1
|
Yu MK, Vart P, Jongs N, Correa-Rotter R, Rossing P, McMurray JJV, Hou FF, Douthat W, Khullar D, Langkilde AM, Wheeler DC, Heerspink HJL, Chertow GM. Effects of Dapagliflozin in Chronic Kidney Disease Across the Spectrum of Age and by Sex. J Gen Intern Med 2024; 39:921-930. [PMID: 38097862 PMCID: PMC11074069 DOI: 10.1007/s11606-023-08397-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 08/24/2023] [Indexed: 05/08/2024]
Abstract
BACKGROUND The sodium-glucose cotransporter type 2 inhibitor dapagliflozin reduces the risk of progressive kidney disease and cardiovascular events in patients with chronic kidney disease, with and without type 2 diabetes. Whether its effects are uniform across the spectrum of age and among men and women is unknown. OBJECTIVE We performed a pre-specified analysis in DAPA-CKD to evaluate efficacy and safety of dapagliflozin according to baseline age and sex. DESIGN Prospective randomized placebo-controlled trial. PARTICIPANTS A total of 4304 adults with chronic kidney disease (estimated glomerular filtration rate (eGFR) 25-75 mL/min/1.73 m2; urinary albumin-to-creatinine ratio 200-5000 mg/g) with and without type 2 diabetes. INTERVENTION Dapagliflozin 10 mg versus placebo once daily. MAIN MEASURES Primary endpoint was a composite of ≥ 50% sustained eGFR decline, end-stage kidney disease, and kidney or cardiovascular death. Secondary endpoints included kidney composite endpoint (same as primary composite endpoint but without cardiovascular death), cardiovascular composite endpoint (hospitalized heart failure or cardiovascular death), and all-cause mortality. KEY RESULTS Median follow-up was 2.4 years. Absolute risks of cardiovascular composite endpoint and all-cause mortality were higher in older patients. Absolute risk of kidney composite endpoint was highest in patients < 50 years (10.7 and 6.2 per 100 patient-years in the placebo and dapagliflozin groups, respectively) and lowest in patients ≥ 80 years (3.0 and 1.2 per 100 patient-years in the placebo and dapagliflozin groups, respectively). There was no evidence of heterogeneity of the effects of dapagliflozin on the primary or secondary endpoints based on age or sex. Neither age nor sex modified the effects of dapagliflozin on total or chronic eGFR slope. CONCLUSIONS Dapagliflozin reduced the risks of mortality, cardiovascular events, and CKD progression in older patients, including in septuagenarians and octogenarians who comprised 25% of participants. Ageism and/or therapeutic nihilism should not discourage the use of dapagliflozin in older women and men who are likely to experience considerable benefit. TRIAL REGISTRY clinicaltrials.gov NIH TRIAL REGISTRY NUMBER: NCT03036150.
Collapse
Affiliation(s)
- Margaret K Yu
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Priya Vart
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Ricardo Correa-Rotter
- The National Medical Science and Nutrition Institute Salvador Zubiran, Mexico City, Mexico
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - John J V McMurray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Fan-Fan Hou
- Division of Nephrology, Nanfang Hospital, Southern Medical University, National Clinical Research Center for Kidney Disease, Guangzhou, China
| | - Walter Douthat
- Department of Nephrology, Hospital Privado Universitario de Cordoba, Cordoba, Argentina
| | - Dinesh Khullar
- Department of Nephrology and Renal Transplant Medicine, Max Super Speciality Hospital, Saket, New Delhi, India
| | | | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Glenn M Chertow
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA, USA.
