.44 to 0.84; low-certainty evidence), but may have no impact on pancreatitis (OR 0.96, 95% CI 0.68 to 1.35; low-certainty evidence). We are uncertain about the effect of GLP-1RA on hypoglycaemia and bone fractures. 3. SGLT2i versus placebo This review shows that SGLT2i probably reduce the risk of CV mortality (OR 0.82, 95% CI 0.70 to 0.95; moderate-certainty evidence), all-cause mortality (OR 0.84, 95% CI 0.74 to 0.96; moderate-certainty evidence), and reduce the risk of HF hospitalisation (OR 0.65, 95% CI 0.59 to 0.71; high-certainty evidence); they do not reduce the risk of myocardial infarction (OR 0.97, 95% CI 0.84 to 1.12; high-certainty evidence) and probably do not reduce the risk of stroke (OR 1.12, 95% CI 0.92 to 1.36; moderate-certainty evidence). In terms of treatment safety, SGLT2i probably reduce the incidence of worsening renal function (OR 0.59, 95% CI 0.43 to 0.82; moderate-certainty evidence), and probably have no effect on hypoglycaemia (OR 0.90, 95% CI 0.75 to 1.07; moderate-certainty evidence) or bone fracture (OR 1.02, 95% CI 0.88 to 1.18; high-certainty evidence), and may have no impact on pancreatitis (OR 0.85, 95% CI 0.39 to 1.86; low-certainty evidence). 4. Network meta-analysis Because we failed to identify direct comparisons between each class of the agents, findings from our network meta-analysis provided limited novel insights. Almost all findings from our network meta-analysis agree with those from the standard meta-analysis. GLP-1RA may not reduce the risk of stroke compared with placebo (OR 0.87, 95% CrI 0.75 to 1.0; moderate-certainty evidence), which showed similar odds estimates and wider 95% Crl compared with standard pairwise meta-analysis. Indirect estimates also supported comparison across all three classes. SGLT2i was ranked the best for CVD and all-cause mortality. AUTHORS' CONCLUSIONS Findings from both standard and network meta-analyses of moderate- to high-certainty evidence suggest that GLP-1RA and SGLT2i are likely to reduce the risk of CVD mortality and all-cause mortality in people with established CVD; high-certainty evidence demonstrates that treatment with SGLT2i reduce the risk of hospitalisation for HF, while moderate-certainty evidence likely supports the use of GLP-1RA to reduce fatal and non-fatal stroke. Future studies conducted in the non-diabetic CVD population will reveal the mechanisms behind how these agents improve clinical outcomes irrespective of their glucose-lowering effects.
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Affiliation(s)
- Takayoshi Kanie
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
| | - Atsushi Mizuno
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
- Penn Medicine Nudge Unit, University of Pennsylvania Philadelphia, Philadelphia, PA, USA
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Yoshimitsu Takaoka
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
| | - Takahiro Suzuki
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
| | - Daisuke Yoneoka
- Division of Biostatistics and Bioinformatics, Graduate School of Public Health, St. Luke's International University, Tokyo, Japan
| | - Yuri Nishikawa
- Department of Gerontological Nursing and Healthcare Systems Management, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan
- Department of Gerontological Nursing, Kyorin University, Tokyo, Japan
| | - Wilson Wai San Tam
- Alice Lee Center for Nursing Studies, NUS Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Jakub Morze
- Department of Human Nutrition, University of Warmia and Mazury, Olsztyn, Poland
| | - Andrzej Rynkiewicz
- Department of Cardiology and Cardiosurgery, School of Medicine, University of Warmia and Mazury, Olsztyn, Poland
| | - Yiqiao Xin
- Health Economics and Health Technology Assessment (HEHTA), Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Olivia Wu
- Health Economics and Health Technology Assessment (HEHTA), Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Rui Providencia
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Joey Sw Kwong
- Global Health Nursing, Graduate School of Nursing Science, St. Luke's International University, Tokyo, Japan
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Jung I, Kwon H, Park SE, Han KD, Park YG, Rhee EJ, Lee WY. The Effects of Glucose Lowering Agents on the Secondary Prevention of Coronary Artery Disease in Patients with Type 2 Diabetes. Endocrinol Metab (Seoul) 2021; 36:977-987. [PMID: 34645126 PMCID: PMC8566121 DOI: 10.3803/enm.2021.1046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 08/06/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Patients with diabetes have a higher risk of requiring repeated percutaneous coronary intervention (PCI) than non-diabetic patients. We aimed to evaluate and compare the effects of anti-diabetic drugs on the secondary prevention of myocardial infarction among type 2 diabetes mellitus patients. METHODS We analyzed the general health check-up dataset and claims data of the Korean National Health Insurance Service of 199,714 participants (age ≥30 years) who underwent PCIs between 2010 and 2013. Those who underwent additional PCI within 1 year of their first PCI (n=3,325) and those who died within 1 year (n=1,312) were excluded. Patients were classified according to their prescription records for glucose-lowering agents. The primary endpoint was the incidence rate of coronary revascularization. RESULTS A total of 35,348 patients were included in the study. Metformin significantly decreased the risk of requiring repeat PCI in all patients (adjusted hazard ratio [aHR], 0.77). In obese patients with body mass index (BMI) ≥25 kg/m2, patients treated with thiazolidinedione (TZD) exhibited a decreased risk of requiring repeat revascularization than those who were not treated with TZD (aHR, 0.77; 95% confidence interval, 0.63 to 0.95). Patients treated with metformin showed a decreased risk of requiring revascularization regardless of their BMI. Insulin, meglitinide, and alpha-glucosidase inhibitor were associated with increased risk of repeated PCI. CONCLUSION The risk of requiring repeat revascularization was lower in diabetic patients treated with metformin and in obese patients treated with TZD. These results suggest that physicians should choose appropriate glucose-lowering agents for the secondary prevention of coronary artery disease.
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Affiliation(s)
- Inha Jung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Hyemi Kwon
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Se Eun Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Kyung-Do Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul,
Korea
| | - Yong-Gyu Park
- Department of Biostatistics, Biomedicine & Health Sciences, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Eun-Jung Rhee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Won-Young Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul,
Korea
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13
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Wangnoo S, Shunmugavelu M, Reddy SVB, Negalur V, Godbole S, Dhandhania VK, Krishna N, Gaurav K. Role of Gliclazide in safely navigating type 2 diabetes mellitus patients towards euglycemia: Expert opinion from India. ENDOCRINE AND METABOLIC SCIENCE 2021. [DOI: 10.1016/j.endmts.2021.100102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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14
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Thethi TK, Bilal A, Pratley RE. Cardiovascular Outcomes Trials of Incretin-Based Therapies. Diabetes Spectr 2021; 34:217-224. [PMID: 34511847 PMCID: PMC8387616 DOI: 10.2337/ds20-0072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The cardiovascular (CV) safety of glucagon-like peptide 1 (GLP-1) receptor agonists has been established in robust cardiovascular outcomes trials (CVOTs) in patients with type 2 diabetes at high CV risk. The GLP-1 receptor agonists liraglutide, dulaglutide, and injectable semaglutide demonstrated a significant CV benefit in these trials and now have indications to reduce the risk of major adverse CV events, including CV death, myocardial infarction, and stroke in adult patients with type 2 diabetes and established cardiovascular disease or high CV risk (dulaglutide). The dipeptidyl peptidase 4 inhibitors have also demonstrated CV safety in dedicated CVOTs but have not been associated with any CV benefit. Guidelines for the treatment of type 2 diabetes have evolved from a glucocentric focus to one that now focuses on reducing overall CV risk by personalizing therapy and using drugs such as GLP-1 receptor agonists with proven CV benefits.
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Affiliation(s)
- Tina K. Thethi
- AdventHealth, Translational Research Institute, Orlando, FL
- AdventHealth Diabetes Institute, Orlando, FL
- Corresponding author: Tina K. Thethi,
| | - Anika Bilal
- AdventHealth, Translational Research Institute, Orlando, FL
| | - Richard E. Pratley
- AdventHealth, Translational Research Institute, Orlando, FL
- AdventHealth Diabetes Institute, Orlando, FL
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15
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Abstract
PURPOSE OF REVIEW This review summarizes recent cardiovascular outcome trials (CVOTs) with glucose-lowering drugs. RECENT FINDINGS The majority of recent CVOTs with glucose-lowering drugs have tested dipeptidyl peptidase-4 inhibitors (DPP4-i), glucagon-like peptide-1 receptors agonists (GLP1-RA), and sodium-glucose cotransporter 2 inhibitors (SGLT2i), but studies have also been performed with other agents including thiazolidinediones and insulin. All CVOTs with DPP4-I, GLP1-RA, and SGLT2-i have demonstrated the cardiovascular (CV) safety of these agents compared to usual care. However, certain GLP1-RAs (liraglutide, subcutaneous semaglutide, albiglutide, dulaglutide) and SGLT2-i (empagliflozin, canagliflozin) have demonstrated a CV benefit, showing significant reductions in composite cardiovascular outcomes. Furthermore, all SGLT2-i also significantly decreased the risk for hospitalization for heart failure. Results from these studies have altered clinical guidelines worldwide and have resulted in new indications for some glucose-lowering drugs. In patients with T2D and high risk for CVD, GLP-1RA or SGLT2-i with proven cardiovascular benefit are recommended, irrespective of glycemic control.
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Affiliation(s)
- Tina K Thethi
- AdventHealth Translational Research Institute, 301 E. Princeton Street, Orlando, FL, 32804, USA.
- AdventHealth Diabetes Institute, Orlando, FL, USA.
| | - Anika Bilal
- AdventHealth Translational Research Institute, 301 E. Princeton Street, Orlando, FL, 32804, USA
| | - Richard E Pratley
- AdventHealth Translational Research Institute, 301 E. Princeton Street, Orlando, FL, 32804, USA
- AdventHealth Diabetes Institute, Orlando, FL, USA
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Nusca A, Tuccinardi D, Pieralice S, Giannone S, Carpenito M, Monte L, Watanabe M, Cavallari I, Maddaloni E, Ussia GP, Manfrini S, Grigioni F. Platelet Effects of Anti-diabetic Therapies: New Perspectives in the Management of Patients with Diabetes and Cardiovascular Disease. Front Pharmacol 2021; 12:670155. [PMID: 34054542 PMCID: PMC8149960 DOI: 10.3389/fphar.2021.670155] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 04/16/2021] [Indexed: 12/14/2022] Open
Abstract
In type 2 diabetes, anti-thrombotic management is challenging, and current anti-platelet agents have demonstrated reduced efficacy. Old and new anti-diabetic drugs exhibited—besides lowering blood glucose levels—direct and indirect effects on platelet function and on thrombotic milieu, eventually conditioning cardiovascular outcomes. The present review summarizes existing evidence on the effects of glucose-lowering agents on platelet properties, addressing pre-clinical and clinical research, as well as drug–drug interactions with anti-platelet agents. We aimed at expanding clinicians’ understanding by highlighting new opportunities for an optimal management of patients with diabetes and cardiovascular disease. We suggest how an improvement of the thrombotic risk in this large population of patients may be achieved by a careful and tailored combination of anti-diabetic and anti-platelet therapies.
