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Tsukamoto S, Kobayashi K, Toyoda M, Tone A, Kawanami D, Suzuki D, Tsuriya D, Machimura H, Shimura H, Wakui H, Takeda H, Yokomizo H, Takeshita K, Chin K, Kanasaki K, Miyauchi M, Saburi M, Morita M, Yomota M, Kimura M, Hatori N, Nakajima S, Ito S, Murata T, Matsushita T, Furuki T, Hashimoto T, Umezono T, Muta Y, Takashi Y, Tamura K. Effect of preceding drug therapy on the renal and cardiovascular outcomes of combined sodium-glucose cotransporter-2 inhibitor and glucagon-like peptide-1 receptor agonist treatment in patients with type 2 diabetes and chronic kidney disease. Diabetes Obes Metab 2024; 26:3248-3260. [PMID: 38764356 DOI: 10.1111/dom.15652] [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: 03/11/2024] [Revised: 04/27/2024] [Accepted: 04/28/2024] [Indexed: 05/21/2024]
Abstract
AIM To conduct a post hoc subgroup analysis of patients with type 2 diabetes (T2D) from the RECAP study, who were treated with sodium-glucose cotransporter-2 (SGLT2) inhibitor and glucagon-like peptide 1 receptor agonist (GLP-1RA) combination therapy, focusing only on those patients who had chronic kidney disease (CKD), to examine whether the composite renal outcome differed between those who received SGLT2 inhibitor treatment first and those who received a GLP-1RA first. METHODS We included 438 patients with CKD (GLP-1RA-first group, n = 223; SGLT2 inhibitor-first group, n = 215) from the 643 T2D patients in the RECAP study. The incidence of the composite renal outcome, defined as progression to macroalbuminuria and/or a ≥50% decrease in estimated glomerular filtration rate (eGFR), was analysed using a propensity score (PS)-matched model. Furthermore, we calculated the win ratio for these composite renal outcomes, which were weighted in the following order: (1) both a ≥50% decrease in eGFR and progression to macroalbuminuria; (2) a decrease in eGFR of ≥50% only; and (3) progression to macroalbuminuria only. RESULTS Using the PS-matched model, 132 patients from each group were paired. The incidence of renal composite outcomes did not differ between the two groups (GLP-1RA-first group, 10%; SGLT2 inhibitor-first group, 17%; odds ratio 1.80; 95% confidence interval [CI] 0.85 to 4.26; p = 0.12). The win ratio of the GLP-1RA-first group versus the SGLT2 inhibitor-first group was 1.83 (95% CI 1.71 to 1.95; p < 0.001). CONCLUSION Although the renal composite outcome did not differ between the two groups, the win ratio of the GLP-1RA-first group versus the SGLT2 inhibitor-first group was significant. These results suggest that, in GLP-1RA and SGLT2 inhibitor combination therapy, the addition of an SGLT2 inhibitor to baseline GLP-1RA treatment may lead to more favourable renal outcomes.
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Affiliation(s)
- Shunichiro Tsukamoto
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kazuo Kobayashi
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Masao Toyoda
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Japan
| | - Atsuhito Tone
- Department of Internal Medicine, Diabetes Center, Okayama Saiseikai General Hospital, Okayama, Japan
| | - Daiji Kawanami
- Department of Endocrinology and Diabetes, Fukuoka University School of Medicine, Fukuoka, Japan
| | | | - Daisuke Tsuriya
- Division of Endocrinology and Metabolism, 2nd Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | | | | | - Hiromichi Wakui
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | | | - Hisashi Yokomizo
- Department of Endocrinology and Diabetes, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Kei Takeshita
- Division of Endocrinology and Metabolism, 2nd Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | | | - Keizo Kanasaki
- Department of Internal Medicine 1, Endocrinology and Metabolism, Shimane University Faculty of Medicine, Izumo, Japan
| | | | - Masuo Saburi
- Department of Diabetology, Endocrinology and Metabolism, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | - Miwa Morita
- Department of Internal Medicine 1, Endocrinology and Metabolism, Shimane University Faculty of Medicine, Izumo, Japan
| | - Miwako Yomota
- Department of Internal Medicine 1, Endocrinology and Metabolism, Shimane University Faculty of Medicine, Izumo, Japan
| | - Moritsugu Kimura
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Japan
| | | | | | - Shun Ito
- Department of Internal Medicine, Sagamihara Red Cross Hospital, Sagamihara, Japan
| | - Takashi Murata
- Department of Clinical Nutrition, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
- Diabetes Center, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Takaya Matsushita
- Department of Diabetology, Endocrinology and Metabolism, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | | | - Takuya Hashimoto
- Division of Endocrinology and Metabolism, 2nd Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | | | - Yoshimi Muta
- Department of Endocrinology and Diabetes, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Yuichi Takashi
- Department of Endocrinology and Diabetes, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Kouichi Tamura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Karakasis P, Patoulias D, Fragakis N, Bernal-López MR, Gómez-Huelgas R. Glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors combination therapy versus monotherapy and major adverse cardiovascular events: Do the benefits add up? Eur J Intern Med 2024:S0953-6205(24)00285-1. [PMID: 38981766 DOI: 10.1016/j.ejim.2024.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Accepted: 07/02/2024] [Indexed: 07/11/2024]
Affiliation(s)
- Paschalis Karakasis
- Second Department of Cardiology, Aristotle University of Thessaloniki, General Hospital Hippokration, Greece.
| | - Dimitrios Patoulias
- Second Department of Cardiology, Aristotle University of Thessaloniki, General Hospital Hippokration, Greece; Outpatient Department of Cardiometabolic Medicine, Aristotle University of Thessaloniki, General Hospital Hippokration, Greece
| | - Nikolaos Fragakis
- Second Department of Cardiology, Aristotle University of Thessaloniki, General Hospital Hippokration, Greece
| | - María Rosa Bernal-López
- Internal Medicine Department, Regional University Hospital of Málaga, Biomedical Research Institute of Málaga (IBIMA), University of Málaga (UMA), Málaga, Spain
| | - Ricardo Gómez-Huelgas
- Internal Medicine Department, Regional University Hospital of Málaga, Biomedical Research Institute of Málaga (IBIMA), University of Málaga (UMA), Málaga, Spain
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McFarlin BE, Duffin KL, Konkar A. Incretin and glucagon receptor polypharmacology in chronic kidney disease. Am J Physiol Endocrinol Metab 2024; 326:E747-E766. [PMID: 38477666 DOI: 10.1152/ajpendo.00374.2023] [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: 11/13/2023] [Accepted: 03/10/2024] [Indexed: 03/14/2024]
Abstract
Chronic kidney disease is a debilitating condition associated with significant morbidity and mortality. In recent years, the kidney effects of incretin-based therapies, particularly glucagon-like peptide-1 receptor agonists (GLP-1RAs), have garnered substantial interest in the management of type 2 diabetes and obesity. This review delves into the intricate interactions between the kidney, GLP-1RAs, and glucagon, shedding light on their mechanisms of action and potential kidney benefits. Both GLP-1 and glucagon, known for their opposing roles in regulating glucose homeostasis, improve systemic risk factors affecting the kidney, including adiposity, inflammation, oxidative stress, and endothelial function. Additionally, these hormones and their pharmaceutical mimetics may have a direct impact on the kidney. Clinical studies have provided evidence that incretins, including those incorporating glucagon receptor agonism, are likely to exhibit improved kidney outcomes. Although further research is necessary, receptor polypharmacology holds promise for preserving kidney function through eliciting vasodilatory effects, influencing volume and electrolyte handling, and improving systemic risk factors.