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| |
Collapse
|
2
|
Mottl AK, Nicholas SB. KDOQI Commentary on the KDIGO 2022 Update to the Clinical Practice Guideline for Diabetes Management in CKD. Am J Kidney Dis 2024; 83:277-287. [PMID: 38142396 DOI: 10.1053/j.ajkd.2023.09.003] [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: 08/09/2023] [Accepted: 09/20/2023] [Indexed: 12/25/2023]
Abstract
The Kidney Disease: Improving Global Outcomes (KDIGO) guideline for diabetes management in chronic kidney disease (CKD) was updated in 2022, just 2 years after the previous update. The need for this rapid update is reflective of the recent and unprecedented positive results of numerous clinical trials aimed at reducing kidney and cardiovascular morbidity and mortality in people with diabetes. The Kidney Disease Outcomes Quality Initiative (KDOQI) work group for diabetes in CKD, convened by the National Kidney Foundation, provides herein a commentary on these changes, particularly the implications for health care in the United States. Changes to the KDIGO guideline mirror the evolution of sodium/glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide 1 receptor agonists from purely antihyperglycemic agents to cardiorenal-metabolic therapeutics, and the lower estimated glomerular filtration rate of≥20mL/min/1.73m2 for SGLT2 inhibitor initiation. New data have also brought the addition of the first-in-class, Federal Drug Administration-approved nonsteroidal mineralocorticoid receptor antagonist finerenone as an agent to reduce cardiorenal end points. While there has been significant progress in innovation, there remain serious challenges to implementation, particularly in the United States where inequities in insurance coverage and high costs limit their use, particularly in vulnerable populations, ultimately widening health care disparities.
Collapse
Affiliation(s)
- Amy K Mottl
- Division of Nephrology, Department of Medicine, University of North Carolina Kidney Center, University of North Carolina, Chapel Hill, North Carolina.
| | - Susanne B Nicholas
- Divisions of Nephrology and Endocrinology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| |
Collapse
|
3
|
Elkeraie AF, Al-Ghamdi S, Abu-Alfa AK, Alotaibi T, AlSaedi AJ, AlSuwaida A, Arici M, Ecder T, Ghnaimat M, Hafez MH, Hassan MH, Sqalli T. Impact of Sodium-Glucose Cotransporter-2 Inhibitors in the Management of Chronic Kidney Disease: A Middle East and Africa Perspective. Int J Nephrol Renovasc Dis 2024; 17:1-16. [PMID: 38196830 PMCID: PMC10771977 DOI: 10.2147/ijnrd.s430532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 11/28/2023] [Indexed: 01/11/2024] Open
Abstract
Chronic kidney disease (CKD) is a major public health concern in the Middle East and Africa (MEA) region and a leading cause of death in patients with type 2 diabetes mellitus (T2DM) and hypertension. Early initiation of sodium-glucose cotransporter - 2 inhibitors (SGLT-2i) and proper sequencing with renin-angiotensin-aldosterone system inhibitors (RAASi) in these patients may result in better clinical outcomes due to their cardioprotective properties and complementary mechanisms of action. In this review, we present guideline-based consensus recommendations by experts from the MEA region, as practical algorithms for screening, early detection, nephrology referral, and treatment pathways for CKD management in patients with hypertension and diabetes mellitus. This study will help physicians take timely and appropriate actions to provide better care to patients with CKD or those at high risk of CKD.
Collapse
Affiliation(s)
- Ahmed Fathi Elkeraie
- Department of Internal Medicine and Nephrology, Alexandria University, Alexandria, Egypt
| | - Saeed Al-Ghamdi
- Department of Medicine, College of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ali K Abu-Alfa
- Department of Internal Medicine, Division of Nephrology and Hypertension, American University of Beirut, Beirut, Lebanon
| | - Torki Alotaibi
- Transplant Nephrology, Hamed Al-Essa Organ Transplant Center, Sabah Health Region, Kuwait City, Kuwait
| | - Ali Jasim AlSaedi
- Department of Nephrology, College of Medicine, University of Baghdad, Nephrology and Transplantation Center, Medical City Complex, Baghdad, Iraq
| | | | - Mustafa Arici
- Department of Nephrology, Faculty of Medicine, Hacettepe University, Altındağ, Ankara, Turkey
| | - Tevfik Ecder
- Department of Medicine, Istinye University; Division of Nephrology, Topkapı, Istanbul, Turkey
| | - Mohammad Ghnaimat
- Department of Nephrology, Specialty Hospital, Jaber Ibn Hayyan St. Shmeisani, Amman, Jordan
| | | | - Mohamed H Hassan
- Department of Medicine, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Tarik Sqalli
- Department of Nephrology, Moroccan Society of Nephrology, Casablanca, Morocco
| |
Collapse
|
4
|
Yi TW, O’Hara DV, Smyth B, Jardine MJ, Levin A, Morton RL. Identifying Barriers and Facilitators for Increasing Uptake of Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitors in British Columbia, Canada, using the Consolidated Framework for Implementation Research. Can J Kidney Health Dis 2023; 11:20543581231217857. [PMID: 38161391 PMCID: PMC10757432 DOI: 10.1177/20543581231217857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 11/01/2023] [Indexed: 01/03/2024] Open