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Affiliation(s)
- Annunziata Nusca
- Unit of Cardiac Sciences, Department of Medicine, Campus Bio-Medico University of Rome, Rome, Italy
| | - Dario Tuccinardi
- Unit of Endocrinology and Diabetes, Department of Medicine, Campus Bio-Medico University of Rome, Rome, Italy
| | - Silvia Pieralice
- Unit of Endocrinology and Diabetes, Department of Medicine, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sara Giannone
- Unit of Cardiac Sciences, Department of Medicine, Campus Bio-Medico University of Rome, Rome, Italy
| | - Myriam Carpenito
- Unit of Cardiac Sciences, Department of Medicine, Campus Bio-Medico University of Rome, Rome, Italy
| | - Lavinia Monte
- Unit of Endocrinology and Diabetes, Department of Medicine, Campus Bio-Medico University of Rome, Rome, Italy
| | - Mikiko Watanabe
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Sapienza University of Rome, Rome, Italy
| | - Ilaria Cavallari
- Unit of Cardiac Sciences, Department of Medicine, Campus Bio-Medico University of Rome, Rome, Italy
| | - Ernesto Maddaloni
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Gian Paolo Ussia
- Unit of Cardiac Sciences, Department of Medicine, Campus Bio-Medico University of Rome, Rome, Italy
| | - Silvia Manfrini
- Unit of Endocrinology and Diabetes, Department of Medicine, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Grigioni
- Unit of Cardiac Sciences, Department of Medicine, Campus Bio-Medico University of Rome, Rome, Italy
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Kadowaki T, Yamamoto F, Taneda Y, Naito Y, Clark D, Lund SS, Okamura T, Kaku K. Effects of anti-diabetes medications on cardiovascular and kidney outcomes in Asian patients with type 2 diabetes: a rapid evidence assessment and narrative synthesis. Expert Opin Drug Saf 2021; 20:707-720. [PMID: 33706621 DOI: 10.1080/14740338.2021.1898585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The cardiovascular and kidney safety of glucose-lowering drugs is a key concern in type 2 diabetes (T2D). We evaluated cardiorenal outcomes with glucose-lowering drugs in Asian patients, who comprise over half of T2D cases globally. RESEARCH DESIGN AND METHODS A rapid evidence assessment was conducted for phase III or IV, double-blind, randomized clinical trials of glucose-lowering drugs reporting cardiovascular or kidney outcomes for Asian T2D patients (Embase, Medline, Cochrane Library databases: 1 January 2008-14 June 2020). RESULTS Fifty-four publications reported exploratory data for Asians from 18 trials of dipeptidyl peptidase-4 (DPP-4) inhibitors, sodium-glucose co-transporter-2 (SGLT2) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, and insulin analogs. SGLT2 inhibitors and several GLP-1 receptor agonists were associated with reduced cardiovascular risk in Asian T2D patients, while DPP-4 inhibitors exhibited cardiovascular safety. SGLT2 inhibitors also appeared to reduce renal risk; however, kidney outcomes were lacking for DPP-4 inhibitors other than linagliptin and GLP-1 receptor agonists in Asian patients. Insulin data were inconclusive as the only trial conducted used different types of insulin as both treatment and comparator. CONCLUSIONS Cardiorenal outcomes with glucose-lowering drugs in Asian T2D patients were similar to outcomes in the overall multinational cohorts of these trials. DPP-4 inhibitors appear to demonstrate cardiovascular safety in Asians, while SGLT2 inhibitors and some GLP-1 receptor agonists may reduce cardiorenal and cardiovascular risk, respectively.
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Affiliation(s)
| | - Fumiko Yamamoto
- Medicine Division, Nippon Boehringer Ingelheim Co., Ltd, Tokyo, Japan
| | - Yusuke Taneda
- Medicine Division, Nippon Boehringer Ingelheim Co., Ltd, Tokyo, Japan
| | - Yusuke Naito
- Medicine Division, Nippon Boehringer Ingelheim Co., Ltd, Tokyo, Japan
| | - Douglas Clark
- TA CardioMetabolism Respiratory Med, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Søren S Lund
- TA CardioMetabolism Respiratory Med, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Tomoo Okamura
- Medicine Division, Nippon Boehringer Ingelheim Co., Ltd, Tokyo, Japan
| | - Kohei Kaku
- General Internal Medicine, Kawasaki Medical School, Okayama, Japan.,Faculty of Health and Welfare Services Management, Kawasaki University of Medical Welfare, Okayama, Japan
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18
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Matuszewski W, Baranowska-Jurkun A, Stefanowicz-Rutkowska MM, Gontarz-Nowak K, Gątarska E, Bandurska-Stankiewicz E. The Safety of Pharmacological and Surgical Treatment of Diabetes in Patients with Diabetic Retinopathy-A Review. J Clin Med 2021; 10:705. [PMID: 33670143 PMCID: PMC7916896 DOI: 10.3390/jcm10040705] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/07/2021] [Accepted: 02/08/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Diabetes mellitus (DM) is a non-infectious pandemic of the modern world; it is estimated that in 2045 it will affect 10% of the world's population. As the prevalence of diabetes increases, the problem of its complications, including diabetic retinopathy (DR), grows. DR is a highly specific neurovascular complication of diabetes that occurs in more than one third of DM patients and accounts for 80% of complete vision loss cases in the diabetic population. We are currently witnessing many groundbreaking studies on new pharmacological and surgical methods of treating diabetes. AIM The aim of the study is to assess the safety of pharmacological and surgical treatment of DM in patients with DR. MATERIAL AND METHODS An analysis of the data on diabetes treatment methods currently available in the world literature and their impact on the occurrence and progression of DR. RESULTS A rapid decrease in glycaemia leads to an increased occurrence and progression of DR. Its greatest risk accompanies insulin therapy and sulfonylurea therapy. The lowest risk of DR occurs with the use of SGLT2 inhibitors; the use of DPP-4 inhibitors and GLP-1 analogues is also safe. Patients undergoing pancreatic islet transplants or bariatric surgeries require intensive monitoring of the state of the eye, both in the perioperative and postoperative period. CONCLUSIONS It is of utmost importance to individualize therapy in diabetic patients, in order to gradually achieve treatment goals with the use of safe methods and minimize the risk of development and progression of DR.
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Affiliation(s)
- Wojciech Matuszewski
- Department of Internal Medicine, Endocrinology, Diabetology and Internal Medicine Clinic, University of Warmia and Mazury in Olsztyn, 10-719 Olsztyn, Poland; (A.B.-J.); (M.M.S.-R.); (K.G.-N.); (E.B.-S.)
| | - Angelika Baranowska-Jurkun
- Department of Internal Medicine, Endocrinology, Diabetology and Internal Medicine Clinic, University of Warmia and Mazury in Olsztyn, 10-719 Olsztyn, Poland; (A.B.-J.); (M.M.S.-R.); (K.G.-N.); (E.B.-S.)
| | - Magdalena Maria Stefanowicz-Rutkowska
- Department of Internal Medicine, Endocrinology, Diabetology and Internal Medicine Clinic, University of Warmia and Mazury in Olsztyn, 10-719 Olsztyn, Poland; (A.B.-J.); (M.M.S.-R.); (K.G.-N.); (E.B.-S.)
| | - Katarzyna Gontarz-Nowak
- Department of Internal Medicine, Endocrinology, Diabetology and Internal Medicine Clinic, University of Warmia and Mazury in Olsztyn, 10-719 Olsztyn, Poland; (A.B.-J.); (M.M.S.-R.); (K.G.-N.); (E.B.-S.)
| | - Ewa Gątarska
- Nephrology, Transplantology and Internal Medicine Clinic, Pomeranian Medicine University in Szczecin, 70-204 Szczecin, Poland;
| | - Elżbieta Bandurska-Stankiewicz
- Department of Internal Medicine, Endocrinology, Diabetology and Internal Medicine Clinic, University of Warmia and Mazury in Olsztyn, 10-719 Olsztyn, Poland; (A.B.-J.); (M.M.S.-R.); (K.G.-N.); (E.B.-S.)
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Espeland MA, Pratley RE, Rosenstock J, Kadowaki T, Seino Y, Zinman B, Marx N, McGuire DK, Andersen KR, Mattheus M, Keller A, Weber M, Johansen OE. Cardiovascular outcomes and safety with linagliptin, a dipeptidyl peptidase-4 inhibitor, compared with the sulphonylurea glimepiride in older people with type 2 diabetes: A subgroup analysis of the randomized CAROLINA trial. Diabetes Obes Metab 2021; 23:569-580. [PMID: 33185002 PMCID: PMC7839453 DOI: 10.1111/dom.14254] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/29/2020] [Accepted: 11/06/2020] [Indexed: 12/12/2022]
Abstract
AIM To compare the cardiovascular (CV) safety of linagliptin with glimepiride in older and younger participants in the CAROLINA trial in both prespecified and post hoc analyses. MATERIALS AND METHODS People aged 40 to 85 years with relatively early type 2 diabetes, inadequate glycaemic control and elevated CV risk were randomly assigned to linagliptin 5 mg or glimepiride 1 to 4 mg. The primary endpoint was time to first occurrence of three-point major adverse CV events (MACE: CV death, non-fatal myocardial infarction, or non-fatal stroke). We evaluated clinical and safety outcomes across age groups. RESULTS Of 6033 participants, 50.7% were aged <65 years, 35.3% were aged 65 to 74 years, and 14.0% were aged ≥75 years. During the 6.3-year median follow-up, CV/mortality outcomes did not differ between linagliptin and glimepiride overall (hazard ratio [HR] for three-point MACE 0.98, 95.47% confidence interval [CI] 0.84, 1.14) or across age groups (interaction P >0.05). Between treatment groups, reductions in glycated haemoglobin were comparable across age groups but moderate-to-severe hypoglycaemia was markedly reduced with linagliptin (HR 0.18, 95% CI 0.15, 0.21) with no differences among age groups (P = 0.23). Mean weight was -1.54 kg (95% CI -1.80, -1.28) lower for linagliptin versus glimepiride. Adverse events increased with age, but were generally balanced between treatment groups. Significantly fewer falls or fractures occurred with linagliptin. CONCLUSIONS Linagliptin and glimepiride were comparable for CV/mortality outcomes across age groups. Linagliptin had significantly lower risk of hypoglycaemia and falls or fractures than glimepiride, including in "older-old" individuals for whom these are particularly important treatment considerations.
