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Mascolo A, Rafaniello C, di Mauro G, Ruggiero D, Campitiello MR, Donniacuo M, Berrino PM, Rossi F, Paolisso G, Capuano A. Sodium-glucose cotransporter-2 (SGLT2) inhibitors and the reporting of falls and fractures: an european pharmacovigilance analysis. Front Pharmacol 2023; 14:1245642. [PMID: 38027019 PMCID: PMC10657831 DOI: 10.3389/fphar.2023.1245642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
Background: The risk of falls and bone fractures with sodium-glucose co-transporter-2 (SGLT2) inhibitors has been characterized by conflicting evidence. Therefore, we decided to investigate the reporting probability of falls and fractures by comparing SGLT2 inhibitors with DPP4 inhibitors. Methods A retrospective, pharmacovigilance study of the European database of Individual Case Safety Reports (ICSRs) was conducted. Disproportionality analyses (Reporting Odds Ratio, ROR) were conducted to compare the reporting probability of falls or fracture between treatments. Results A total of 507 ICSRs reporting at least one fall or fracture with SGLT2 inhibitors were identified. The most reported SGLT2 inhibitor was canagliflozin (N = 188; 36.9%), followed by empagliflozin (N = 176; 34.5%), and dapagliflozin (N = 143; 28.0%). A total of 653 events related to fall or bone fracture were reported. Fall was the most reported event (N = 333; 51.0%). Among fractures (N = 320; 49.0%), the most reported were foot fractures (N = 40; 6.1%) and hip fractures (N = 32; 4.9%). SGLT2 inhibitors were associated with a lower reporting probability of fall than DPP4 inhibitors (ROR, 0.66; 95%CI, 0.57-0.78). The lower reporting probability of fall was also observed when the single SGLT2 inhibitor was compared to DPP4 inhibitors: dapagliflozin (ROR, 0.67; 95%CI, 0.53-0.83), canagliflozin (ROR, 0.56; 95%CI, 0.45-0.70), and empagliflozin (ROR, 0.77; 95%CI, 0.63-0.94). For fractures, canagliflozin showed a slightly significant increased reporting when compared with DPP4 inhibitors (not confirmed in the sensitivity analysis), whereas all other comparison showed no statistically significant difference. Conclusion SGLT2 inhibitors were associated with a lower reporting probability of fall than DPP4 inhibitors, in accordance with the reassuring evidence about the safety profile of these drugs. Future researches will help to confirm their long-term safety profile.
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Affiliation(s)
- Annamaria Mascolo
- Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Naples, Italy
- Department of Experimental Medicine–Section of Pharmacology “L. Donatelli”, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Concetta Rafaniello
- Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Naples, Italy
- Department of Experimental Medicine–Section of Pharmacology “L. Donatelli”, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Gabriella di Mauro
- Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Naples, Italy
- Department of Experimental Medicine–Section of Pharmacology “L. Donatelli”, University of Campania “Luigi Vanvitelli”, Naples, Italy
- UOC Pharmacy, AORN Santobono-Pausilipon Children’s Hospital, Naples, Italy
| | - Donatella Ruggiero
- Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Naples, Italy
- Department of Experimental Medicine–Section of Pharmacology “L. Donatelli”, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Maria Rosaria Campitiello
- Department of obstetrics and gynaecology and physiopathology of human reproduction, ASL Salerno, Salerno, Italy
| | - Maria Donniacuo
- Department of Experimental Medicine–Section of Pharmacology “L. Donatelli”, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Pasquale Maria Berrino
- Department of Specialized Medicine, Diagnostic and Experimental, University of Bologna “Alma Mater Studiorum”, Bologna, Italy
| | - Francesco Rossi
- Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Naples, Italy
- Department of Experimental Medicine–Section of Pharmacology “L. Donatelli”, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Giuseppe Paolisso
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
- UniCamillus, International Medical University, Rome, Italy
| | - Annalisa Capuano
- Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Naples, Italy