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Affiliation(s)
- Brandon E McFarlin
- Lilly Research Laboratories, Lilly Corporate CenterIndianapolisIndianaUnited States
| | - Kevin L Duffin
- Lilly Research Laboratories, Lilly Corporate CenterIndianapolisIndianaUnited States
| | - Anish Konkar
- Lilly Research Laboratories, Lilly Corporate CenterIndianapolisIndianaUnited States
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Nikolaidou A, Ventoulis I, Karakoulidis G, Anastasiou V, Daios S, Papadopoulos SF, Didagelos M, Parissis J, Karamitsos T, Kotsa K, Ziakas A, Kamperidis V. Hypoglycemic Drugs in Patients with Diabetes Mellitus and Heart Failure: A Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:912. [PMID: 38929529 PMCID: PMC11205945 DOI: 10.3390/medicina60060912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 05/26/2024] [Accepted: 05/27/2024] [Indexed: 06/28/2024]
Abstract
Over the last few years, given the increase in the incidence and prevalence of both type 2 diabetes mellitus (T2DM) and heart failure (HF), it became crucial to develop guidelines for the optimal preventive and treatment strategies for individuals facing these coexisting conditions. In patients aged over 65, HF hospitalization stands out as the predominant reason for hospital admissions, with their prognosis being associated with the presence or absence of T2DM. Historically, certain classes of glucose-lowering drugs, such as thiazolidinediones (rosiglitazone), raised concerns due to an observed increased risk of myocardial infarction (MI) and cardiovascular (CV)-related mortality. In response to these concerns, regulatory agencies started requiring CV outcome trials for all novel antidiabetic agents [i.e., dipeptidyl peptidase-4 inhibitors (DPP-4 inhibitors), glucagon-like peptide-1 receptor agonists (GLP-1 RAs), and sodium-glucose cotransporter-2 inhibitors (SGLT2is)] with the aim to assess the CV safety of these drugs beyond glycemic control. This narrative review aims to address the current knowledge about the impact of glucose-lowering agents used in T2DM on HF prevention, prognosis, and outcome.
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Affiliation(s)
- Anastasia Nikolaidou
- 1st Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece; (A.N.); (G.K.); (V.A.); (S.D.); (S.-F.P.); (M.D.); (T.K.); (A.Z.)
| | - Ioannis Ventoulis
- Department of Occupational Therapy, University of Western Macedonia, Keptse Area, 50200 Ptolemaida, Greece;
| | - Georgios Karakoulidis
- 1st Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece; (A.N.); (G.K.); (V.A.); (S.D.); (S.-F.P.); (M.D.); (T.K.); (A.Z.)
| | - Vasileios Anastasiou
- 1st Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece; (A.N.); (G.K.); (V.A.); (S.D.); (S.-F.P.); (M.D.); (T.K.); (A.Z.)
| | - Stylianos Daios
- 1st Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece; (A.N.); (G.K.); (V.A.); (S.D.); (S.-F.P.); (M.D.); (T.K.); (A.Z.)
| | - Spyridon-Filippos Papadopoulos
- 1st Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece; (A.N.); (G.K.); (V.A.); (S.D.); (S.-F.P.); (M.D.); (T.K.); (A.Z.)
| | - Matthaios Didagelos
- 1st Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece; (A.N.); (G.K.); (V.A.); (S.D.); (S.-F.P.); (M.D.); (T.K.); (A.Z.)
| | - John Parissis
- Emergency Medicine Department, Attikon University Hospital, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 10679 Athens, Greece;
| | - Theodoros Karamitsos
- 1st Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece; (A.N.); (G.K.); (V.A.); (S.D.); (S.-F.P.); (M.D.); (T.K.); (A.Z.)
| | - Kalliopi Kotsa
- Division of Endocrinology and Metabolism, Diabetes Center, 1st Department of Internal Medicine, AHEPA University Hospital, School of Medicine, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
| | - Antonios Ziakas
- 1st Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece; (A.N.); (G.K.); (V.A.); (S.D.); (S.-F.P.); (M.D.); (T.K.); (A.Z.)
| | - Vasileios Kamperidis
- 1st Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece; (A.N.); (G.K.); (V.A.); (S.D.); (S.-F.P.); (M.D.); (T.K.); (A.Z.)
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Simms-Williams N, Treves N, Yin H, Lu S, Yu O, Pradhan R, Renoux C, Suissa S, Azoulay L. Effect of combination treatment with glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors on incidence of cardiovascular and serious renal events: population based cohort study. BMJ 2024; 385:e078242. [PMID: 38663919 PMCID: PMC11043905 DOI: 10.1136/bmj-2023-078242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/29/2024] [Indexed: 04/29/2024]
Abstract
OBJECTIVE To determine whether the combined use of glucagon-like peptide-1 (GLP-1) receptor agonists and sodium-glucose cotransporter-2 (SGLT-2) inhibitors is associated with a decreased risk of major adverse cardiovascular events and serious renal events compared with either drug class alone among patients with type 2 diabetes, and to assess the effect of the combination on the individual components of major adverse cardiovascular events, heart failure, and all cause mortality. DESIGN Population based cohort study using a prevalent new-user design, emulating a trial. SETTING UK Clinical Practice Research Datalink linked to Hospital Episode Statistics Admitted Patient Care and Office for National Statistics databases. PARTICIPANTS Two prevalent new-user cohorts were assembled between January 2013 and December 2020, with follow-up until the end of March 2021. The first cohort included 6696 patients who started GLP-1 receptor agonists and added on SGLT-2 inhibitors, and the second included 8942 patients who started SGLT-2 inhibitors and added on GLP-1 receptor agonists. Combination users were matched, in a 1:1 ratio, to patients prescribed the same background drug, duration of background drug, and time conditional propensity score. MAIN OUTCOME MEASURES Cox proportional hazards models were fitted to estimate the hazard ratios and 95% confidence intervals of major adverse cardiovascular events and serious renal events, separately, comparing the GLP-1 receptor agonist-SGLT-2 inhibitor combination with the background drug, either GLP-1 receptor agonists or SGLT-2 inhibitors, depending on the cohort. Secondary outcomes included associations with the individual components of major adverse cardiovascular events (myocardial infarction, ischaemic stroke, cardiovascular mortality), heart failure, and all cause mortality. RESULTS Compared with GLP-1 receptor agonists, the SGLT-2 inhibitor-GLP-1 receptor agonist combination was associated with a 30% lower risk of major adverse cardiovascular events (7.0 v 10.3 events per 1000 person years; hazard ratio 0.70, 95% confidence interval 0.49 to 0.99) and a 57% lower risk of serious renal events (2.0 v 4.6 events per 1000 person years; hazard ratio 0.43, 0.23 to 0.80). Compared with SGLT-2 inhibitors, the GLP-1 receptor agonist-SGLT-2 inhibitor combination was associated with a 29% lower risk of major adverse cardiovascular events (7.6 v 10.7 events per 1000 person years; hazard ratio 0.71, 0.52 to 0.98), whereas serious renal events generated a wide confidence interval (1.4 v 2.0 events per 1000 person years; hazard ratio 0.67, 0.32 to 1.41). Secondary outcomes generated similar results but with wider confidence intervals. CONCLUSIONS In this cohort study, the GLP-1 receptor agonist-SGLT-2 inhibitor combination was associated with a lower risk of major adverse cardiovascular events and serious renal events compared with either drug class alone.