Abstract
Background Care gaps remain in modern health care despite the availability of robust, evidence-based medications. Although sodium-glucose cotransporter-2 (SGLT2) inhibitors have demonstrated profound benefits in improving both cardiovascular and kidney outcomes in patients, the uptake of these medications remain suboptimal, and the causes have not been systematically explored. Objective The purpose of this study was to use the Consolidated Framework for Implementation Research (CFIR) to describe the barriers and facilitators faced by clinicians in British Columbia, Canada, when prescribing an SGLT2 inhibitor. To achieve this, we conducted semistructured interviews using the CFIR with practicing family physicians, nephrologists, endocrinologists, and cardiologists in British Columbia. Design Semistructured interviews. Setting British Columbia, Canada. Participants Actively practicing family physicians, nephrologists, endocrinologists, and cardiologists in British Columbia. Methods Twenty-one clinicians were interviewed using questions derived from the CFIR. The audio recordings were transcribed verbatim, and each transcription was individually analyzed in duplicate using thematic analysis. The analysis focused on identifying barriers and facilitators to using SGLT2 inhibitors in clinical practice and coded using the CFIR constructs. Once the transcriptions were coded, overarching themes were created. Results Five overarching themes were identified to the barriers and facilitators to using SGLT2 inhibitors: current perceptions and beliefs, clinician factors, patient factors, medication factors, and health care system factors. The current perceptions and beliefs were that SGLT2 inhibitors are efficacious and have distinct advantages over other agents but are underutilized in British Columbia. Clinician factors included varying levels of knowledge of and comfort in prescribing SGLT2 inhibitors, and patient factors included intolerable adverse events and additional pill burden, but many were enthusiastic about potential benefits. Multiple SGLT2 inhibitor related adverse events like mycotic infections and euglycemic diabetic ketoacidosis and the difficulty in obtaining reimbursement for these medications were also identified as a barrier to prescribing these medications. Facilitators for the use of SGLT2 inhibitors included consensus among colleagues, influential leaders, and peers in support of their use, and endorsement by national guidelines. Limitations The experience from the clinicians regarding costs and the reimbursement process is limited to British Columbia as each province has its own procedures. There may be responder bias as clinicians were approached through purposive sampling. Conclusion This study highlights different themes to the barriers and facilitators of using SGLT2 inhibitors in British Columbia. The identification of these barriers provides a specific target for improvement, and the facilitators can be leveraged for the increased use of SGLT2 inhibitors. Efforts to address and optimize these barriers and facilitators in a systematic approach may lead to an increase in the use of these efficacious medications.
Collapse
Affiliation(s)
- Tae Won Yi
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- National Health and Medical Research Council Clinical Trials Centre, The University of Sydney, Camperdown, NSW, Australia
- Division of Nephrology, The University of British Columbia, Vancouver, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Daniel V. O’Hara
- National Health and Medical Research Council Clinical Trials Centre, The University of Sydney, Camperdown, NSW, Australia
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Brendan Smyth
- National Health and Medical Research Council Clinical Trials Centre, The University of Sydney, Camperdown, NSW, Australia
- Department of Renal Medicine, St George Hospital, Kogarah, NSW, Australia
| | - Meg J. Jardine
- National Health and Medical Research Council Clinical Trials Centre, The University of Sydney, Camperdown, NSW, Australia
- Department of Nephrology, Concord Repatriation General Hospital, Sydney, Australia
| | - Adeera Levin
- Division of Nephrology, The University of British Columbia, Vancouver, Canada
| | - Rachael L. Morton
- National Health and Medical Research Council Clinical Trials Centre, The University of Sydney, Camperdown, NSW, Australia
| |
Collapse
|
5
|
Maxey J, Gupta A, Houchens N. Quality and safety in the literature: April 2023. BMJ Qual Saf 2023; 32:235-240. [PMID: 36931631 DOI: 10.1136/bmjqs-2023-015977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 01/27/2023] [Indexed: 03/19/2023]
Affiliation(s)
- Jordan Maxey
- Medicine Service, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Ashwin Gupta
- Medicine Service, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Nathan Houchens
- Medicine Service, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| |
Collapse
|