- Department of Experimental Medicine–Section of Pharmacology “L. Donatelli”, University of Campania “Luigi Vanvitelli”, Naples, Italy
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van Hulten V, Driessen JHM, Starup-Linde JK, Al-Mashhadi ZK, Viggers R, Klungel OH, Souverein PC, Vestergaard P, Stehouwer CDA, van den Bergh JP. The associations of sodium-glucose cotransporter-2 inhibitors versus dipeptidyl peptidase-4 inhibitors as add-on to metformin with fracture risk in patients with type 2 diabetes mellitus. Diabetes Obes Metab 2023; 25:3235-3247. [PMID: 37503747 DOI: 10.1111/dom.15220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/28/2023] [Accepted: 07/02/2023] [Indexed: 07/29/2023]
Abstract
AIM To investigate whether sodium-glucose cotransporter-2 (SGLT2) inhibitor use as compared to dipeptidyl peptidase-4 (DPP-4) inhibitor use as add-on to metformin is associated with the risk of any fracture or major osteoporotic fractures (MOFs). METHODS A cohort study using the Clinical Practice Research Datalink (CPRD) Aurum database was conducted. All patients aged 18 years and older with a first-ever prescription for a DPP-4 inhibitor or an SGLT2 inhibitor as add-on to metformin between January 1, 2013 and June 30, 2020 were selected. Patients starting with SGLT2 inhibitors were matched (up to 1:3) on propensity scores to patients starting with DPP-4 inhibitors. Propensity scores were calculated based on sex, age, body mass index, comorbidities, comedication and lifestyle factors. Cox proportional hazard models were used to estimate the risk of fracture with SGLT2 inhibitor use as compared to DPP-4 inhibitor use. RESULTS A total of 13 807 SGLT2 inhibitor users (age 55.4 ± 10.6 years, 36.7% female) were included in this study, matched with 28 524 DPP-4 inhibitor users (age 55.4 ± 8.0 years, 36.4% female). The risk of any fracture with current SGLT2 inhibitor use was similar compared with current DPP-4 inhibitor use (adjusted hazard ratio [aHR] 1.09, 95% confidence interval [CI] 0.91-1.31), as was the risk of MOFs (aHR 0.89, 95% CI 0.64-1.22) and the risk of fractures at any of the individual MOF sites. Additionally, no association was found with duration of SGLT2 inhibitor use (longest duration >811 days) for any of the individual SGLT2 inhibitor agents, or after stratification by sex and age. CONCLUSION Use of SGLT2 inhibitors was not associated with the risk of any fracture, MOFs or fracture at the individual MOF sites when compared to DPP-4 inhibitor use.
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Affiliation(s)
- Veerle van Hulten
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+ (MUMC+), Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Johanna H M Driessen
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+ (MUMC+), Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Jakob K Starup-Linde
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Zheer K Al-Mashhadi
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Rikke Viggers
- Steno Diabetes Center North Denmark, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Olaf H Klungel
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Patrick C Souverein
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Peter Vestergaard
- Steno Diabetes Center North Denmark, Aalborg, Denmark
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - Coen D A Stehouwer
- Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre+ (MUMC+), Maastricht, Netherlands
| | - Joop P van den Bergh
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
- Department of Internal Medicine, Division of Rheumatology, Maastricht University Medical Centre+ (MUMC+), Maastricht, The Netherlands
- Department of Internal Medicine, Subdivision of Endocrinology, VieCuri Medical Center, Venlo, The Netherlands
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Yildirim G, Bergamo ETP, Poudel SB, Ruff RR, Dixit M, Hu B, Mijares DQ, Witek L, Chlebek C, Harrison DE, Strong R, Miller RA, Ladiges W, Bromage TG, Rosen CJ, Yakar S. Long-term effects of canagliflozin treatment on the skeleton of aged UM-HET3 mice. GeroScience 2023; 45:1933-1951. [PMID: 37166526 PMCID: PMC10400751 DOI: 10.1007/s11357-023-00803-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 04/18/2023] [Indexed: 05/12/2023] Open
Abstract