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Affiliation(s)
- Nikita Simms-Williams
- Institute of Applied Health Research College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Nir Treves
- Department of Clinical Pharmacy, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Hui Yin
- Institute of Applied Health Research College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Sally Lu
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Canada
| | - Oriana Yu
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Canada
- Division of Endocrinology, Jewish General Hospital, Montreal, QC, Canada
| | - Richeek Pradhan
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Christel Renoux
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- Departments of Neurology and Neurosurgery, Jewish General Hospital, Montreal, QC, Canada
| | - Samy Suissa
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Laurent Azoulay
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- Gerald Bronfman Department of Oncology, McGill University, Montreal, QC, Canada
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Wang N, Zhang C. Oxidative Stress: A Culprit in the Progression of Diabetic Kidney Disease. Antioxidants (Basel) 2024; 13:455. [PMID: 38671903 PMCID: PMC11047699 DOI: 10.3390/antiox13040455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/01/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
Diabetic kidney disease (DKD) is the principal culprit behind chronic kidney disease (CKD), ultimately developing end-stage renal disease (ESRD) and necessitating costly dialysis or kidney transplantation. The limited therapeutic efficiency among individuals with DKD is a result of our finite understanding of its pathogenesis. DKD is the result of complex interactions between various factors. Oxidative stress is a fundamental factor that can establish a link between hyperglycemia and the vascular complications frequently encountered in diabetes, particularly DKD. It is crucial to recognize the essential and integral role of oxidative stress in the development of diabetic vascular complications, particularly DKD. Hyperglycemia is the primary culprit that can trigger an upsurge in the production of reactive oxygen species (ROS), ultimately sparking oxidative stress. The main endogenous sources of ROS include mitochondrial ROS production, NADPH oxidases (Nox), uncoupled endothelial nitric oxide synthase (eNOS), xanthine oxidase (XO), cytochrome P450 (CYP450), and lipoxygenase. Under persistent high glucose levels, immune cells, the complement system, advanced glycation end products (AGEs), protein kinase C (PKC), polyol pathway, and the hexosamine pathway are activated. Consequently, the oxidant-antioxidant balance within the body is disrupted, which triggers a series of reactions in various downstream pathways, including phosphoinositide 3-kinase/protein kinase B (PI3K/Akt), transforming growth factor beta/p38-mitogen-activated protein kinase (TGF-β/p38-MAPK), nuclear factor kappa B (NF-κB), adenosine monophosphate-activated protein kinase (AMPK), and the Janus kinase/signal transducer and activator of transcription (JAK/STAT) signaling. The disease might persist even if strict glucose control is achieved, which can be attributed to epigenetic modifications. The treatment of DKD remains an unresolved issue. Therefore, reducing ROS is an intriguing therapeutic target. The clinical trials have shown that bardoxolone methyl, a nuclear factor erythroid 2-related factor 2 (Nrf2) activator, blood glucose-lowering drugs, such as sodium-glucose cotransporter 2 inhibitors, and glucagon-like peptide-1 receptor agonists can effectively slow down the progression of DKD by reducing oxidative stress. Other antioxidants, including vitamins, lipoic acid, Nox inhibitors, epigenetic regulators, and complement inhibitors, present a promising therapeutic option for the treatment of DKD. In this review, we conduct a thorough assessment of both preclinical studies and current findings from clinical studies that focus on targeted interventions aimed at manipulating these pathways. We aim to provide a comprehensive overview of the current state of research in this area and identify key areas for future exploration.
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Affiliation(s)
| | - Chun Zhang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
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Del Prato S. Diabetes and vascular disease: New therapeutic avenues. Vascul Pharmacol 2024; 154:107247. [PMID: 38036017 DOI: 10.1016/j.vph.2023.107247] [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: 11/08/2023] [Accepted: 11/25/2023] [Indexed: 12/02/2023]
Abstract
Vascular disease remains a major burden for people with type 2 diabetes due to the syndromic nature of the disease. Therefore, strategies that go beyond the mere glycemic control need to be enacted. Recent evidence has been gathered showing the cardiorenal potential of medications such as glucagon-like peptide1-receptor agonists (GLP1RA) and sodium-glucose transporter 2-inhibitors (SGLT2i). Even greater are the expectations for the new dual glucose-dependent insulinotropic-peptide (GIP) and GLP1 agonists. Along with these new diabetes drugs, opportunities are now provided for renal protecting agents like finerenone. Finally, new pharmacologic venues are currently under investigation for treating diabetic cardiomyopathy, a cause for heart failure in diabetes.
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Affiliation(s)
- Stefano Del Prato
- Interdisciplinary Research Center "Health Science", Sant'Anna School of Advanced Studies, Pisa, Italy.
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Al-Ozairi E, Narula K, Miras AD, Taghadom E, Samad AE, Al Kandari J, Alyosef A, Mashankar A, Al-Najim W, le Roux CW. Obesity Treatments to Improve Type 1 Diabetes (OTID): a randomized controlled trial of the combination of glucagon-like peptide 1 analogues and sodium-glucose cotransporter 2 inhibitors-protocol for Obesity Treatments to Improve Type 1 Diabetes (the OTID trial). Trials 2024; 25:129. [PMID: 38365744 PMCID: PMC10874012 DOI: 10.1186/s13063-024-07930-3] [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: 06/14/2023] [Accepted: 01/16/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND The guidelines of the American Diabetes Association and European Association for the Study of Diabetes suggest that patients with obesity type 2 diabetics and chronic kidney disease need either glucagon-like peptide 1 receptor analogues or sodium-glucose cotransporter-2 inhibitors. If neither achieve metabolic control, then the recommendation is to combine both drugs. The evidence base for combining glucagon-like peptide 1 receptor analogues and sodium-glucose cotransporter-2 inhibitors is not well researched, and hence, the impact of the guidelines is limited. The aim of this randomized controlled trial is to test the impact of the combination of glucagon-like peptide 1 receptor analogues/sodium-glucose cotransporter-2 inhibitors on body weight and kidney damage, in patients with type 1 diabetes and chronic kidney disease. In addition, we will explore the associated changes in the metabolic pathways with each of the treatments used in this randomized controlled trial. METHODS In this 6-month randomized control trial, 60 participants aged between 21 and 65 years, with a body mass index above 25 kg/m2, and type 1 diabetics with chronic kidney disease will be randomized to receive 1 of 5 possible treatments: (1) standard care (control), (2) glucagon-like peptide 1 receptor analogues alone, (3) sodium-glucose cotransporter-2 inhibitors alone, (4) combination of glucagon-like peptide 1 receptor analogues and sodium-glucose cotransporter-2 inhibitors and (5) combination of glucagonlike peptide 1 receptor analogues and sodium-glucose cotransporter-2 inhibitors with intensive lifestyle advice. The primary objective will be the percentage change in total body weight from baseline at 6 months. The secondary objectives are to compare the change in glycaemia; blood pressure; dyslipidaemia; albuminuria; proportion of participants reaching weight loss of ≥ 5%, ≥ 10% and ≥ 15%; and change in BMI (kg/m2) from baseline and change in waist circumference (cm). All the experiments will be conducted at the Dasman Diabetes Institute after approval from the local research and ethics committee. DISCUSSION The present randomized controlled trial aims to investigate the impact of the combination of glucagon-like peptide 1 receptor analogues and sodium-glucose cotransporter-2 inhibitors on body weight and kidney damage in patients with type 1 diabetes mellitus and chronic kidney disease, as well as exploring the associated changes in the metabolic pathways with each of the treatments used. This study addresses the current gap in the evidence base regarding the combination of these two drugs, which is particularly relevant given the American Diabetes Association and European Association for the Study of Diabetes guidelines recommending their combined use for patients with obesity, type 2 diabetes, and chronic kidney disease who do not achieve metabolic control with either drug alone. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05390307 Trial registration date - 25th May 2022.