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Affiliation(s)
- Mark A. Espeland
- Division of Gerontology and Geriatric MedicineWake Forest School of MedicineWinston‐SalemNorth Carolina
| | | | | | | | - Yutaka Seino
- Kansai Electric Power Medical Research InstituteKobeJapan
- Kansai Electric Power HospitalOsakaJapan
| | - Bernard Zinman
- Lunenfeld‐Tanenbaum Research Institute, Mount Sinai HospitalUniversity of TorontoTorontoOntarioCanada
| | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital AachenRWTH Aachen UniversityAachenGermany
| | - Darren K. McGuire
- Division of CardiologyDepartment of Internal Medicine, University of Texas Southwestern Medical Center, and Parkland Health and Hospital SystemDallasTexas
| | | | | | - Annett Keller
- Boehringer Ingelheim Pharma GmbH & Co. KGIngelheimGermany
| | - Maria Weber
- Boehringer Ingelheim International GmbHIngelheimGermany
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Weinrauch LA, Liu J, Segal AR, Woodward J, D'Elia JA. SGLT-2 inhibitors may be targeting higher risk patients with diabetes possibly justifying higher cost: Single center repeated cross-sectional analysis. J Diabetes Complications 2021; 35:107761. [PMID: 33234402 DOI: 10.1016/j.jdiacomp.2020.107761] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 09/23/2020] [Accepted: 09/23/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION We studied the use of all hypoglycemic agents in periods before and after introduction of SGLT-2 inhibitors in the USA by repeated cross sectional analysis to initially assess improvement in HbA1c control among patients with type 2 diabetes and hypertension. We sought to identify changes in glucose management related to the availability of the SGLT-2 inhibiting agents. We hypothesized that patients transitioned to SGLT-2 inhibitor-based therapy represented a higher risk group that derived benefits in terms of Hba1c control. METHODS Deidentified records of patients seen at least twice during the relevant time periods at Joslin Clinic between January 1, 2010 and December 31, 2012 and/or between January 1, 2014 and December 31, 2016 were examined. Records required all of the following: demographic information of gender, age, height, weight, BMI, HbA1c, eGFR, blood pressure, smoking status and completed medication lists. RESULTS 10,191 patients met criteria for analysis, 7769 seen in period 1 and 6576 in period 2. 4625 patients were seen in both periods. The group of patients defined by SGLT-2 use had significantly higher BMI and HbA1c. Notable shifts in medication use were observed as SGLT-2 use increased from none to 14%. Increased use (all p < 0.001) of GLP-1 agents (16.0 to 23.8%), insulin (56.1 to 60.5%) and statins (78.4 to 81.5%) and statistically significant decreases (all p < 0.001) in use of biguanides (69.5 to 66.3%) and sulfonylurea compounds (44.7 to 39.4%), thiazolidinediones (13.6 to 3.4%) and diuretics (32.4 to 28.9%) were observed. Statistically significant decreases (all p < 0.001) of HbA1c (7.9 to 7.8%), BMI (32.5 to 32.1), eGFR (80.6 to 77.5 ml/min) and increased systolic blood pressure (130 to 132 mm Hg) were documented. CONCLUSIONS In the absence of glycemia treatment resistance or clinical heart failure SGLT-2 inhibitor use may not be cost effective. Enthusiasm for use of SGLT-2 inhibition should be based upon long-term cardiorenal protection rather than short-term glycemia control given limited impact upon HbA1c levels in our tertiary care type 2 diabetes population.
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Affiliation(s)
- Larry A Weinrauch
- Kidney and Hypertension Section, Joslin Diabetes Center, E. P Joslin Research Laboratory, USA; Department of Medicine, Beth Israel Deaconess Hospital, USA; Cardiovascular Division, Brigham and Women's Hospital, USA.
| | - Jiankang Liu
- Cardiovascular Division, Brigham and Women's Hospital, USA
| | - Alissa R Segal
- Kidney and Hypertension Section, Joslin Diabetes Center, E. P Joslin Research Laboratory, USA; Department of Pharmacy Practice, MCPHS University, Boston, MA, USA
| | - Jason Woodward
- Kidney and Hypertension Section, Joslin Diabetes Center, E. P Joslin Research Laboratory, USA
| | - John A D'Elia
- Kidney and Hypertension Section, Joslin Diabetes Center, E. P Joslin Research Laboratory, USA; Department of Medicine, Beth Israel Deaconess Hospital, USA
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21
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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22
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Sachinidis A, Nikolic D, Stoian AP, Papanas N, Tarar O, Rizvi AA, Rizzo M. Cardiovascular outcomes trials with incretin-based medications: a critical review of data available on GLP-1 receptor agonists and DPP-4 inhibitors. Metabolism 2020; 111:154343. [PMID: 32810485 DOI: 10.1016/j.metabol.2020.154343] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 08/06/2020] [Accepted: 08/08/2020] [Indexed: 12/11/2022]
Abstract
Glucagon-like peptide-1 receptor agonists (GLP-1RAs) and dipeptidyl peptidase-4 (DPP-4) inhibitors are so called "incretin-based therapies" (IBTs) that represent innovative therapeutic approaches and are commonly used in clinical practice for the treatment of type 2 diabetes mellitus (T2DM). The cardiovascular outcome trials (CVOTs) have provided useful information that has helped to shape changes in clinical practice guidelines for the management of T2DM. At the same time, the mechanisms that may explain the nonglycemic and cardiovascular (CV) benefits of these medications are still being explored. A summary of the main findings from CVOTs performed to-date with particular emphasis on various outcomes and inconsistencies observed in the trials is provided. Overall, available data is favourable to the early deployment of GLP-1RAs in clinical practice, fully in line with recommendations from international scientific guidelines, and based on their effects on glucose metabolism parameters, body weight reduction and CV outcomes. Evidence further suggest that the CV benefits of GLP-1RAs may not be a class effect, with GLP-1 analogues having a greater benefit rather than exendin-based agents.
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Affiliation(s)
- Alexandros Sachinidis
- Department of Health Promotion Sciences Maternal and Infantile Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy; 2nd Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dragana Nikolic
- Department of Health Promotion Sciences Maternal and Infantile Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy.
| | - Anca Pantea Stoian
- Department of Diabetes, Nutrition and Metabolic Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Nikolaos Papanas
- Diabetes Centre-Diabetic Foot Clinic, Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Omer Tarar
- Division of Endocrinology, Diabetes and Metabolism, School of Medicine, University of South Carolina, USA
| | - Ali A Rizvi
- Division of Endocrinology, Diabetes and Metabolism, School of Medicine, University of South Carolina, USA; Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, GA, USA
| | - Manfredi Rizzo
- Department of Health Promotion Sciences Maternal and Infantile Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy; Division of Endocrinology, Diabetes and Metabolism, School of Medicine, University of South Carolina, USA
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23
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Giorgino F, Vora J, Fenici P, Solini A. Cardiovascular protection with sodium-glucose co-transporter-2 inhibitors in type 2 diabetes: Does it apply to all patients? Diabetes Obes Metab 2020; 22:1481-1495. [PMID: 32285611 PMCID: PMC7496739 DOI: 10.1111/dom.14055] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 04/04/2020] [Accepted: 04/05/2020] [Indexed: 12/13/2022]
Abstract
Patients with type 2 diabetes (T2D) are at an increased risk of cardiovascular disease (CVD). Cardiovascular risk in these patients should be considered as a continuum, and comprehensive treatment strategies should aim to target multiple disease risk factors. Large-scale clinical trials of sodium-glucose co-transporter-2 (SGLT2) inhibitors have shown an impact on cardiovascular outcomes, including heart failure hospitalization and cardiovascular death, which appears to be independent of their glucose-lowering efficacy. Reductions in major cardiovascular events appear to be greatest in patients with established CVD, particularly those with prior myocardial infarction, but are independent of heart failure or renal risk. Most large-scale trials of SGLT2 inhibitors predominantly include patients with T2D with pre-existing CVD and high cardiovascular risk at baseline, limiting their applicability to patients typically observed in clinical practice. Real-world evidence from observational studies suggests that there might also be beneficial effects of SGLT2 inhibitors on heart failure hospitalization and all-cause mortality in various cohorts of lower risk patients. The most common adverse events reported in clinical and observational studies are genital infections; however, the overall risk of these events appears to be low and easily managed. Similar safety profiles have been reported for elderly and younger patients. There is still some debate regarding the safety of canagliflozin in patients at high risk of fracture and amputation. Outstanding questions include specific patterns of cardiovascular protection according to baseline risk.
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Affiliation(s)
- Francesco Giorgino
- Department of Emergency and Organ TransplantationUniversity of Bari Aldo MoroBariItaly
| | - Jiten Vora
- Department of Diabetes and EndocrinologyUniversity of Liverpool, LiverpoolUK
| | | | - Anna Solini
- Department of Surgical, MedicalMolecular and Critical Area Pathology, University of PisaPisaItaly
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24
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Boomsma JM, Exalto LG, Barkhof F, Chen CL, Hilal S, Leeuwis AE, Prins ND, Saridin FN, Scheltens P, Teunissen CE, Verwer JH, Weinstein HC, van der Flier WM, Biessels GJ. Prediction of poor clinical outcome in vascular cognitive impairment: TRACE-VCI study. ALZHEIMER'S & DEMENTIA (AMSTERDAM, NETHERLANDS) 2020; 12:e12077. [PMID: 32789162 PMCID: PMC7416669 DOI: 10.1002/dad2.12077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/13/2020] [Accepted: 07/13/2020] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Prognostication in memory clinic patients with vascular brain injury (eg possible vascular cognitive impairment [VCI]) is often uncertain. We created a risk score to predict poor clinical outcome. METHODS Using data from two longitudinal cohorts of memory clinic patients with vascular brain injury without advanced dementia, we created (n = 707) and validated (n = 235) the risk score. Poor clinical outcome was defined as substantial cognitive decline (change of Clinical Dementia Rating ≥1 or institutionalization) or major vascular events or death. Twenty-four candidate predictors were evaluated using Cox proportional hazard models. RESULTS Age, clinical syndrome diagnosis, Disability Assessment for Dementia, Neuropsychiatric Inventory, and medial temporal lobe atrophy most strongly predicted poor outcome and constituted the risk score (C-statistic 0.71; validation cohort 0.78). Of note, none of the vascular predictors were retained in this model. The 2-year risk of poor outcome was 6.5% for the lowest (0-5) and 55.4% for the highest sum scores (10-13). DISCUSSION This is the first, validated, prediction score for 2-year clinical outcome of patients with possible VCI.