Sodium glucose cotransporter-2 inhibitors (SGLT2is) promote urinary glucose excretion and decrease plasma glucose levels independent of insulin. Canagliflozin (CANA) is an SGLT2i, which is widely prescribed, to reduce cardiovascular complications, and as a second-line therapy after metformin in the treatment of type 2 diabetes mellitus. Despite the robust metabolic benefits, reductions in bone mineral density (BMD) and cortical fractures were reported for CANA-treated subjects. In collaboration with the National Institute on Aging (NIA)-sponsored Interventions Testing Program (ITP), we tested skeletal integrity of UM-HET3 mice fed control (137 mice) or CANA-containing diet (180 ppm, 156 mice) from 7 to 22 months of age. Micro-computed tomography (micro-CT) revealed that CANA treatment caused significant thinning of the femur mid-diaphyseal cortex in both male and female mice, did not affect trabecular bone architecture in the distal femur or the lumbar vertebra-5 in male mice, but was associated with thinning of the trabeculae at the distal femur in CANA-treated female mice. In male mice, CANA treatment is associated with significant reductions in cortical bone volumetric BMD by micro-CT, and by quantitative backscattered scanning electron microscopy. Raman microspectroscopy, taken at the femur mid-diaphyseal posterior cortex, showed significant reductions in the mineral/matrix ratio and an increased carbonate/phosphate ratio in CANA-treated male mice. These data were supported by thermogravimetric assay (TGA) showing significantly decreased mineral and increased carbonate content in CANA-treated male mice. Finally, the sintered remains of TGA were subjected to X-ray diffraction and showed significantly higher fraction of whitlockite, a calcium orthophosphate mineral, which has higher resorbability than hydroxyapatite. Overall, long-term CANA treatment compromised bone morphology and mineral composition of bones, which likely contribute to increased fracture risk seen with this drug.
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Affiliation(s)
- Gozde Yildirim
- David B. Kriser Dental Center, Department of Molecular Pathobiology, New York University College of Dentistry, 345 East 24Th Street, New York, NY 10010-4086 USA
| | - Edmara T. P. Bergamo
- David B. Kriser Dental Center, Biomaterials Division, Department of Molecular Pathobiology, NYU College of Dentistry, New York, NY 10010-4086 USA
| | - Sher Bahadur Poudel
- David B. Kriser Dental Center, Department of Molecular Pathobiology, New York University College of Dentistry, 345 East 24Th Street, New York, NY 10010-4086 USA
| | - Ryan R. Ruff
- David B. Kriser Dental Center, Department of Epidemiology and Health Promotion, New York University College of Dentistry, New York, NY 10010-4086 USA
| | - Manisha Dixit
- David B. Kriser Dental Center, Department of Molecular Pathobiology, New York University College of Dentistry, 345 East 24Th Street, New York, NY 10010-4086 USA
| | - Bin Hu
- David B. Kriser Dental Center, Department of Molecular Pathobiology, New York University College of Dentistry, 345 East 24Th Street, New York, NY 10010-4086 USA
| | - Dindo Q. Mijares
- David B. Kriser Dental Center, Biomaterials Division, Department of Molecular Pathobiology, NYU College of Dentistry, New York, NY 10010-4086 USA
| | - Lukasz Witek
- David B. Kriser Dental Center, Biomaterials Division, Department of Molecular Pathobiology, NYU College of Dentistry, New York, NY 10010-4086 USA
- Department of Biomedical Engineering, Tandon School of Engineering New York University, Brooklyn, NY 11201 USA
| | - Carolyn Chlebek
- Center for Clinical and Translational Research, Maine Medical Center Research Institute, Scarborough, USA
| | | | - Randy Strong
- Geriatric Research, Education and Clinical Center and Research Service, South Texas Veterans Health Care System, San Antonio, TX USA
- Barshop Institute for Longevity and Aging Studies and Department of Pharmacology, The University of Texas Health Science Center, San Antonio, TX USA
| | - Richard A. Miller
- Department of Pathology and Geriatrics Center, University of Michigan, Ann Arbor, MI USA
| | - Warren Ladiges
- Department of Comparative Medicine, School of Medicine, University of Washington, Seattle, WA USA
| | - Timothy G. Bromage
- David B. Kriser Dental Center, Department of Molecular Pathobiology, New York University College of Dentistry, 345 East 24Th Street, New York, NY 10010-4086 USA