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Affiliation(s)
| | - Kavita Narula
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK.
| | - Alexander D Miras
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- School of Medicine, Ulster University, Coleraine, UK
| | - Etab Taghadom
- Dasman Diabetes Institute, Kuwait City, Kuwait
- Amiri Hospital, Ministry of Health, Kuwait City, Kuwait
| | | | - Jumana Al Kandari
- Dasman Diabetes Institute, Kuwait City, Kuwait
- Amiri Hospital, Ministry of Health, Kuwait City, Kuwait
| | - Anas Alyosef
- Amiri Hospital, Ministry of Health, Kuwait City, Kuwait
| | | | - Werd Al-Najim
- School of Medicine, Ulster University, Coleraine, UK
- Diabetes Complications Research Centre, Conway Institute, University College of Dublin, Dublin, Ireland
| | - Carel W le Roux
- School of Medicine, Ulster University, Coleraine, UK
- Diabetes Complications Research Centre, Conway Institute, University College of Dublin, Dublin, Ireland
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Solini A, Tricò D, Del Prato S. Incretins and cardiovascular disease: to the heart of type 2 diabetes? Diabetologia 2023; 66:1820-1831. [PMID: 37542009 PMCID: PMC10473999 DOI: 10.1007/s00125-023-05973-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 06/22/2023] [Indexed: 08/06/2023]
Abstract
Major cardiovascular outcome trials and real-life observations have proven that glucagon-like peptide-1 (GLP-1) receptor agonists (GLP-1RAs), regardless of structural GLP-1 homology, exert clinically relevant cardiovascular protection. GLP-1RAs provide cardioprotective benefits through glycaemic and non-glycaemic effects, including improved insulin secretion and action, body-weight loss, blood-pressure lowering and improved lipid profile, as well as via direct effects on the heart and vasculature. These actions are likely combined with anti-inflammatory and antioxidant properties that translate into robust and consistent reductions in atherothrombotic events, particularly in people with type 2 diabetes and established atherosclerotic CVD. GLP-1RAs may also have an impact on obesity and chronic kidney disease, conditions for which cardiovascular risk-reducing options are limited. The available evidence has prompted professional and medical societies to recommend GLP-1RAs for mitigation of the cardiovascular risk in people with type 2 diabetes. This review summarises the clinical evidence for cardiovascular protection with use of GLP-1RAs and the main mechanisms underlying this effect. Moreover, it looks into how the availability of upcoming dual and triple incretin receptor agonists might expand the possibility for cardiovascular protection in people with type 2 diabetes.
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Affiliation(s)
- Anna Solini
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa, Italy
| | - Domenico Tricò
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Stefano Del Prato
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
- Interdisciplinary Research Center "Health Science", Sant'Anna School of Advanced Studies, Pisa, Italy.
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10
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Riley DR, Essa H, Austin P, Preston F, Kargbo I, Ibarburu GH, Ghuman R, Cuthbertson DJ, Lip GYH, Alam U. All-cause mortality and cardiovascular outcomes with sodium-glucose Co-transporter 2 inhibitors, glucagon-like peptide-1 receptor agonists and with combination therapy in people with type 2 diabetes. Diabetes Obes Metab 2023; 25:2897-2909. [PMID: 37385958 DOI: 10.1111/dom.15185] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 06/04/2023] [Accepted: 06/05/2023] [Indexed: 07/01/2023]
Abstract
AIM To assess the relationship of sodium-glucose cotransporter-2 inhibitors (SGLT2i), glucagon-like peptide-1 receptor analogues (GLP-1RA) and their combination (SGLT2i + GLP-1RA) with 5-year risk of all-cause mortality, hospitalization and cardiovascular/macrovascular disease in people with type 2 diabetes. MATERIALS AND METHODS Retrospective cohort analysis of 2.2 million people with type 2 diabetes receiving insulin across 85 health care organizations using a global federated health research network. Three intervention cohorts (SGLT2i, GLP-1RA and SGLT2i + GLP-1RA) were compared against a control cohort (no SGLT2i/GLP-1RA). Propensity score matching for age, ischaemic heart disease, sex, hypertension, chronic kidney disease, heart failure and glycated haemoglobin was used to balance cohorts 1:1 (SGLT2i, n = 143 600; GLP-1RA, n = 186 841; SGLT-2i + GLP-1RA, n = 108 504). A sub-analysis comparing combination and monotherapy cohorts was also performed. RESULTS The intervention cohorts showed a reduced hazard ratio (HR, 95% confidence interval) over 5 years compared with the control cohort for all-cause mortality (SGLT2i 0.49, 0.48-0.50; GLP-1RA 0.47, 0.46-0.48; combination 0.25, 0.24-0.26), hospitalization (0.73, 0.72-0.74; 0.69, 0.68-0.69; 0.60, 0.59-0.61) and acute myocardial infarct (0.75, 0.72-0.78; 0.70, 0.68-0.73; 0.63, 0.60-0.66), respectively. All other outcomes showed a significant risk reduction in favour of the intervention cohorts. The sub-analysis showed a significant risk reduction in all-cause mortality for combination therapy versus SGLT2i (0.53, 0.50-0.55) and GLP-1RA (0.56, 0.54-0.59). CONCLUSIONS SGLT2i, GLP-1RAs or combination therapy confers mortality and cardiovascular protection in people with type 2 diabetes over 5 years. Combination therapy was associated with the greatest risk reduction in all-cause mortality versus a propensity matched control cohort. In addition, combination therapy offers a reduction in 5-year all-cause mortality when compared directly against either monotherapy.