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Affiliation(s)
- Jooske M.F. Boomsma
- Department of Neurology and NeurosurgeryUMC Utrecht Brain CenterUniversity Medical Center UtrechtUtrecht UniversiteitUtrechtthe Netherlands
- Department of NeurologyOLVG WestAmsterdamthe Netherlands
| | - Lieza G. Exalto
- Department of Neurology and NeurosurgeryUMC Utrecht Brain CenterUniversity Medical Center UtrechtUtrecht UniversiteitUtrechtthe Netherlands
| | - Frederik Barkhof
- Department of Radiology and Nuclear MedicineVrije Universiteit AmsterdamAmsterdamthe Netherlands
- Institute of NeurologyUCLLondonUK
- Institute of Healthcare EngineeringUCLLondonUK
| | - Christopher L.H. Chen
- Department of PharmacologyNational University of SingaporeSingapore
- Memory Aging and Cognition CenterNational University Health SystemSingapore
| | - Saima Hilal
- Department of PharmacologyNational University of SingaporeSingapore
- Memory Aging and Cognition CenterNational University Health SystemSingapore
| | - Anna E. Leeuwis
- Alzheimer Center AmsterdamDepartment of NeurologyAmsterdam NeuroscienceVrije Universiteit AmsterdamAmsterdam UMCAmsterdamthe Netherlands
| | - Niels D. Prins
- Alzheimer Center AmsterdamDepartment of NeurologyAmsterdam NeuroscienceVrije Universiteit AmsterdamAmsterdam UMCAmsterdamthe Netherlands
| | - Francis N. Saridin
- Department of PharmacologyNational University of SingaporeSingapore
- Memory Aging and Cognition CenterNational University Health SystemSingapore
| | - Philip Scheltens
- Alzheimer Center AmsterdamDepartment of NeurologyAmsterdam NeuroscienceVrije Universiteit AmsterdamAmsterdam UMCAmsterdamthe Netherlands
| | - Charlotte E. Teunissen
- Neurochemistry LaboratoryDepartment of Clinical ChemistryAmsterdam NeuroscienceVrije Universiteit AmsterdamAmsterdam UMCAmsterdamthe Netherlands
| | - Jurre H. Verwer
- Department of Neurology and NeurosurgeryUMC Utrecht Brain CenterUniversity Medical Center UtrechtUtrecht UniversiteitUtrechtthe Netherlands
| | | | - Wiesje M. van der Flier
- Alzheimer Center AmsterdamDepartment of NeurologyAmsterdam NeuroscienceVrije Universiteit AmsterdamAmsterdam UMCAmsterdamthe Netherlands
- Department of EpidemiologyVrije Universiteit AmsterdamAmsterdam UMCAmsterdamthe Netherlands
| | - Geert Jan Biessels
- Department of Neurology and NeurosurgeryUMC Utrecht Brain CenterUniversity Medical Center UtrechtUtrecht UniversiteitUtrechtthe Netherlands
| | - the TRACE‐VCI study group
- Department of Neurology and NeurosurgeryUMC Utrecht Brain CenterUniversity Medical Center UtrechtUtrecht UniversiteitUtrechtthe Netherlands
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25
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Khunti K, Hassanein M, Lee MK, Mohan V, Amod A. Role of Gliclazide MR in the Management of Type 2 Diabetes: Report of a Symposium on Real-World Evidence and New Perspectives. Diabetes Ther 2020; 11:33-48. [PMID: 32440835 PMCID: PMC7415040 DOI: 10.1007/s13300-020-00833-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Indexed: 12/12/2022] Open
Abstract
In patients with type 2 diabetes mellitus (T2DM) who require additional glucose-lowering on top of first-line metformin monotherapy, sulfonylureas are the most common choice for second-line therapy followed by dipeptidyl peptidase inhibitors (DPP-4i). This article summarises presentations at a symposium entitled "Real-World Evidence and New Perspectives with Gliclazide MR" held at the International Diabetes Federation Congress in Busan, South Korea on 4 December 2019. Although guideline recommendations vary between countries, the guidelines with the highest quality ratings include sulfonylureas as one of the preferred choices as second-line therapy for T2DM. Data from randomised controlled trials (RCTs) have consistently demonstrated that sulfonylureas are effective glucose-lowering agents and that the risk of severe hypoglycaemia with these agents is low. In addition, both RCTs and real-world observational studies have shown no increased risk of mortality or cardiovascular disease with the use of newer-generation sulfonylureas compared with other classes of glucose-lowering treatments. However, differences between sulfonylureas do exist, with gliclazide being associated with a significantly lower risk of mortality or cardiovascular mortality compared with glibenclamide, as well as the lowest incidence of severe hypoglycaemia compared with other agents in this class. Recent real-world studies into the effectiveness and safety of gliclazide appear to confirm these findings, and publication of new data from these studies in patients with T2DM in the UK, and in Muslim patients who are fasting during Ramadan, are awaited with interest. Another study being undertaken with gliclazide is a pan-India study in patients with maturity-onset diabetes of the young (MODY) subtypes 1, 3 and 12. Patients with these MODY subtypes respond particularly well to sulfonylurea treatment, and sulfonylureas are the first-line agents of choice in these patients. These new and ongoing studies will add to the cumulative data on the efficacy and safety of certain sulfonylureas in patients with diabetes.
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Affiliation(s)
- Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Mohamed Hassanein
- Department of Endocrinology, Dubai Hospital, Dubai, United Arab Emirates
| | - Moon-Kyu Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Soonchunhyang University Gumi Hospital-Soonchunhyang University School of Medicine, Gumi, Kyungsangbuk-do, 39371, South Korea
| | | | - Aslam Amod
- Life Chatsmed Garden Hospital and Nelson R. Mandela School of Medicine, Durban, South Africa
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26
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Chawla R, Madhu SV, Makkar BM, Ghosh S, Saboo B, Kalra S. RSSDI-ESI Clinical Practice Recommendations for the Management
of Type 2 Diabetes Mellitus 2020. Int J Diabetes Dev Ctries 2020. [PMCID: PMC7371966 DOI: 10.1007/s13410-020-00819-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Rajeev Chawla
- North Delhi Diabetes Centre Rohini, New Delhi, India
| | - S. V. Madhu
- Centre for Diabetes, Endocrinology & Metabolism, UCMS-GTB Hospital, Delhi, India
| | - B. M. Makkar
- Dr Makkar’s Diabetes & Obesity Centre Paschim Vihar, New Delhi, India
| | - Sujoy Ghosh
- Department of Endocrinology & Metabolism, Institute of Post Graduate Medical Education & Research, Kolkata, West Bengal India
| | - Banshi Saboo
- DiaCare - A Complete Diabetes Care Centre, Ahmedabad, India
| | - Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, Haryana India
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27
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John M, Kalra S, Nair T. Modern sulphonylureas and cardiovascular adverse effects: Will CAROLINA put an end to the controversy? Indian Heart J 2020; 72:312-315. [PMID: 32861392 PMCID: PMC7474120 DOI: 10.1016/j.ihj.2020.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/30/2020] [Accepted: 07/07/2020] [Indexed: 12/15/2022] Open
Abstract
Sulphonylureas (SU) form an important role in management of people with type 2 diabetes. This safety history of SU was tainted for various reasons, the predominant one being lack of demonstration of cardiovascular safety. Since its introduction, SU's have never been subjected to a formal study for its cardiovascular safety. The cardiovascular safety of SUs was derived from small, inadequately powered randomised controlled trials (RCT) and observational studies. CAROLINA (CARdiovascular Outcome study of LINAgliptin versus glimepiride in patients with type 2 diabetes) trial planned as a cardiovascular outcome trial randomised people with type 2 diabetes and high cardiovascular risk to Linagliptin and Glimepiride. This opinion paper outlines the salient features of this landmark trial and its implications in general cardiology practice.
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Affiliation(s)
- Mathew John
- Department of Endocrinology and Diabetes, Providence Endocrine and Diabetes Specialty Centre, Trivandrum, Kerala, 695011, India.
| | - Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, Haryana, 132001, India.
| | - Tiny Nair
- Department of Cardiology, PRS Hospital, Trivandrum, Kerala, 695002, India.
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28
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Kadowaki T, Wang G, Rosenstock J, Yabe D, Peng Y, Kanasaki K, Mu Y, Mattheus M, Keller A, Okamura T, Johansen OE, Marx N. Effect of linagliptin, a dipeptidyl peptidase-4 inhibitor, compared with the sulfonylurea glimepiride on cardiovascular outcomes in Asians with type 2 diabetes: subgroup analysis of the randomized CAROLINA® trial. Diabetol Int 2020; 12:87-100. [PMID: 33479584 DOI: 10.1007/s13340-020-00447-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 06/05/2020] [Indexed: 12/15/2022]
Abstract
Objective Linagliptin, a dipeptidyl peptidase-4 inhibitor, recently demonstrated cardiovascular (CV) safety versus placebo in Asians with advanced type 2 diabetes mellitus (T2DM) in the CARMELINA® trial. We assessed its CV safety compared with the sulfonylurea glimepiride in Asians with relatively early T2DM in the CAROLINA® trial. Methods Based on prespecified and post hoc subgroup analyses of the multinational CAROLINA® trial in which adults with relatively early T2DM and elevated CV risk were randomized to linagliptin or glimepiride added to usual care, we analyzed data for participants from Asian countries. This included the primary outcome defined as time to first CV death, non-fatal myocardial infarction, or non-fatal stroke [three-point major adverse cardiovascular events (3P-MACE)]. Results Of the 6033 participants, 933 (15.5%) were from Asia. During a median follow-up of 6.2 years, 3P-MACE occurred in 9.5% and 11.1% of the linagliptin and glimepiride groups, respectively (hazard ratio [HR] 0.85; 95% confidence interval [CI] 0.57-1.26]), consistent with the overall population (HR 0.98; 95% CI 0.84-1.13; P = 0.17 for treatment by region interaction). Similarly, there were no significant differences between groups for other outcomes, including CV death (HR 0.73; 95% CI 0.38-1.38), non-CV mortality (HR 0.76; 95% CI 0.37-1.57) and hospitalization for heart failure (HR 0.89; 95% CI 0.36-2.19). Hypoglycemia adverse events occurred in 13.1% of linagliptin patients versus 42.1% of glimepiride patients (HR 0.25; 95% CI 0.19-0.33; P < 0.0001) despite similar glycemic control. Body weight was slightly lower with linagliptin relative to glimepiride: weighted average mean difference over 256 weeks of - 1.82 kg (95% CI - 2.28 to - 1.35). Conclusions In Asian patients, linagliptin demonstrated similar CV safety to glimepiride with a markedly lower rate of hypoglycemia and modestly lower weight.