| | - Clifford J. Rosen
- Center for Clinical and Translational Research, Maine Medical Center Research Institute, Scarborough, USA
| | - Shoshana Yakar
- David B. Kriser Dental Center, Department of Molecular Pathobiology, New York University College of Dentistry, 345 East 24Th Street, New York, NY 10010-4086 USA
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Abstract
Patients with chronic kidney disease (CKD) exhibit tremendously elevated risk for cardiovascular disease, particularly ischemic heart disease, due to premature vascular and cardiac aging and accelerated ectopic calcification. The presence of cardiovascular calcification associates with increased risk in patients with CKD. Disturbed mineral homeostasis and diverse comorbidities in these patients drive increased systemic cardiovascular calcification in different manifestations with diverse clinical consequences, like plaque instability, vessel stiffening, and aortic stenosis. This review outlines the heterogeneity in calcification patterning, including mineral type and location and potential implications on clinical outcomes. The advent of therapeutics currently in clinical trials may reduce CKD-associated morbidity. Development of therapeutics for cardiovascular calcification begins with the premise that less mineral is better. While restoring diseased tissues to a noncalcified homeostasis remains the ultimate goal, in some cases, calcific mineral may play a protective role, such as in atherosclerotic plaques. Therefore, developing treatments for ectopic calcification may require a nuanced approach that considers individual patient risk factors. Here, we discuss the most common cardiac and vascular calcification pathologies observed in CKD, how mineral in these tissues affects function, and the potential outcomes and considerations for therapeutic strategies that seek to disrupt the nucleation and growth of mineral. Finally, we discuss future patient-specific considerations for treating cardiac and vascular calcification in patients with CKD-a population in need of anticalcification therapies.
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Affiliation(s)
- Joshua D Hutcheson
- Department of Biomedical Engineering, Florida International University, Miami, FL (J.D.H.)
| | - Claudia Goettsch
- Department of Internal Medicine I, Division of Cardiology, Medical Faculty, RWTH Aachen University, Germany (C.G.)
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Jiang L, Jia Y, Wang X, Wang Z, Lv X, Jia Y, Feng Y, Yin H, Yan M, Fan X, Liu Y. Insights into efficacy and safety of dapagliflozin treatment for the management in older adults with type 2 diabetes: a systematic review and meta-analysis. Expert Opin Drug Saf 2023; 22:407-416. [PMID: 36608279 DOI: 10.1080/14740338.2023.2166485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 12/08/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND This study aimed to evaluate the efficacy and safety of dapagliflozin as a monotherapy glucose-lowering drug treatment for older adults with diabetes. RESEARCH DESIGN & METHODS Randomized controlled trial reports were retrieved from PubMed, Embase Cochrane Library, and Web of Science from database inception to 8 May 2021. Publication bias and heterogeneity were assessed using the Cochrane risk-of-bias tool and the Cochrane Q statistic, respectively. RESULTS Compared with placebo, dapagliflozin as a monotherapy glucose-lowering drug did improve the control of glycosylated hemoglobin and fasting plasma glucose levels in older adults. Our analysis also confirmed that the body weight of older adults was well controlled under treatment of dapagliflozin as a monotherapy glucose-lowering drug. Patients in older adults with diabetes took a higher risk of genital infection and renal impairment or failure after treatment of dapagliflozin. In addition, treatment with dapagliflozin reduced the risk of hypoglycemia, and did not reveal increased risk of urinary tract infection and developing fractures compared to placebo in older adults. CONCLUSIONS Dapagliflozin as a monotherapy glucose-lowering drug appeared to be an effective treatment for older adults with diabetes, although it might increase risk of genital infection and renal impairment or failure.