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Affiliation(s)
- David R Riley
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, UK
| | - Hani Essa
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, UK
- Department of Medicine, University Hospital Aintree, Liverpool University NHS Foundation Trust, Liverpool, UK
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | | | - Frank Preston
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, UK
- Department of Medicine, University Hospital Aintree, Liverpool University NHS Foundation Trust, Liverpool, UK
| | | | | | | | - Daniel J Cuthbertson
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, UK
- Department of Medicine, University Hospital Aintree, Liverpool University NHS Foundation Trust, Liverpool, UK
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Gregory Y H Lip
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, UK
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Uazman Alam
- Department of Medicine, University Hospital Aintree, Liverpool University NHS Foundation Trust, Liverpool, UK
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Pain Research Institute, University of Liverpool and Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
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11
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Han X, Liu X, Zhao X, Wang X, Sun Y, Qu C, Liang J, Yang B. Dapagliflozin ameliorates sepsis-induced heart injury by inhibiting cardiomyocyte apoptosis and electrical remodeling through the PI3K/Akt pathway. Eur J Pharmacol 2023; 955:175930. [PMID: 37479014 DOI: 10.1016/j.ejphar.2023.175930] [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: 03/26/2023] [Revised: 07/19/2023] [Accepted: 07/19/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND Sepsis-induced heart injury is one of the leading causes of circulation disorders worldwide. Dapagliflozin, a sodium-glucose cotransporter 2 inhibitor mainly used for controlling blood glucose, has been shown to exert a protective effect on cardiomyocytes. However, the protective effect of dapagliflozin against sepsis-induced cardiac injury and the underlying mechanism needs to be studied. AIM This study aims to investigate the effect of dapagliflozin on sepsis-induced cardiomyopathy and the potential mechanisms involved. METHODS The rat model of sepsis was constructed by intraperitoneal injection of lipopolysaccharide. Echocardiography and electrophysiological studies were performed to detect changes in cardiac function and electrical activity. Cardiac pathological alternation and cardiomyocyte apoptosis were measured by H&E staining, serological analysis, immunohistochemical, immunofluorescence, and TUNEL assays. Western blot and qRT-PCR were performed to elucidate the underlying mechanism of dapagliflozin. Additionally, corresponding experiments in H9c2 cells were performed to further validate the mechanisms in vitro. RESULTS Dapagliflozin improved cardiac dysfunction and reduced the susceptibility to ventricular arrhythmias in sepsis rats by ameliorating cardiac inflammation, suppressing cardiomyocyte apoptosis, and alleviating ventricular electrical remodeling. The PI3K/Akt signaling pathway inhibitor inhibited the anti-apoptotic effect of dapagliflozin, indicating that the protective effect was related to the activation of the PI3K/Akt pathway. CONCLUSION Dapagliflozin ameliorated sepsis-induced cardiac injury by suppressing electrical remodeling and cardiomyocyte apoptosis, which could be attributed to the PI3K/Akt pathway.
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Affiliation(s)
- Xueyu Han
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, PR China; Cardiovascular Research Institute, Wuhan University, Wuhan, 430060, PR China; Hubei Key Laboratory of Cardiology, Wuhan, 430060, PR China.
| | - Xin Liu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, PR China; Cardiovascular Research Institute, Wuhan University, Wuhan, 430060, PR China; Hubei Key Laboratory of Cardiology, Wuhan, 430060, PR China.
| | - Xin Zhao
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, PR China; Cardiovascular Research Institute, Wuhan University, Wuhan, 430060, PR China; Hubei Key Laboratory of Cardiology, Wuhan, 430060, PR China.
| | - Xiukun Wang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, PR China; Cardiovascular Research Institute, Wuhan University, Wuhan, 430060, PR China; Hubei Key Laboratory of Cardiology, Wuhan, 430060, PR China.
| | - Yazhou Sun
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, PR China; Cardiovascular Research Institute, Wuhan University, Wuhan, 430060, PR China; Hubei Key Laboratory of Cardiology, Wuhan, 430060, PR China.
| | - Chuan Qu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, PR China; Cardiovascular Research Institute, Wuhan University, Wuhan, 430060, PR China; Hubei Key Laboratory of Cardiology, Wuhan, 430060, PR China.
| | - Jinjun Liang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, PR China; Cardiovascular Research Institute, Wuhan University, Wuhan, 430060, PR China; Hubei Key Laboratory of Cardiology, Wuhan, 430060, PR China.
| | - Bo Yang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, PR China; Cardiovascular Research Institute, Wuhan University, Wuhan, 430060, PR China; Hubei Key Laboratory of Cardiology, Wuhan, 430060, PR China.
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Learned A, Robinson SA, Nguyen TT. Comprehensive Care of Lower-Extremity Wounds. Surg Clin North Am 2023; 103:745-765. [PMID: 37455035 DOI: 10.1016/j.suc.2023.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
There are 5 common types of chronic nonhealing lower-extremity wounds: arterial, venous, diabetic foot ulcer, pressure, and mixed or atypical. Each chronic wound type has distinct features, and understanding the underlying cause will dictate the wound treatment plan. Here, the authors review the distinguishing wound properties for these 5 common chronic nonhealing lower-extremity wounds and outline a comprehensive treatment plan that addresses wound perfusion, debridement, infection control, moisture balance, and use of complementary advanced wound care products.
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Affiliation(s)
- Allison Learned
- Department of Surgery, Division of Vascular Surgery, University of Massachusetts Chan Medical School, 55 North Lake Avenue, Worcester, MA 01655, USA
| | - Sudie-Ann Robinson
- Department of Surgery, Division of Vascular Surgery, University of Massachusetts Chan Medical School, 55 North Lake Avenue, Worcester, MA 01655, USA
| | - Tammy T Nguyen
- Department of Surgery, Division of Vascular Surgery, University of Massachusetts Chan Medical School, 55 North Lake Avenue, Worcester, MA 01655, USA; University of Massachusetts Diabetes Center of Excellence.
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13
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Cases A. Glucagon-like peptide 1(GLP-1) receptor agonists in the management of the patient with type 2diabetes mellitus and chronic kidney disease: an approach for the nephrologist. Nefrologia 2023; 43:399-412. [PMID: 37813741 DOI: 10.1016/j.nefroe.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: 02/28/2022] [Revised: 07/14/2022] [Accepted: 07/23/2022] [Indexed: 10/11/2023] Open
Abstract
Diabetic kidney disease, a common complication in patients with type 2 diabetes mellitus, is associated with a markedly increased morbidity and mortality, especially of cardiovascular origin, and faster progression to end-stage renal disease. To date, reducing cardiovascular and renal risk in this population was based on strict control of cardiovascular risk factors and the renin-angiotensin system blockade. More recently, sodium-glucose cotransporter type 2 inhibitors have demonstrated to offer cardiovascular and renal protection, but the residual risk remains high and their antihyperglycemic efficacy is limited in moderate-severe CKD. Therefore, drugs with a potent antihyperglycemic effect, independent of the glomerular filtration rate, with a low risk of hypoglycemia, that reduce weight in overweight/obese patients and that provide cardiovascular and renal protection, such as GLP-1 receptor agonists, are needed. However, these drugs require subcutaneous administration, which may limit their early use. The recent availability of oral semaglutide may facilitate the early introduction of this family with proven cardiovascular and renal benefits and excellent safety profile. In this review the family is analyzed as well as their cardiovascular and renal effects.
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Affiliation(s)
- Aleix Cases
- Departament de Medicina, Facultat de Medicina, Campus Clínic, Universitat de Barcelona, Barcelona, Spain.