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Affiliation(s)
- Takashi Kadowaki
- Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470 Japan
| | - Guang Wang
- Department of Endocrinology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Julio Rosenstock
- Dallas Diabetes Research Center at Medical City and University of Texas Southwestern Medical Center, Dallas, TX USA
| | - Daisuke Yabe
- Department of Diabetes and Endocrinology, Gifu University Graduate School of Medicine, Gifu, Japan.,Yutaka Seino Distinguished Center for Diabetes Research, Kansai Electric Power Medical Research Institute, Kobe, Japan.,Division of Molecular and Metabolic Medicine, Department of Physiology and Cell Biology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yongde Peng
- Department of Endocrinology and Metabolism, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Keizo Kanasaki
- Internal Medicine 1, Faculty of Medicine, Shimane University, Shimane, Japan.,Division of Anticipatory Molecular Food Science and Technology, Medical Research Institute, Kanazawa Medical University, Ishikawa, Japan
| | - Yiming Mu
- Department of Endocrinology, Chinese People's Liberation Army General Hospital, Beijing, China
| | | | - Annett Keller
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | | | | | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
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29
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Abstract
This review describes a presentation at a recent symposium entitled "SUs in the treatment of T2DM: a fresh look and new insights" on Wednesday September 18, 2019 at the 55th Annual Meeting of the European Association for the Study of Diabetes (EASD) in Barcelona, Spain. It examines the current role of sulfonylureas (SUs) in the management of type 2 diabetes mellitus (T2DM) and gives the author's personal perspective of how this therapeutic class has performed in both local and international guidelines. The place of SUs within current guidelines is highlighted, and a critical appraisal of the reasons for the differences between guidelines given. Finally, comparison of evidence-based guidelines and consensus reports is discussed.
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Affiliation(s)
- Aslam Amod
- Department of Diabetes and Endocrinology, Life Chatsmed Garden Hospital, Nelson R Mandela School of Medicine, Durban, South Africa.
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30
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Chilton RJ, Dungan KM, Shubrook JH, Umpierrez GE. Cardiovascular risk and the implications for clinical practice of cardiovascular outcome trials in type 2 diabetes. Prim Care Diabetes 2020; 14:193-212. [PMID: 31704161 DOI: 10.1016/j.pcd.2019.09.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 09/18/2019] [Accepted: 09/30/2019] [Indexed: 12/25/2022]
Abstract
Cardiovascular disease (CVD) is the primary cause of morbidity and mortality in patients with type 2 diabetes (T2D). This review examines the impact of cardiovascular outcome trials (CVOTs) on clinical practice. To date, all CVOTs have shown non-inferiority versus placebo (both added to standard of care) against a primary endpoint of 3- or 4-point major adverse cardiovascular event (MACE), confirming CV safety of these treatments. Additionally, some CVOTs have shown superiority to placebo against the same MACE endpoint, suggesting a cardioprotective action for these treatments. This is reflected in guideline updates, which primary care physicians should consider when personalizing treatments.
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Affiliation(s)
- Robert J Chilton
- Division of Cardiology, University of Texas Health Science Center, San Antonio, TX, USA.
| | - Kathleen M Dungan
- Division of Endocrinology, Diabetes and Metabolism, Ohio State University, Columbus, OH, USA
| | - Jay H Shubrook
- Touro University California College of Osteopathic Medicine, Primary Care Department, Vallejo, CA, USA
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31
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Abstract
This review addresses the question of the cardiovascular (CV) safety of sulfonylureas (SUs) in patients with type 2 diabetes mellitus (T2DM) when directly tested against comparator agents in CV outcome trials. Presented at a recent symposium entitled "SUs in the treatment of T2DM: a fresh look and new insights" held on Wednesday September 18, 2019 during the 55th Annual Meeting of the European Association for the Study of Diabetes (EASD) in Barcelona Spain, this review discusses the initial evidence that sparked concerns over the CV safety of SUs as well as more recent findings from large studies of SUs (i.e. ADVANCE, TOSCA.IT and CAROLINA trials), highlighting the differences in CV and hypoglycaemia risks among the various SUs. Finally, the impact of glycaemic control on CV outcomes is also discussed, where the data suggest that the recent positive CV outcomes with some antihyperglycaemic agents may have been driven in part by improved glycaemic control.
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Affiliation(s)
- Lawrence A Leiter
- Division of Endocrinology and Metabolism, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Canada.
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32
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Guthrie R. Linagliptin in patients with type 2 diabetes and cardiovascular and/or renal disease: results from a cardiovascular and renal outcomes trial. Postgrad Med 2020; 132:314-319. [DOI: 10.1080/00325481.2020.1742524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Robert Guthrie
- The Department of Emergency Medicine, The Ohio State University, Dublin, OH, USA
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33
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Khunti K, Davies MJ, Seidu S. Cardiovascular outcome trials of glucose-lowering therapies. Expert Rev Pharmacoecon Outcomes Res 2020; 20:237-249. [PMID: 32403956 DOI: 10.1080/14737167.2020.1763796] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Early initiated and long-term sustained intensive glucose control is associated with a significantly decreased risk of cardiovascular events and all-cause mortality, over and above the well-established decline in the risk of microvascular disease. Based on the recent cardiovascular outcome trial (CVOT) data, this review focuses on the various benefits of the newer medications with their positioning in the treatment algorithm and explores the place of the older medications in the management of type 2 diabetes mellitus (T2DM). AREAS COVERED We searched the literature for glucose-lowering therapies for patients with T2DM. We included CVOTs conducted for newer sulphonylureas, thiazolidinediones, insulin degludec, DPP-4 inhibitors, SGLT2 inhibitors, and GLP-1 receptor agonists. EXPERT OPINION Selection of glucose-lowering therapy in the management of T2DM should be individualized and based on patient characteristics, associated comorbidities, patient preference, affordability and adherence to treatment. In view of the benefits seen in the CVOTs with SGLT2 inhibitors and GLP-1 receptor agonists, these newer classes should be the preferred choice in patients with/without established atherosclerotic cardiovascular disease and chronic kidney disease.
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Affiliation(s)
- Kamlesh Khunti
- Diabetes Research Centre, Leicester General Hospital, University of Leicester , Leicester, UK
| | - Melanie J Davies
- Diabetes Research Centre, Leicester General Hospital, University of Leicester , Leicester, UK
| | - Samuel Seidu
- Diabetes Research Centre, Leicester General Hospital, University of Leicester , Leicester, UK
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Douros A, Dell'Aniello S, Yu OHY, Suissa S. Comparative cardiovascular and hypoglycaemic safety of glimepiride in type 2 diabetes: A population-based cohort study. Diabetes Obes Metab 2020; 22:254-262. [PMID: 31596043 DOI: 10.1111/dom.13893] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 09/26/2019] [Accepted: 09/30/2019] [Indexed: 12/15/2022]
Abstract
AIM To assess the incidence of cardiovascular and hypoglycaemic adverse events associated with glimepiride compared with other second-generation sulphonylureas among patients with type 2 diabetes in a real-world clinical setting. MATERIALS AND METHODS We identified all sulphonylurea initiators between 1998 and 2017 in the UK Clinical Practice Research Datalink. Using a prevalent new-user design, glimepiride initiators were matched 1:4 with initiators of other second-generation sulphonylureas on calendar time, prior sulphonylurea use, and time-conditional high-dimensional propensity score. Cox proportional hazards models yielded adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for myocardial infarction, ischaemic stroke, severe hypoglycaemia, cardiovascular death, and all-cause mortality. RESULTS Among 66 032 sulphonylurea new users, 6438 initiated glimepiride and were matched to up to 20 582 initiators of other second-generation sulphonylureas. During a mean follow-up of 1.3 years, glimepiride was associated with a similar incidence of myocardial infarction (HR 0.99, 95% CI 0.75-1.30) and ischaemic stroke (HR 0.96, 95% CI 0.72-1.27) compared with other second-generation sulphonylureas, while there was a non-significant trend towards a higher incidence of severe hypoglycaemia (HR 1.24, 95% CI 0.92-1.68). Glimepiride was also associated with a lower incidence of all-cause mortality (HR 0.77, 95% CI 0.67-0.89), and a non-significant but similar trend for cardiovascular death (HR 0.83, 95% CI 0.65-1.05). CONCLUSIONS Glimepiride was associated with a lower incidence of all-cause mortality compared with other second-generation sulphonylureas.
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Affiliation(s)
- Antonios Douros
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- Institute of Clinical Pharmacology and Toxicology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sophie Dell'Aniello
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
| | - Oriana Hoi Yun Yu
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
- Division of Endocrinology, Jewish General Hospital, Montreal, Quebec, Canada
| | - Samy Suissa
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- Division of Clinical Epidemiology, Department of Medicine, McGill University, Montreal, Quebec, Canada
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Nath B, Suvarna VR. CARdiovascular Outcome study of LINAgliptin versus glimepiride in patients with T2D trial. Perspect Clin Res 2020; 11:44-46. [PMID: 32154149 PMCID: PMC7034143 DOI: 10.4103/picr.picr_157_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 12/02/2019] [Accepted: 12/12/2019] [Indexed: 12/26/2022] Open
Affiliation(s)
- Baishali Nath
- Department of Medical, Eris Lifesciences Limited, Ahmedabad, Gujarat, India
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Sharma A, Pagidipati NJ, Califf RM, McGuire DK, Green JB, Demets D, George JT, Gerstein HC, Hobbs T, Holman RR, Lawson FC, Leiter LA, Pfeffer MA, Reusch J, Riesmeyer JS, Roe MT, Rosenberg Y, Temple R, Wiviott S, McMurray J, Granger C. Impact of Regulatory Guidance on Evaluating Cardiovascular Risk of New Glucose-Lowering Therapies to Treat Type 2 Diabetes Mellitus: Lessons Learned and Future Directions. Circulation 2020; 141:843-862. [PMID: 31992065 DOI: 10.1161/circulationaha.119.041022] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Responding to concerns about the potential for increased risk of adverse cardiovascular outcomes, specifically myocardial infarction, associated with certain glucose-lowering therapies, the US Food and Drug Administration and the Committee for Medicinal Products for Human Use of the European Medicines Agency issued guidance to the pharmaceutical industry in 2008. Glucose-lowering therapies were granted regulatory approval primarily from smaller studies that have demonstrated reductions in glycated hemoglobin concentration. Such studies were overall underpowered and of insufficient duration to show any effect on cardiovascular outcomes. The 2008 guidance aimed to ensure the cardiovascular safety of new glucose-lowering therapies to treat patients with type 2 diabetes mellitus. This resulted in a plethora of new cardiovascular outcome trials, most designed primarily as placebo-controlled noninferiority trials, but with many also powered for superiority. Several of these outcome trials demonstrated cardiovascular benefits of the newer agents, resulting in the first-ever cardiovascular protection indications for glucose-lowering therapies. Determining whether the guidance continues to have value in its current form is critically important as we move forward after the first decade of implementation. In February 2018, a think tank comprising representatives from academia, industry, and regulatory agencies convened to consider the guidance in light of the findings of the completed cardiovascular outcome trials. The group made several recommendations for future regulatory guidance and for cardiovascular outcome trials of glucose-lowering therapies. These recommendations include requiring only the 1.3 noninferiority margin for regulatory approval, conducting trials for longer durations, considering studying glucose-lowering therapies as first-line management of type 2 diabetes mellitus, considering heart failure or kidney outcomes within the primary outcome, considering head-to-head active comparator trials, increasing the diversity of patients enrolled, evaluating strategies to streamline registries and the study of unselected populations, and identifying ways to improve translation of trial results to general practice.