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Affiliation(s)
- Lili Jiang
- School of Life and Pharmaceutical Sciences, Dalian University of Technology, Panjin, Liaoning, China
| | - Yanyan Jia
- School of Life and Pharmaceutical Sciences, Dalian University of Technology, Panjin, Liaoning, China
| | - Xiaoyu Wang
- School of Life and Pharmaceutical Sciences, Dalian University of Technology, Panjin, Liaoning, China
| | - Zhe Wang
- School of Life and Pharmaceutical Sciences, Dalian University of Technology, Panjin, Liaoning, China
| | - Xin Lv
- School of Life and Pharmaceutical Sciences, Dalian University of Technology, Panjin, Liaoning, China
| | - Yaqin Jia
- School of Life and Pharmaceutical Sciences, Dalian University of Technology, Panjin, Liaoning, China
| | - Yuyi Feng
- School of Life and Pharmaceutical Sciences, Dalian University of Technology, Panjin, Liaoning, China
| | - Hang Yin
- School of Life and Pharmaceutical Sciences, Dalian University of Technology, Panjin, Liaoning, China
| | - Mingrui Yan
- School of Life and Pharmaceutical Sciences, Dalian University of Technology, Panjin, Liaoning, China
| | - Xiaoyu Fan
- School of Life and Pharmaceutical Sciences, Dalian University of Technology, Panjin, Liaoning, China
| | - Yong Liu
- School of Life and Pharmaceutical Sciences, Dalian University of Technology, Panjin, Liaoning, China
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Čertíková Chábová V, Zakiyanov O. Sodium Glucose Cotransporter-2 Inhibitors: Spotlight on Favorable Effects on Clinical Outcomes beyond Diabetes. Int J Mol Sci 2022; 23:ijms23052812. [PMID: 35269954 PMCID: PMC8911473 DOI: 10.3390/ijms23052812] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 02/28/2022] [Accepted: 03/02/2022] [Indexed: 12/16/2022] Open
Abstract
Sodium glucose transporter type 2 (SGLT2) molecules are found in proximal tubules of the kidney, and perhaps in the brain or intestine, but rarely in any other tissue. However, their inhibitors, intended to improve diabetes compensation, have many more beneficial effects. They improve kidney and cardiovascular outcomes and decrease mortality. These benefits are not limited to diabetics but were also found in non-diabetic individuals. The pathophysiological pathways underlying the treatment success have been investigated in both clinical and experimental studies. There have been numerous excellent reviews, but these were mostly restricted to limited aspects of the knowledge. The aim of this review is to summarize the known experimental and clinical evidence of SGLT2 inhibitors' effects on individual organs (kidney, heart, liver, etc.), as well as the systemic changes that lead to an improvement in clinical outcomes.
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Rau M, Thiele K, Hartmann NUK, Möllmann J, Wied S, Hohl M, Marx N, Lehrke M. Effects of empagliflozin on markers of calcium and phosphate homeostasis in patients with type 2 diabetes – Data from a randomized, placebo-controlled study. Bone Rep 2022; 16:101175. [PMID: 35242892 PMCID: PMC8857445 DOI: 10.1016/j.bonr.2022.101175] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 02/11/2022] [Indexed: 01/10/2023] Open
Abstract
Background and aim Sodium-glucose cotransporter-2 (SGLT2) inhibitors, glucose-lowering drugs that increase urinary glucose excretion have been shown to reduce CV events in patients with type 2 diabetes (T2D). Furthermore, several studies have demonstrated that treatment with SGLT2 inhibitors affect calcium and phosphate homeostasis, but the effect of empagliflozin on these biomarkers is hitherto not investigated in detail. Therefore, this analysis of the EMPA hemodynamics study examined effects of empagliflozin on calcium and phosphate homeostasis. Methods In this placebo-controlled, randomized, double-blind study patients with T2D were randomized to empagliflozin 10 mg (n = 20) or placebo (n = 22). Biomarkers of calcium and phosphate homeostasis were assessed before, and after 3 days and 3 months of treatment. Results After 3 days of treatment empagliflozin significantly increased serum levels of phosphate (baseline: 1.10 ± 0.21 mmol/L; day 3: 1.25 ± 0.23 mmol/L; p = 0.036), parathyroid hormone (PTH) (baseline: 57.40 ± 30.49 pg/mL; day 3: 70.23 ± 39.25 pg/mL; p = 0.025), fibroblast growth factor 23 (FGF23) (baseline: 77.92 ± 24.31 pg/mL; day 3: 109.18 ± 58.20 pg/mL; p = 0.001) and decreased 1,25-dihydroxyvitamin D (baseline: 35.01 ± 14.01 ng/L; day 3: 22.09 ± 10.02 mg/L; p < 0.001), while no difference of these parameters was recorded after 3 months of treatment. Empagliflozin had no significant effects on serum calcium and markers of bone resorption (collagen type 1 β-carboxy-telopeptide = β-CTX) or formation (osteocalcin) after 3 days and 3 months of treatment. Conclusions Empagliflozin treatment of patients with T2D transiently increases serum phosphate, PTH and FGF23, and decreases 1,25-dihydroxyvitamin D. This might reflect a temporal increase of sodium driven phosphate reabsorption in the proximal tubule of the kidney caused by increased sodium availability in response to SGLT2 inhibition. Empagliflozin transiently increases serum phosphate. This might reflect an increase of Na+ driven phosphate reabsorption in the kidney. Empagliflozin had no effects on markers of bone resorption or formation.