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14
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Michos ED, Bakris GL, Rodbard HW, Tuttle KR. Glucagon-like peptide-1 receptor agonists in diabetic kidney disease: A review of their kidney and heart protection. Am J Prev Cardiol 2023; 14:100502. [PMID: 37313358 PMCID: PMC10258236 DOI: 10.1016/j.ajpc.2023.100502] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 04/07/2023] [Accepted: 05/12/2023] [Indexed: 06/15/2023] Open
Abstract
Importance Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of morbidity and mortality for patients with type 2 diabetes (T2D) and chronic kidney disease (CKD). However, testing for albuminuria among patients with T2D is substantially underutilized in clinical practice; many patients with CKD go unrecognized. For patients with T2D at high cardiovascular risk, or with established CVD, the glucagon-like peptide-1 receptor agonists (GLP1-RA) have been shown to reduce ASCVD in cardiovascular outcome trials, while potential kidney outcomes are being explored. Observations A recent meta-analysis found that GLP1-RA reduced 3-point major adverse cardiovascular events by 14% [HR, 0.86 (95% CI, 0.80-0.93)] in patients with T2D. The benefits of GLP1-RA to reduce ASCVD were at least as large among people with estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2. GLP1-RA also conferred a 21% reduction in the composite kidney outcome [HR, 0.79 (0.73-0.87)]; however, this result was achieved largely through reduction in albuminuria. It remains uncertain whether GLP1-RA would confer similar favorable results for eGFR decline and/or progression to end-stage kidney disease. Postulated mechanisms by which GLP1-RA confer protection against CVD and CKD include blood pressure lowering, weight loss, improved glucose control, and decreasing oxidative stress. Ongoing studies in T2D and CKD include a kidney outcome trial with semaglutide (FLOW, NCT03819153) and a mechanism of action study (REMODEL, NCT04865770) examining semaglutide's effect on kidney inflammation and fibrosis. Ongoing cardiovascular outcome studies are examining an oral GLP1-RA (NCT03914326), GLP1-RA in patients without T2D (NCT03574597), and dual GIP/GLP1-RA agonists (NCT04255433); the secondary kidney outcomes of these trials will be informative. Conclusions and relevance Despite their well-described ASCVD benefits and potential kidney protective mechanisms, GLP1-RA remain underutilized in clinical practice. This highlights the need for cardiovascular clinicians to influence and implement use of GLP1-RA in appropriate patients, including those with T2D and CKD at higher risk for ASCVD.
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Affiliation(s)
- Erin D. Michos
- Division of Cardiology, Johns Hopkins University School of Medicine, Blalock 524-B, 600N. Wolfe Street, Baltimore, MD 21287, United States
| | - George L. Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, IL, United States
| | | | - Katherine R. Tuttle
- Providence Medical Research Center, Providence Health Care, Spokane, WA, United States
- Nephrology Division, Kidney Research Institute and Institute of Translational Health Sciences, University of Washington, Seattle, WA, United States
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15
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Gourdy P, Darmon P, Dievart F, Halimi JM, Guerci B. Combining glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter-2 inhibitors (SGLT2is) in patients with type 2 diabetes mellitus (T2DM). Cardiovasc Diabetol 2023; 22:79. [PMID: 37005640 PMCID: PMC10067319 DOI: 10.1186/s12933-023-01798-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 03/12/2023] [Indexed: 04/04/2023] Open
Abstract
Due to their cardiovascular protective effect, glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter-2 inhibitors (SGLT2is) represent breakthrough therapies for type 2 diabetes mellitus (T2DM). In this review article, we discuss the mechanistic and clinical synergies that make the combined use of GLP-1RAs and SGLT2is appealing in patients with T2DM. Overall, the presented cumulative evidence supports the benefits of GLP-1RA plus SGLT2i combination therapy on metabolic-cardiovascular-renal disease in patients with T2DM, with a low hypoglycemia risk. Accordingly, we encourage the adoption of GLP-1RA plus SGLT2i combination therapy in patients with T2DM and established atherosclerotic cardiovascular disease (ASCVD) or multiple risk factors for ASCVD (i.e., age ≥ 55 years, overweight/obesity, dyslipidemia, hypertension, current tobacco use, left ventricular hypertrophy, and/or proteinuria). Regarding renal effects, the evidence of SGLT2is in preventing kidney failure is more abundant than for GLP-1RAs, which showed a beneficial effect on albuminuria but not on hard kidney endpoints. Hence, in case of persistent albuminuria and/or uncontrolled metabolic risks (i.e., inadequate glycemic control, hypertension, overweight/obesity) on SGLT2i therapy, GLP-1RAs should be considered as the preferential add-on therapy in T2DM patients with chronic kidney disease. Despite the potential clinical benefits of GLP-1RA plus SGLT2i combination therapy in patients with T2DM, several factors may delay this combination to become a common practice soon, such as reimbursement and costs associated with polypharmacy. Altogether, when administering GLP-1RA plus SGLT2i combination therapy, it is important to adopt an individualized approach to therapy taking into account individual preferences, costs and coverage, toxicity profile, consideration of kidney function and glucose-lowering efficacy, desire for weight loss, and comorbidities.
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Affiliation(s)
- Pierre Gourdy
- Endocrinology, Diabetology and Nutrition Department, Toulouse University Hospital, Toulouse, France.
- Institute of Metabolic and Cardiovascular Diseases, UMR1297 INSERM/UPS, Toulouse University, Toulouse, France.
| | - Patrice Darmon
- Aix Marseille University, INSERM, INRA, C2VN, Marseille, France
| | - François Dievart
- Department of Cardiology, Villette Private Hospital, Dunkirk, France
| | - Jean-Michel Halimi
- Department of Nephrology, Tours University Hospital, Tours, France
- EA4245, Tours University, Tours, France
| | - Bruno Guerci
- Department of Endocrinology, Diabetology, and Nutrition, Brabois Adult Hospital, University of Lorraine, Vandoeuvre-Lès-Nancy, France
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16
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Davies MJ, Aroda VR, Collins BS, Gabbay RA, Green J, Maruthur NM, Rosas SE, Del Prato S, Mathieu C, Mingrone G, Rossing P, Tankova T, Tsapas A, Buse JB. Management of hyperglycaemia in type 2 diabetes, 2022. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 2022; 65:1925-1966. [PMID: 36151309 PMCID: PMC9510507 DOI: 10.1007/s00125-022-05787-2] [Citation(s) in RCA: 301] [Impact Index Per Article: 150.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 08/18/2022] [Indexed: 01/11/2023]
Abstract
The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the previous consensus statements on the management of hyperglycaemia in type 2 diabetes in adults, published since 2006 and last updated in 2019. The target audience is the full spectrum of the professional healthcare team providing diabetes care in the USA and Europe. A systematic examination of publications since 2018 informed new recommendations. These include additional focus on social determinants of health, the healthcare system and physical activity behaviours including sleep. There is a greater emphasis on weight management as part of the holistic approach to diabetes management. The results of cardiovascular and kidney outcomes trials involving sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists, including assessment of subgroups, inform broader recommendations for cardiorenal protection in people with diabetes at high risk of cardiorenal disease. After a summary listing of consensus recommendations, practical tips for implementation are provided.
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Affiliation(s)
- Melanie J Davies
- Leicester Diabetes Research Centre, University of Leicester, Leicester, UK.
- Leicester National Institute for Health Research (NIHR) Biomedical Research Centre, University Hospitals of Leicester NHS Trust, Leicester, UK.
| | - Vanita R Aroda
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Billy S Collins
- National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | | | - Jennifer Green
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Nisa M Maruthur
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sylvia E Rosas
- Kidney and Hypertension Unit, Joslin Diabetes Center, Harvard Medical School, Boston, MA, USA
| | - Stefano Del Prato
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Chantal Mathieu
- Clinical and Experimental Endocrinology, KU Leuven, Leuven, Belgium
| | - Geltrude Mingrone
- Università Cattolica del Sacro Cuore, Rome, Italy
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Division of Diabetes and Nutritional Sciences, School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, London, UK
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Tsvetalina Tankova
- Department of Endocrinology, Medical University - Sofia, Sofia, Bulgaria
| | - Apostolos Tsapas
- Diabetes Centre, Clinical Research and Evidence-based Medicine Unit, Aristotle University Thessaloniki, Thessaloniki, Greece
- Harris Manchester College, University of Oxford, Oxford, UK
| | - John B Buse
- University of North Carolina School of Medicine, Chapel Hill, NC, USA.