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Affiliation(s)
- Abhinav Sharma
- Division of Cardiology, McGill University Health Centre, Montreal, QC, Canada (A.S.).,Division of Cardiovascular Medicine, Stanford University School of Medicine, CA (A.S.)
| | - Neha J Pagidipati
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (N.J.P., J.B.G., M.T.R., C.G.)
| | - Robert M Califf
- Verily Life Sciences and Duke University School of Medicine, Durham, NC (R.M.C.)
| | | | - Jennifer B Green
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (N.J.P., J.B.G., M.T.R., C.G.)
| | | | | | | | | | - Rury R Holman
- Diabetes Trials Unit, University of Oxford, UK (R.R.H.)
| | | | | | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P.)
| | - Jane Reusch
- University of Colorado School of Medicine, Denver (J.R.)
| | | | - Matthew T Roe
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (N.J.P., J.B.G., M.T.R., C.G.)
| | - Yves Rosenberg
- National Heart, Lung, and Blood Institute, Bethesda, MD (Y.R.)
| | - Robert Temple
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD (R.T.)
| | | | | | - Christopher Granger
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (N.J.P., J.B.G., M.T.R., C.G.)
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Effect of empagliflozin beyond glycemic control: Cardiovascular benefit in patients with type 2 diabetes and established cardiovascular disease. Rev Port Cardiol 2020; 38:721-735. [PMID: 31892455 DOI: 10.1016/j.repc.2019.02.008] [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: 06/04/2018] [Revised: 01/16/2019] [Accepted: 02/03/2019] [Indexed: 11/22/2022] Open
Abstract
The prevalence of type 2 diabetes (T2D) continues to increase, and its association with cardiovascular (CV) disease has led to the inclusion of CV endpoints in clinical trials on the treatment of T2D. This article explores the various trials already performed and under development in this field, with particular focus on the EMPA-REG OUTCOME trial. In this trial, empagliflozin, a sodium-glucose co-transporter 2 inhibitor, demonstrated a reduction in CV risk in patients with T2D and established CV disease, in addition to CV safety and a decrease in glycated hemoglobin. This represents a paradigm shift that has led to changes in the international guidelines for the treatment of T2D. These results were maintained in subsequent subgroup analysis for heart failure, chronic kidney disease and peripheral arterial disease, although there are many questions concerning the mechanisms involved in these effects, including whether they are hemodynamic, metabolic or due to decreased myocardial cytoplasmic sodium concentrations. With this reduction in risk for major CV events in patients with T2D, the EMPA-REG OUTCOME trial demonstrated CV protection from a hypoglycemic drug for the first time, and opened a new era in the treatment and management of T2D. This study has led to the development of ongoing trials that will establish which patients will benefit most from this therapy, particularly with regard to comorbidities.
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Chawla R, Madhu SV, Makkar BM, Ghosh S, Saboo B, Kalra S. RSSDI-ESI Clinical Practice Recommendations for the Management of Type 2 Diabetes Mellitus 2020. Indian J Endocrinol Metab 2020; 24:1-122. [PMID: 32699774 PMCID: PMC7328526 DOI: 10.4103/ijem.ijem_225_20] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Rajeev Chawla
- North Delhi Diabetes Centre, Rohini, New Delhi, India
| | - S. V. Madhu
- Centre for Diabetes, Endocrinology and Metabolism, UCMS-GTB Hospital, New Delhi, India
| | - B. M. Makkar
- Dr. Makkar's Diabetes and Obesity Centre, Paschim Vihar, New Delhi, India
| | - Sujoy Ghosh
- Department of Endocrinology and Metabolism, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - Banshi Saboo
- DiaCare - A Complete Diabetes Care Centre, Ahmedabad, Gujarat, India
| | - Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, Haryana, India
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(New antidiabetics and cardiovascular safety in the light of clinical trials). COR ET VASA 2019. [DOI: 10.33678/cor.2019.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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40
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Dedov II, Shestakova MV, Mayorov AY, Vikulova OK, Galstyan GR, Kuraeva TL, Peterkova VA, Smirnova OM, Starostina EG, Surkova EV, Sukhareva OY, Tokmakova AY, Shamkhalova MS, Jarek-Martynova IR, Artemova EV, Beshlieva DD, Bondarenko ON, Volevodz NN, Grigoryan OR, Gomova IS, Dzhemilova ZN, Esayan RM, Ibragimova LI, Kalashnikov VY, Kononenko IV, Laptev DN, Lipatov DV, Motovilin OG, Nikonova TV, Rozhivanov RV, Shestakova EA. Standards of specialized diabetes care. Edited by Dedov I.I., Shestakova M.V., Mayorov A.Yu. 9th edition. DIABETES MELLITUS 2019. [DOI: 10.14341/dm12211] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Dear Colleagues!
We are glad to present the 9th Edition (revised) of Standards of Diabetes Care. These evidence-based guidelines were designed to standardize and facilitate diabetes care in all regions of the Russian Federation.
The Standards are updated on the regular basis to incorporate new data and relevant recommendations from national and international clinical societies, including World Health Organization Guidelines (WHO, 2011, 2013), International Diabetes Federation (IDF, 2011, 2012, 2013), American Diabetes Association (ADA, 2018, 2019), American Association of Clinical Endocrinologists (AACE, 2019), International Society for Pediatric and Adolescent Diabetes (ISPAD, 2014, 2018) and Russian Association of Endocrinologists (RAE, 2011, 2012, 2015). Current edition of the Standards also integrates results of completed randomized clinical trials (ADVANCE, ACCORD, VADT, UKPDS, SAVOR, TECOS, LEADER, EXAMINE, ELIXA, SUSTAIN, DEVOTE, EMPA-REG OUTCOME, CANVAS, DECLARE, CARMELINA, REWIND, etc.), as well as findings from the national studies of diabetes mellitus (DM), conducted in close partnership with a number of Russian hospitals.
Latest data indicates that prevalence of DM in the world increased during the last decade more than two-fold, reaching some 463 million patients by the end of 2019. According to the current estimation by the International Diabetes Federation, 578 million patients will be suffering from diabetes mellitus by by 2030 and 700 million by 2045.
Like many other countries, Russian Federation experiences a sharp rise in the prevalence of DM. According to Russian Federal Diabetes Register, there are at least 4 584 575 patients with DM in this country by the end of 2018 (3,1% of population) with 92% (4 238 503) Type 2 DM, 6% (256 202) Type 1 DM and 2% (89 870) other types of DM, including 8 006 women with gestational DM. However, these results underestimates real quantity of patients, because they consider only registered cases. Results of Russian epidemiological study (NATION) con- firmed that only 54% of Type 2 DM are diagnosed. So real number of patients with DM in Russia is 9 million patients (about 6% of population). This is a great long-term problem, because a lot of patients are not diagnosed, so they dont receive any treatment ant have high risk of vascular complications.
Severe consequences of the global pandemics of DM include its vascular complications: nephropathy, retinopathy, coronary, cerebral, coronary and peripheral vascular disease. These conditions are responsible for the majority of cases of diabetes-related disability and death.
In сurrent edition of the Standards:
New goals of glycemic control for the elderly, based on the presence of functional dependence, as well as for pregnant women, children and adolescents, are given.
Added a snippet that describes the continuous glucose monitoring.
Only low-density lipoprotein cholesterol level is used as a target for lipid metabolism.
Proposes more stringent target levels of blood pressure.
It also features updated guidelines on stratification of treatment in newly diagnosed Type 2 diabetes: the excess of the initial level of HbA1c over the target level was used as a criterion.
In the recommendations for the personalization of the choice of antidiabetic agents, it is taken into account that in certain clinical situations (the presence of atherosclerotic cardiovascular diseases and their risk factors, chronic heart failure, chronic kidney disease, obesity, the risk of hypoglycemia) certain classes of hypoglycemic agents (or individual drugs) have proven advantages.
Recommendations for psychosocial support are added.
The position of metabolic surgery as a method of treatment of DM with morbid obesity is updated.
Recommendations for diagnostic and treatment of hypogonadism syndrome in men with DM are added.
For the first time, evidence levels of confidence and credibility levels of recommendations for diagnostic, therapeutic, rehabilitative and preventive interventions based on a systematic review of the literature are given in accordance with the recommendations of the Center for Healthcare Quality Assessment and Control of the Ministry of Health of the Russian Federation.
This text represents a consensus by the absolute majority of national experts, achieved through a number of fruitful discus- sions held at national meetings and forums.
These guidelines are intended for endocrinologists, primary care physicians and other medical professionals involved in the treatment of DM.
On behalf of the Working Group
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41
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Dedov II, Shestakova MV, Mayorov AY, Vikulova OK, Galstyan GR, Kuraeva TL, Peterkova VA, Smirnova OM, Starostina EG, Surkova EV, Sukhareva OY, Tokmakova AY, Shamkhalova MS, Jarek-Martynova IR, Artemova EV, Beshlieva DD, Bondarenko ON, Volevodz NN, Grigoryan OR, Gomova IS, Dzhemilova ZN, Esayan RM, Ibragimova LI, Kalashnikov VY, Kononenko IV, Laptev DN, Lipatov DV, Motovilin OG, Nikonova TV, Rozhivanov RV, Shestakova EA. Standards of specialized diabetes care. Edited by Dedov I.I., Shestakova M.V., Mayorov A.Yu. 9th edition. DIABETES MELLITUS 2019. [DOI: 10.14341/dm221s1] [Citation(s) in RCA: 154] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Dear Colleagues!
We are glad to present the 9th Edition (revised) of Standards of Diabetes Care. These evidence-based guidelines were designed to standardize and facilitate diabetes care in all regions of the Russian Federation.
The Standards are updated on the regular basis to incorporate new data and relevant recommendations from national and international clinical societies, including World Health Organization Guidelines (WHO, 2011, 2013), International Diabetes Federation (IDF, 2011, 2012, 2013), American Diabetes Association (ADA, 2018, 2019), American Association of Clinical Endocrinologists (AACE, 2019), International Society for Pediatric and Adolescent Diabetes (ISPAD, 2014, 2018) and Russian Association of Endocrinologists (RAE, 2011, 2012, 2015). Current edition of the Standards also integrates results of completed randomized clinical trials (ADVANCE, ACCORD, VADT, UKPDS, SAVOR, TECOS, LEADER, EXAMINE, ELIXA, SUSTAIN, DEVOTE, EMPA-REG OUTCOME, CANVAS, DECLARE, CARMELINA, REWIND, etc.), as well as findings from the national studies of diabetes mellitus (DM), conducted in close partnership with a number of Russian hospitals.
Latest data indicates that prevalence of DM in the world increased during the last decade more than two-fold, reaching some 463 million patients by the end of 2019. According to the current estimation by the International Diabetes Federation, 578 million patients will be suffering from diabetes mellitus by by 2030 and 700 million by 2045.