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Affiliation(s)
- Matthias Rau
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Kirsten Thiele
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | | | - Julia Möllmann
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Stephanie Wied
- Department of Medical Statistics, RWTH Aachen University, Aachen, Germany
| | - Mathias Hohl
- Department of Internal Medicine III, University Hospital Saarland, Saarland University, Homburg/Saar, Germany
| | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
- Corresponding author at: Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Pauwelsstraße 30, D-52074 Aachen, Germany.
| | - Michael Lehrke
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
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Zhuo M, Hawley CE, Paik JM, Bessette LG, Wexler DJ, Kim DH, Tong AY, Kim SC, Patorno E. Association of Sodium-Glucose Cotransporter-2 Inhibitors With Fracture Risk in Older Adults With Type 2 Diabetes. JAMA Netw Open 2021; 4:e2130762. [PMID: 34705014 PMCID: PMC8552056 DOI: 10.1001/jamanetworkopen.2021.30762] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Whether sodium-glucose cotransporter-2 inhibitors (SGLT-2i) are associated with an increased risk of fractures in older adults with type 2 diabetes (T2D) outside of clinical trials remains unknown. OBJECTIVE To examine the association of incident fracture among older adults with T2D with initiating an SGLT-2i compared with initiating a dipeptidyl peptidase 4 inhibitor (DPP-4i) or a glucagon-like peptide 1 receptor agonist (GLP-1RA). DESIGN, SETTING, AND PARTICIPANTS This is a population-based, new-user cohort study including older adults (aged ≥65 years) with T2D enrolled in Medicare fee-for-service from April 2013 to December 2017. Data analysis was performed from October 2020 to April 2021. EXPOSURES New users of an SGLT-2i, DPP-4i, or GLP-1RA without a previous fracture were matched in a 1:1:1 ratio using 3-way propensity score matching. MAIN OUTCOMES AND MEASURES The primary outcome was a composite end point of nontraumatic pelvic fracture, hip fracture requiring surgery, or humerus, radius, or ulna fracture requiring intervention within 30 days. After 3-way 1:1:1 propensity score matching, multivariable Cox proportional hazards regression models were used to generate hazard ratios (HRs) for SGLT-2i compared with DPP-4i and GLP-1RA and Kaplan-Meier curves to visualize fracture risk over time across groups. RESULTS Of 466 933 new initiators of study drugs, 62 454 patients were new SGLT-2i users. After 3-way matching, 45 889 (73%) new SGLT-2i users were matched to new users of DPP-4i and GLP-1RA, yielding a cohort of 137 667 patients (mean [SD] age, 72 [5] years; 64 126 men [47%]) matched 1:1:1 for analyses. There was no difference in the risk of fracture in SGLT-2i users compared with DPP-4i users (HR, 0.90; 95% CI, 0.73-1.11) or GLP-1RA users (HR, 1.00; 95% CI, 0.80-1.25). Results were consistent across categories of sex, frailty (nonfrail, prefrail, and frail), age (<75 and ≥75 years), and insulin use (baseline users and nonusers). CONCLUSIONS AND RELEVANCE In this nationwide Medicare cohort, initiating an SGLT-2i was not associated with an increased risk of fracture in older adults with T2D compared with initiating a DPP-4i or GLP-1RA, with consistent results across categories of frailty, age, and insulin use. These findings add to the evidence base evaluating the potential risks associated with SGLT-2i use for older adults outside of randomized clinical trials.