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Du L, Qin J, Wang D, Zhao Y, Xu N, Wu C, Yuan J. Meta-analysis assessing the effectiveness of SGLT2i+GLP1RA combination therapy versus monotherapy on cardiovascular and cerebrovascular outcomes in diabetic patients. Front Physiol 2022; 13:1028486. [DOI: 10.3389/fphys.2022.1028486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 10/26/2022] [Indexed: 11/09/2022] Open
Abstract
Relevant meta-analyses have confirmed the cardiovascular and renal benefits of sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1RA) among patients with type 2 diabetes (T2D) and/or cardiorenal disease. However, it is not established whether the combination therapy of SGLT2i and GLP1RA will yield an additive benefit on cardiorenal endpoints. Lopez and colleagues recently did a cohort study (Lopez et al., Am. J. Cardiol., 2022, 181, 87–93) and aimed to address this issue. However, their findings are not consistent with those of previous studies. To confirm Lopez et al.’s findings (Lopez et al., Am. J. Cardiol., 2022, 181, 87–93) and address the aforementioned inconsistencies, we conducted a meta-analysis based on relevant studies. Our meta-analysis identified that SGLT2i + GLP1RA combination therapy was significantly associated with the reduced risks of cardiovascular/cerebrovascular atherosclerotic, heart failure-associated, and death outcomes compared with SGLT2i/GLP1RA monotherapy. These might support this combination therapy used for better reducing cardiovascular and death events in T2D patients, especially in those with high or very high cardiovascular risk. This is a commentary on a previous article (Lopez et al.’s study (Lopez et al., Am. J. Cardiol., 2022, 181, 87–93)) published outside of Frontiers. Therefore, we submitted this manuscript as an Opinion article, as suggested in the Author Guidelines.
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18
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Davies MJ, Aroda VR, Collins BS, Gabbay RA, Green J, Maruthur NM, Rosas SE, Del Prato S, Mathieu C, Mingrone G, Rossing P, Tankova T, Tsapas A, Buse JB. Management of Hyperglycemia in Type 2 Diabetes, 2022. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care 2022; 45:2753-2786. [PMID: 36148880 PMCID: PMC10008140 DOI: 10.2337/dci22-0034] [Citation(s) in RCA: 472] [Impact Index Per Article: 236.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 08/04/2022] [Indexed: 02/07/2023]
Abstract
The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the previous consensus statements on the management of hyperglycemia in type 2 diabetes in adults, published since 2006 and last updated in 2019. The target audience is the full spectrum of the professional health care team providing diabetes care in the U.S. and Europe. A systematic examination of publications since 2018 informed new recommendations. These include additional focus on social determinants of health, the health care system, and physical activity behaviors, including sleep. There is a greater emphasis on weight management as part of the holistic approach to diabetes management. The results of cardiovascular and kidney outcomes trials involving sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists, including assessment of subgroups, inform broader recommendations for cardiorenal protection in people with diabetes at high risk of cardiorenal disease. After a summary listing of consensus recommendations, practical tips for implementation are provided.
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Affiliation(s)
- Melanie J. Davies
- Leicester Diabetes Research Centre, University of Leicester, Leicester, U.K
- Leicester National Institute for Health Research Biomedical Research Centre, University Hospitals of Leicester NHS Trust, Leicester, U.K
| | - Vanita R. Aroda
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | | | | | - Jennifer Green
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Nisa M. Maruthur
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sylvia E. Rosas
- Kidney and Hypertension Unit, Joslin Diabetes Center, Harvard Medical School, Boston, MA
| | - Stefano Del Prato
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Chantal Mathieu
- Clinical and Experimental Endocrinology, KU Leuven, Leuven, Belgium
| | - Geltrude Mingrone
- Università Cattolica del Sacro Cuore, Rome, Italy
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Division of Diabetes and Nutritional Sciences, School of Cardiovascular and Metabolic Medicine and Sciences, King’s College London, London, U.K
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Apostolos Tsapas
- Diabetes Centre, Clinical Research and Evidence-Based Medicine Unit, Aristotle University Thessaloniki, Thessaloniki, Greece
- Harris Manchester College, University of Oxford, Oxford, U.K
| | - John B. Buse
- University of North Carolina School of Medicine, Chapel Hill, NC
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Forst T, Mathieu C, Giorgino F, Wheeler DC, Papanas N, Schmieder RE, Halabi A, Schnell O, Streckbein M, Tuttle KR. New strategies to improve clinical outcomes for diabetic kidney disease. BMC Med 2022; 20:337. [PMID: 36210442 PMCID: PMC9548386 DOI: 10.1186/s12916-022-02539-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 08/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diabetic kidney disease (DKD), the most common cause of kidney failure and end-stage kidney disease worldwide, will develop in almost half of all people with type 2 diabetes. With the incidence of type 2 diabetes continuing to increase, early detection and management of DKD is of great clinical importance. MAIN BODY This review provides a comprehensive clinical update for DKD in people with type 2 diabetes, with a special focus on new treatment modalities. The traditional strategies for prevention and treatment of DKD, i.e., glycemic control and blood pressure management, have only modest effects on minimizing glomerular filtration rate decline or progression to end-stage kidney disease. While cardiovascular outcome trials of SGLT-2i show a positive effect of SGLT-2i on several kidney disease-related endpoints, the effect of GLP-1 RA on kidney-disease endpoints other than reduced albuminuria remain to be established. Non-steroidal mineralocorticoid receptor antagonists also evoke cardiovascular and kidney protective effects. CONCLUSION With these new agents and the promise of additional agents under clinical development, clinicians will be more able to personalize treatment of DKD in patients with type 2 diabetes.
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Affiliation(s)
- Thomas Forst
- Clinical Research Services, Mannheim GmbH, Grenadierstrasse 1, D-68167, Mannheim, Germany.
| | - Chantal Mathieu
- Department of Endocrinology, UZ Gasthuisberg, Katholieke Universiteit, Leuven, Belgium
| | - Francesco Giorgino
- Department of Emergency and Organ Transplantation Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, Bari, Italy
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK
| | - Nikolaos Papanas
- Diabetes Centre, Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Roland E Schmieder
- Department of Nephrology and Hypertension, University Hospital Erlangen, Erlangen, Germany
| | | | | | - Marina Streckbein
- Clinical Research Services, Mannheim GmbH, Grenadierstrasse 1, D-68167, Mannheim, Germany
| | - Katherine R Tuttle
- Division of Nephrology, Institute of Translational Health Sciences, University of Washington, Seattle, WA, USA
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20
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Agonistas del receptor de péptido similar al glucagón tipo 1 (GLP-1) en el manejo del paciente con diabetes mellitus tipo 2. Una aproximación para el nefrólogo. Nefrologia 2022. [DOI: 10.1016/j.nefro.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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21
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Chew NWS, Ng CH, Truong E, Noureddin M, Kowdley KV. Nonalcoholic Steatohepatitis Drug Development Pipeline: An Update. Semin Liver Dis 2022; 42:379-400. [PMID: 35709720 DOI: 10.1055/a-1877-9656] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Nonalcoholic steatohepatitis (NASH) is a burgeoning global health crisis that mirrors the obesity pandemic. This global health crisis has stimulated active research to develop novel NASH pharmacotherapies targeting dysregulated inflammatory, cellular stress, and fibrogenetic processes that include (1) metabolic pathways to improve insulin sensitivity, de novo lipogenesis, and mitochondrial utilization of fatty acids; (2) cellular injury or inflammatory targets that reduce inflammatory cell recruitment and signaling; (3) liver-gut axis targets that influence bile acid enterohepatic circulation and signaling; and (4) antifibrotic targets. In this review, we summarize several of the therapeutic agents that have been studied in phase 2 and 3 randomized trials. In addition to reviewing novel therapeutic drugs targeting nuclear receptor pathways, liver chemokine receptors, liver lipid metabolism, lipotoxicity or cell death, and glucagon-like peptide-1 receptors, we also discuss the rationale behind the use of combination therapy and the lessons learned from unsuccessful or negative clinical trials.