Like many other countries, Russian Federation experiences a sharp rise in the prevalence of DM. According to Russian Federal Diabetes Register, there are at least 4 584 575 patients with DM in this country by the end of 2018 (3,1% of population) with 92% (4 238 503) Type 2 DM, 6% (256 202) Type 1 DM and 2% (89 870) other types of DM, including 8 006 women with gestational DM. However, these results underestimates real quantity of patients, because they consider only registered cases. Results of Russian epidemiological study (NATION) con- firmed that only 54% of Type 2 DM are diagnosed. So real number of patients with DM in Russia is 9 million patients (about 6% of population). This is a great long-term problem, because a lot of patients are not diagnosed, so they dont receive any treatment ant have high risk of vascular complications.
Severe consequences of the global pandemics of DM include its vascular complications: nephropathy, retinopathy, coronary, cerebral, coronary and peripheral vascular disease. These conditions are responsible for the majority of cases of diabetes-related disability and death.
In сurrent edition of the Standards:
New goals of glycemic control for the elderly, based on the presence of functional dependence, as well as for pregnant women, children and adolescents, are given.
Added a snippet that describes the continuous glucose monitoring.
Only low-density lipoprotein cholesterol level is used as a target for lipid metabolism.
Proposes more stringent target levels of blood pressure.
It also features updated guidelines on stratification of treatment in newly diagnosed Type 2 diabetes: the excess of the initial level of HbA1c over the target level was used as a criterion.
In the recommendations for the personalization of the choice of antidiabetic agents, it is taken into account that in certain clinical situations (the presence of atherosclerotic cardiovascular diseases and their risk factors, chronic heart failure, chronic kidney disease, obesity, the risk of hypoglycemia) certain classes of hypoglycemic agents (or individual drugs) have proven advantages.
Recommendations for psychosocial support are added.
The position of metabolic surgery as a method of treatment of DM with morbid obesity is updated.
Recommendations for diagnostic and treatment of hypogonadism syndrome in men with DM are added.
For the first time, evidence levels of confidence and credibility levels of recommendations for diagnostic, therapeutic, rehabilitative and preventive interventions based on a systematic review of the literature are given in accordance with the recommendations of the Center for Healthcare Quality Assessment and Control of the Ministry of Health of the Russian Federation.
This text represents a consensus by the absolute majority of national experts, achieved through a number of fruitful discus- sions held at national meetings and forums.
These guidelines are intended for endocrinologists, primary care physicians and other medical professionals involved in the treatment of DM.
On behalf of the Working Group
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42
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Affiliation(s)
- Matthew C Riddle
- Division of Endocrinology, Diabetes & Clinical Nutrition, Oregon Health & Science University, Portland, OR
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Patorno E, Schneeweiss S, Gopalakrishnan C, Martin D, Franklin JM. Using Real-World Data to Predict Findings of an Ongoing Phase IV Cardiovascular Outcome Trial: Cardiovascular Safety of Linagliptin Versus Glimepiride. Diabetes Care 2019; 42:2204-2210. [PMID: 31239281 PMCID: PMC6868466 DOI: 10.2337/dc19-0069] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 06/14/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Using real-world data (RWD) from three U.S. claims data sets, we aim to predict the findings of the CARdiovascular Outcome Trial of LINAgliptin Versus Glimepiride in Type 2 Diabetes (CAROLINA) comparing linagliptin versus glimepiride in patients with type 2 diabetes (T2D) at increased cardiovascular risk by using a novel framework that requires passing prespecified validity checks before analyzing the primary outcome. RESEARCH DESIGN AND METHODS Within Medicare and two commercial claims data sets (May 2011-September 2015), we identified a 1:1 propensity score-matched (PSM) cohort of T2D patients 40-85 years old at increased cardiovascular risk who initiated linagliptin or glimepiride by adapting eligibility criteria from CAROLINA. PSM was used to balance >120 confounders. Validity checks included the evaluation of expected power, covariate balance, and two control outcomes for which we expected a positive association and a null finding. We registered the protocol (NCT03648424, ClinicalTrials.gov) before evaluating the composite cardiovascular outcome based on CAROLINA's primary end point. Hazard ratios (HR) and 95% CIs were estimated in each data source and pooled with a fixed-effects meta-analysis. RESULTS We identified 24,131 PSM pairs of linagliptin and glimepiride initiators with sufficient power for noninferiority (>98%). Exposure groups achieved excellent covariate balance, including key laboratory results, and expected associations between glimepiride and hypoglycemia (HR 2.38 [95% CI 1.79-3.13]) and between linagliptin and end-stage renal disease (HR 1.08 [0.66-1.79]) were replicated. Linagliptin was associated with a 9% decreased risk in the composite cardiovascular outcome with a CI including the null (HR 0.91 [0.79-1.05]), in line with noninferiority. CONCLUSIONS In a nonrandomized RWD study, we found that linagliptin has noninferior risk of a composite cardiovascular outcome compared with glimepiride.
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Affiliation(s)
- Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Chandrasekar Gopalakrishnan
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - David Martin
- Office of Medical Policy, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - Jessica M Franklin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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Górriz JL, Cos Claramunt FX, Duque N, Matali A. Review of the renal endpoints used in cardiovascular safety clinical trials in type 2 diabetes mellitus patients and their importance in primary care. Prim Care Diabetes 2019; 13:485-494. [PMID: 31400992 DOI: 10.1016/j.pcd.2019.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 07/12/2019] [Accepted: 07/16/2019] [Indexed: 01/07/2023]
Abstract
Chronic kidney disease (CKD) is one of the most common complications of type 2 diabetes mellitus (T2DM). Furthermore, CKD confers a considerable increase in the risk of cardiovascular (CV) morbidity and mortality. In line with the need to improve knowledge in this field, this article aims to describe the renal endpoints used in the different cardiovascular outcome trials (CVOTs). The objective is to better know the renal variables used in the different CVOTs in order to optimize the implementation of advances in the prevention of progressive diabetic kidney disease in patients with T2DM in clinical practice.
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Affiliation(s)
- Jose Luis Górriz
- Nephrology Department, Hospital Clínico Universitario, INCLIVA, Valencia, Spain; Universidad de Valencia, Valencia, Spain; Grupo Español de Estudio de Nefropatía Diabética (GEENDIAB), Spain.
| | - Francesc Xavier Cos Claramunt
- Innovation and Health in Primary Care Barcelona City, Gerencia Barcelona Ciutat, Institut Català de la Salut, Barcelona, Spain; Universidad Autónoma de Barcelona, Foundation University Institute for Primary Health Care Research Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain; Primary Care Diabetes Europe (PCDE), Antwerpen, Belgium
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Canivell S, Mata-Cases M, Vlacho B, Gratacòs M, Real J, Mauricio D, Franch-Nadal J. How Many Patients with Type 2 Diabetes Meet the Inclusion Criteria of the Cardiovascular Outcome Trials with SGLT2 Inhibitors? Estimations from a Population Database in a Mediterranean Area. J Diabetes Res 2019; 2019:2018374. [PMID: 31815146 PMCID: PMC6877986 DOI: 10.1155/2019/2018374] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 09/30/2019] [Accepted: 10/16/2019] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE Regulatory agencies require the assessment of cardiovascular (CV) safety for new type 2 diabetes (T2D) therapies through CV outcome trials (CVOTs). However, patients included in CVOTs assessing sodium-glucose cotransporter-2 inhibitors (SGLT2i) might not be representative of those seen in clinical practice. This study examined the proportion of patients that would have been enrolled into three main SGLT2i CVOTs to determine whether these trials' eligibility criteria can be applied to a real-world Mediterranean T2D population. METHODS Cross-sectional, retrospective, cohort study of T2D patients registered in primary care centres of the Catalan Institute of Health using medical records from a population database (SIDIAP) that includes approximately 74% of the population in Catalonia (Spain). Eligibility criteria were according to those of three SGLT2i CVOTs: EMPA-REG OUTCOME (empagliflozin), CANVAS (canagliflozin), and DECLARE-TIMI 58 (dapagliflozin). RESULTS By the end of 2016, the database included 373,185 patients with T2D with a mean age of 70 ± 12 years, 54.9% male, with a mean duration of T2D of 9 ± 6 years, and a mean glycated haemoglobin (HbA1c) of 7.12% ± 1.32 (59% with HbA1c < 7%). Of these, 86,534 (23%) had established CV disease and 28% chronic renal failure (estimated glomerular filtration < 60 ml/min/1.73m2). Among all included patients, only 8.2% would have qualified for enrolment into the EMPA-REG OUTCOME trial, 29.6% into the CANVAS program, and 38% into the DECLARE-TIMI 58 trial. The main limiting factors for inclusion would have been a previous history of CV disease and the baseline HbA1c value. CONCLUSION The external validity of the analysed CVOTs is clearly limited when applying the same eligibility criteria to a T2D Mediterranean population.
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Affiliation(s)
- Silvia Canivell
- DAP-Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
- Primary Health Care Center Sant Martí de Provençals, Gerència d'Atenció Primaria, Institut Català de la Salut, Barcelona, Spain
- Health Sciences Research Institute and Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Manel Mata-Cases
- DAP-Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
- CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
- Primary Health Care Center La Mina, Gerència d'Àmbit d'Atenció Primària Barcelona Ciutat, Institut Català de la Salut, Sant Adrià de Besòs, Spain
| | - Bogdan Vlacho
- DAP-Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Mònica Gratacòs
- DAP-Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Jordi Real
- DAP-Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
- CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
| | - Dídac Mauricio
- DAP-Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
- CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
- Department of Endocrinology & Nutrition, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - Josep Franch-Nadal
- DAP-Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
- CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
- Primary Health Care Center Raval Sud, Gerència d'Atenció Primaria, Institut Català de la Salut, Barcelona, Spain
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Webb DR, Davies MJ, Jarvis J, Seidu S, Khunti K. The right place for Sulphonylureas today. Diabetes Res Clin Pract 2019; 157:107836. [PMID: 31479704 DOI: 10.1016/j.diabres.2019.107836] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 08/22/2019] [Indexed: 12/28/2022]
Abstract
The place of Sulphonylurea based insulin secretagogues in the management of Type 2 diabetes appears as controversial today as it was fifty years ago. Newer therapies are associated with less hypoglycaemia and weight gain than Sulphonylureas but currently cost more and lack assurances which come with long-term exposure. Emergence of recent CVOT data for SGLT-2 inhibitors and GLP-1 receptor agonists is likely to influence therapeutic choices and guidance is now supportive of their earlier use in cases at high risk of cardiovascular disease. Meta-analyses of Sulphonylurea trials have failed to indicate a consistent effect (positive or negative) on cardiovascular disease or mortality, although are limited by the relative scarcity of studies directly reporting these outcomes. The CAROLINA trial is reassuring in demonstrating cardiovascular safety for the Sulphonylurea Glimepiride when compared directly with the DPP-4 inhibitor Linagliptin, suggesting either of these agents would be relatively safe second line options after Metformin in the majority of patients. This review provides a balanced assessment of available Sulphonylurea treatments in the context of current cardiovascular outcome trial data (CVOT) data and hopefully assists informed decision making about the place of these drugs in contemporary glucose lowering practice.