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Affiliation(s)
- Min Zhuo
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Division of Renal Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Chelsea E. Hawley
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- New England Geriatric Research, Education and Clinical Center, VA Bedford Healthcare System, Bedford, Massachusetts
| | - Julie M. Paik
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Division of Renal Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- New England Geriatric Research, Education and Clinical Center, VA Boston Healthcare System, Boston, Massachusetts
| | - Lily G. Bessette
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Deborah J. Wexler
- Diabetes Center, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Dae H. Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Marcus Institute for Aging Research, Hebrew Senior Life, Harvard Medical School, Boston, Massachusetts
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Angela Y. Tong
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Seoyoung C. Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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Zhang YS, Zheng YD, Yuan Y, Chen SC, Xie BC. Effects of Anti-Diabetic Drugs on Fracture Risk: A Systematic Review and Network Meta-Analysis. Front Endocrinol (Lausanne) 2021; 12:735824. [PMID: 34721294 PMCID: PMC8553257 DOI: 10.3389/fendo.2021.735824] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 09/22/2021] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Available data on the effects of anti-diabetic drugs on fracture risk are contradictory. Therefore, our study aimed to analyze all available data on the effects of anti-diabetic drugs on fracture risk in type 2 diabetes mellitus (T2DM) patients. METHODS Embase, Medline, ClinicalTrials.gov, and Cochrane CENTRAL were searched for relevant trials. All data analyses were performed with STATA (12.0) and R language (3.6.0). Risk ratio (RR) with its 95% confidence interval (CI) was calculated by combining data for the fracture effects of anti-diabetic drugs, including sodium-glucose co-transporter 2 (SGLT2) inhibitors, dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, meglitinides, α-glucosidase inhibitors, thiazolidinediones, biguanides, insulin, and sulfonylureas. RESULTS One hundred seventeen eligible randomized controlled trials (RCTs) with 221,364 participants were included in this study. Compared with placebo, trelagliptin (RR 3.51; 1.58-13.70) increased the risk of fracture, whereas albiglutide (RR 0.29; 0.04-0.93) and voglibose (RR 0.03; 0-0.11) decreased the risk of fracture. Other medications were comparable in terms of their effects on fracture risk, and no statistical significance was observed. In terms of fractures, voglibose (0.01%) may be the safest option, and trelagliptin (13.64%) may be the worst. Sensitivity analysis results were consistent with those of the main analysis. No statistically significant differences were observed in the regression coefficients of age (1.03; 0.32-2.1), follow-up duration (0.79; 0.27-1.64), and sex distribution (0.63; 0.15-1.56). CONCLUSIONS We found varied results on the association between the use of anti-diabetic drugs and fracture risk. Specifically, trelagliptin raised the risk of fracture, whereas voglibose and albiglutide showed benefit with statistical difference. Other drugs were comparable in terms of their effects on fracture risk. Some drugs (omarigliptin, sitagliptin, vildagliptin, saxagliptin, empagliflozin, ertugliflozin, rosiglitazone, pioglitazone, and nateglinide) may increase the risk of fracture, while others (such as dulaglutide, exenatide, liraglutide, semaglutide, lixisenatide, linagliptin, alogliptin, canagliflozin, dapagliflozin, glipizide, gliclazide, glibenclamide, glimepiride, metformin, and insulin) may show benefits. The risk of fracture was independent of age, sex distribution, and the duration of exposure to anti-diabetic drugs. When developing individualized treatment strategies, the clinical efficacy of anti-diabetic drugs must be weighed against their benefits and risks brought about by individual differences of patients. SYSTEMATIC REVIEW REGISTRATION This Systematic Review was prospectively registered on the PROSPERO (https://www.crd.york.ac.uk/PROSPERO/, registration number CRD42020189464).
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Affiliation(s)
- Yu-Sheng Zhang
- Department of Pharmacy, The First People’s Hospital of Foshan, Foshan, China
| | - Yan-Dan Zheng
- Department of Clinical Laboratory, The First People’s Hospital of Foshan, Foshan, China
| | - Yan Yuan
- Department of Pharmacy, The First People’s Hospital of Foshan, Foshan, China
| | - Shi-Chun Chen
- Affiliated Dongguan Hospital, Southern Medical University, Dongguan, Guangdong, China
- *Correspondence: Shi-Chun Chen, ; Bao-Cheng Xie,
| | - Bao-Cheng Xie
- Affiliated Dongguan Hospital, Southern Medical University, Dongguan, Guangdong, China
- *Correspondence: Shi-Chun Chen, ; Bao-Cheng Xie,
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