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Affiliation(s)
- David R Webb
- University of Leicester, Diabetes Research Centre, Leicester Diabetes Centre, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK.
| | - Melanie J Davies
- University of Leicester, Diabetes Research Centre, Leicester Diabetes Centre, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK.
| | - Janet Jarvis
- University Hospitals of Leicester NHS Trust, Leicester Diabetes Centre, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK.
| | - Sam Seidu
- University of Leicester, Diabetes Research Centre, Leicester Diabetes Centre, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK.
| | - Kamlesh Khunti
- University of Leicester, Diabetes Research Centre, Leicester Diabetes Centre, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK.
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Groeneveld ON, van den Berg E, Johansen OE, Schnaidt S, Hermansson K, Zinman B, Espeland MA, Biessels GJ. Oxidative stress and endothelial dysfunction are associated with reduced cognition in type 2 diabetes. Diab Vasc Dis Res 2019; 16:577-581. [PMID: 31068001 DOI: 10.1177/1479164119848093] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE Type 2 diabetes is associated with cognitive dysfunction, but the mechanisms are unknown. We assessed the relationships of biomarkers of oxidation, endothelial function and inflammation with cognition in participants of the CAROLINA® trial (CARdiovascular Outcome Trial of LINAgliptin Versus Glimepiride in Type 2 Diabetes). METHODS Baseline circulating biomarkers of oxidation (8-iso-prostaglandin F2α), endothelial function (asymmetric dimethylarginine, endothelin-1) and inflammation (C-reactive protein, interleukin-6, tumour necrosis factor-α), based on linear regression, were related to cognition on five domains, as measured with an automated battery. RESULTS In 37 patients (mean age 66.7 ± 8.7 years, median HbA1c 6.9%/52 mmol/mol), 8-iso-prostaglandin F2α was associated with reduced mental flexibility and attention (standardised regression coefficients -0.47, -0.34), whereas asymmetric dimethylarginine was associated with reduced psychomotor speed and attention (standardised regression coefficients -0.39, -0.34). No significant associations were observed between biomarkers of inflammation and cognition. CONCLUSION Elevated biomarkers of oxidation and endothelial function are associated and may play a role in reduced psychomotor speed, mental flexibility and attention in type 2 diabetes.
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Affiliation(s)
- Onno N Groeneveld
- Department of Neurology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Esther van den Berg
- Department of Neurology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Neurology, Erasmus MC - University Medical Center, Rotterdam, The Netherlands
| | - Odd Erik Johansen
- Therapeutic Area Cardiometabolism, Boehringer Ingelheim, Asker, Norway
| | - Sven Schnaidt
- Global Biostatistics and Data Sciences, Boehringer Ingelheim, Ingelheim am Rhein, Germany
| | | | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Mark A Espeland
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Geert Jan Biessels
- Department of Neurology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
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Monteiro P, Aguiar C, Matos P, Silva-Nunes J, Birne R, Branco P, Calado J, Melo M, Polónia J. Effect of empagliflozin beyond glycemic control: Cardiovascular benefit in patients with type 2 diabetes and established cardiovascular disease. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.repce.2019.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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49
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Rosenstock J, Kahn SE, Johansen OE, Zinman B, Espeland MA, Woerle HJ, Pfarr E, Keller A, Mattheus M, Baanstra D, Meinicke T, George JT, von Eynatten M, McGuire DK, Marx N. Effect of Linagliptin vs Glimepiride on Major Adverse Cardiovascular Outcomes in Patients With Type 2 Diabetes: The CAROLINA Randomized Clinical Trial. JAMA 2019; 322:1155-1166. [PMID: 31536101 PMCID: PMC6763993 DOI: 10.1001/jama.2019.13772] [Citation(s) in RCA: 357] [Impact Index Per Article: 71.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 08/15/2019] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Type 2 diabetes is associated with increased cardiovascular risk. In placebo-controlled cardiovascular safety trials, the dipeptidyl peptidase-4 inhibitor linagliptin demonstrated noninferiority, but it has not been tested against an active comparator. OBJECTIVE This trial assessed cardiovascular outcomes of linagliptin vs glimepiride (sulfonylurea) in patients with relatively early type 2 diabetes and risk factors for or established atherosclerotic cardiovascular disease. DESIGN, SETTING, AND PARTICIPANTS Randomized, double-blind, active-controlled, noninferiority trial, with participant screening from November 2010 to December 2012, conducted at 607 hospital and primary care sites in 43 countries involving 6042 participants. Adults with type 2 diabetes, glycated hemoglobin of 6.5% to 8.5%, and elevated cardiovascular risk were eligible for inclusion. Elevated cardiovascular risk was defined as documented atherosclerotic cardiovascular disease, multiple cardiovascular risk factors, aged at least 70 years, and evidence of microvascular complications. Follow-up ended in August 2018. INTERVENTIONS Patients were randomized to receive 5 mg of linagliptin once daily (n = 3023) or 1 to 4 mg of glimepiride once daily (n = 3010) in addition to usual care. Investigators were encouraged to intensify glycemic treatment, primarily by adding or adjusting metformin, α-glucosidase inhibitors, thiazolidinediones, or insulin, according to clinical need. MAIN OUTCOMES AND MEASURES The primary outcome was time to first occurrence of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke with the aim to establish noninferiority of linagliptin vs glimepiride, defined by the upper limit of the 2-sided 95.47% CI for the hazard ratio (HR) of linagliptin relative to glimepiride of less than 1.3. RESULTS Of 6042 participants randomized, 6033 (mean age, 64.0 years; 2414 [39.9%] women; mean glycated hemoglobin, 7.2%; median duration of diabetes, 6.3 years; 42% with macrovascular disease; 59% had undergone metformin monotherapy) were treated and analyzed. The median duration of follow-up was 6.3 years. The primary outcome occurred in 356 of 3023 participants (11.8%) in the linagliptin group and 362 of 3010 (12.0%) in the glimepiride group (HR, 0.98 [95.47% CI, 0.84-1.14]; P < .001 for noninferiority), meeting the noninferiority criterion but not superiority (P = .76). Adverse events occurred in 2822 participants (93.4%) in the linagliptin group and 2856 (94.9%) in the glimepiride group, with 15 participants (0.5%) in the linagliptin group vs 16 (0.5%) in the glimepiride group with adjudicated-confirmed acute pancreatitis. At least 1 episode of hypoglycemic adverse events occurred in 320 (10.6%) participants in the linagliptin group and 1132 (37.7%) in the glimepiride group (HR, 0.23 [95% CI, 0.21-0.26]). CONCLUSIONS AND RELEVANCE Among adults with relatively early type 2 diabetes and elevated cardiovascular risk, the use of linagliptin compared with glimepiride over a median 6.3 years resulted in a noninferior risk of a composite cardiovascular outcome. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01243424.
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Affiliation(s)
- Julio Rosenstock
- Dallas Diabetes Research Center at Medical City, Dallas, Texas
- University of Texas Southwestern Medical Center, Dallas
| | - Steven E. Kahn
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, VA Puget Sound Health Care System, Seattle, Washington
- University of Washington, Seattle
| | | | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada
- Division of Endocrinology, University of Toronto, Toronto, Canada
| | - Mark A. Espeland
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | | | - Egon Pfarr
- Boehringer Ingelheim International GmbH & Co KG, Ingelheim, Germany
| | - Annett Keller
- Boehringer Ingelheim International GmbH & Co KG, Ingelheim, Germany
| | | | | | - Thomas Meinicke
- Boehringer Ingelheim International GmbH & Co KG, Biberach, Germany
| | | | | | | | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Germany
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50
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Nauck MA, McGuire DK, Pieper KS, Lokhnygina Y, Strandberg TE, Riefflin A, Delibasi T, Peterson ED, White HD, Scott R, Holman RR. Sitagliptin does not reduce the risk of cardiovascular death or hospitalization for heart failure following myocardial infarction in patients with diabetes: observations from TECOS. Cardiovasc Diabetol 2019; 18:116. [PMID: 31481069 PMCID: PMC6719352 DOI: 10.1186/s12933-019-0921-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 08/22/2019] [Indexed: 12/11/2022] Open
Abstract
Background To examine the effects of the DPP-4i sitagliptin on CV outcomes during and after incident MI in the Trial Evaluating Cardiovascular Outcomes with Sitagliptin (TECOS). Methods TECOS randomized 14,671 participants with type 2 diabetes and atherosclerotic cardiovascular disease (ASCVD) to sitagliptin or placebo, in addition to usual care. For those who had a within-trial MI, we analyzed case fatality, and for those with a nonfatal MI, we examined a composite cardiovascular (CV) outcome (CV death or hospitalization for heart failure [hHF]) by treatment group, using Cox proportional hazards models left-censored at the time of the first within-trial MI, without and with adjustment for potential confounders, in intention-to-treat analyses. Results During TECOS, 616 participants had ≥ 1 MI (sitagliptin group 300, placebo group 316, HR 0.95, 95% CI 0.81–1.11, P = 0.49), of which 25 were fatal [11 and 14, respectively]). Of the 591 patients with a nonfatal MI, 87 (15%) died subsequently, with 66 (11%) being CV deaths, and 57 (10%) experiencing hHF. The composite outcome occurred in 58 (20.1%; 13.9 per 100 person-years) sitagliptin group participants and 50 (16.6%; 11.7 per 100 person-years) placebo group participants (HR 1.21, 95% CI 0.83–1.77, P = 0.32, adjusted HR 1.23, 95% CI 0.83–1.82, P = 0.31). On-treatment sensitivity analyses also showed no significant between-group differences in post-MI outcomes. Conclusions In patients with type 2 diabetes and ASCVD experiencing an MI, sitagliptin did not reduce subsequent risk of CV death or hHF, contrary to expectations derived from preclinical animal models. Trial registration clinicaltrials.gov no. NCT00790205
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Affiliation(s)
- Michael A Nauck
- Division of Diabetology, Medical Department I, St. Josef-Hospital (Ruhr-University), Bochum, Germany.
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Karen S Pieper
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Yuliya Lokhnygina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Timo E Strandberg
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland.,Center for Life Course Health Research, University of Oulu, Oulu, Finland
| | - Axel Riefflin
- Practise Internal Medicine/Diabetology, Husby, Germany
| | - Tuncay Delibasi
- Department of Internal Medicine, Hacettepe University, Ankara, Turkey
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Harvey D White
- Coronary Care and Cardiovascular Research at the Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Russell Scott
- Don Beaven Medical Research Center, Christchurch Hospital, Christchurch, New Zealand
| | - Rury R Holman
- Diabetes Trials Unit, Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Churchill Hospital, Oxford, UK
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