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Affiliation(s)
- Nicholas W S Chew
- Department of Cardiology, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Cheng Han Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Emily Truong
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Mazen Noureddin
- Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Fatty Liver Program, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Kris V Kowdley
- Liver Institute Northwest and Elson S. Floyd College of Medicine, Washington State University, Seattle, Washington
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22
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Singh AK, Singh R. Metabolic and cardiovascular benefits with combination therapy of SGLT-2 inhibitors and GLP-1 receptor agonists in type 2 diabetes. World J Cardiol 2022; 14:329-342. [PMID: 35979179 PMCID: PMC9258221 DOI: 10.4330/wjc.v14.i6.329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 03/17/2022] [Accepted: 05/23/2022] [Indexed: 02/06/2023] Open
Abstract
Both GLP-1 receptor agonists (GLP-1RA) and SGLT-2 inhibitors (SGLT-2I) are newer classes of anti-diabetic agents that lower HbA1c moderately and decrease body weight and systolic blood pressure (SBP) modestly. Combination therapy with GLP-1RA plus SGLT-2I have shown a greater reduction in HbA1c, body weight, and SBP compared to either agent alone without any significant increase in hypoglycemia or other side effects. Since several agents from each class of these drugs have shown an improvement in cardiovascular (CV) and renal outcomes in their respective cardiovascular outcome trials (CVOT), combination therapy is theoretically expected to have additional CV and renal benefits. In this comprehensive opinion review, we found HbA1c lowering with GLP-1RA plus SGLT-2I to be less than additive compared to the sum of HbA1c lowering with either agent alone, although body weight lowering was nearly additive and the SBP lowering was more than additive. Our additional meta-analysis of CV outcomes with GLP-1RA plus SGLT-2I combination therapy from the pooled data of five CVOT found a similar reduction in three-point major adverse cardiovascular events compared to GLP-1RA or SGLT-2I alone, against placebo. Interestingly, a greater benefit in reduction of heart failure hospitalization with GLP-1RA plus SGLT-2I combination therapy was noted in the pooled meta-analysis of two randomized controlled trials. Future adequately powered trials can confirm whether additional CV or renal benefit is truly exerted by GLP-1RA plus SGLT-2I combination therapy.
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Affiliation(s)
- Awadhesh Kumar Singh
- Department of Diabetes and Endocrinology, G.D Hospital and Diabetes Institute, Kolkata 700013, India
| | - Ritu Singh
- Department of Reproductive Endocrinology, G.D Hospital and Diabetes Institute, Kolkata 700013, India
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23
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Yau K, Dharia A, Alrowiyti I, Cherney DZ. Prescribing SGLT2 Inhibitors in Patients with Chronic Kidney Disease: Expanding Indications and Practical Considerations. Kidney Int Rep 2022; 7:1463-1476. [PMID: 35812300 PMCID: PMC9263228 DOI: 10.1016/j.ekir.2022.04.094] [Citation(s) in RCA: 71] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/08/2022] [Accepted: 04/25/2022] [Indexed: 12/20/2022] Open
Affiliation(s)
- Kevin Yau
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Atit Dharia
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ibrahim Alrowiyti
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - David Z.I. Cherney
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Correspondence: David Z.I. Cherney, Division of Nephrology, Department of Medicine, Toronto General Hospital, 585 University Avenue, 8N-845, Toronto, Ontario, M5G 2N2, Canada.
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24
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Lau KTK, Wong CKH, Au ICH, Lau WCY, Man KKC, Chui CSL, Wong ICK. Switching to Versus Addition of Incretin-Based Drugs Among Patients With Type 2 Diabetes Taking Sodium-Glucose Cotransporter-2 Inhibitors. J Am Heart Assoc 2022; 11:e023489. [PMID: 35322676 PMCID: PMC9075422 DOI: 10.1161/jaha.121.023489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background Evidence is limited in comparing treatment modification by substitution or add‐on of glucose‐lowering medications in patients with type 2 diabetes. This observational study aims to compare switching versus add‐on of incretin‐based drugs among patients with type 2 diabetes on background sodium‐glucose cotransporter‐2 inhibitors (SGLT2i). Methods and Results This population‐based, retrospective cohort study was conducted using the IQVIA Medical Research Data, including adults with type 2 diabetes on background SGLT2i from 2005 to 2020. New users of incretin‐based drugs were allocated into the “Switch” group if they had discontinued SGLT2i treatment, or the “Add‐on” group if their background SGLT2i was continued. Baseline characteristics of patients were balanced between groups. Study outcomes were all‐cause mortality, cardiovascular diseases, kidney diseases, hypoglycemia, and ketoacidosis. Patients were observed from the index date of initiating incretin‐based drugs until the earliest of an outcome event, death, or data cut‐off date. Changes in anthropometric and metabolic parameters were also compared between groups from baseline to 12‐month follow‐up. A total of 2888 patients were included, classified into “Switch” (n=1461) or “Add‐on” group (n=1427). Median follow‐up was 18 months with 5183 person‐years. Overall, no significant differences in the risks of study outcomes were observed between groups; however, patients in the “Add‐on” group achieved significantly greater reductions in glycated hemoglobin, weight, percentage weight loss, and systolic blood pressure than their “Switch” counterparts. Conclusions Initiating incretin‐based drugs as add‐on among patients with type 2 diabetes on background SGLT2i was associated with risks of clinical end points comparable to switching treatments, in addition to better glycemic and weight control observed with the combination approach.
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Affiliation(s)
- Kristy T K Lau
- Department of Pharmacology and Pharmacy Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong SAR China
| | - Carlos K H Wong
- Department of Pharmacology and Pharmacy Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong SAR China.,Department of Family Medicine and Primary Care School of Clinical Medicine Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong SAR China.,Laboratory of Data Discovery for Health (D24H) Hong Kong Science Park, New Territories Hong Kong SAR China
| | - Ivan C H Au
- Department of Pharmacology and Pharmacy Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong SAR China
| | - Wallis C Y Lau
- Department of Pharmacology and Pharmacy Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong SAR China.,Research Department of Policy and Practice University College London School of Pharmacy London UK
| | - Kenneth K C Man
- Department of Pharmacology and Pharmacy Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong SAR China.,Research Department of Policy and Practice University College London School of Pharmacy London UK
| | - Celine S L Chui
- Laboratory of Data Discovery for Health (D24H) Hong Kong Science Park, New Territories Hong Kong SAR China.,School of Nursing Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong SAR China.,School of Public Health Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong SAR China
| | - Ian C K Wong
- Department of Pharmacology and Pharmacy Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong SAR China.,Laboratory of Data Discovery for Health (D24H) Hong Kong Science Park, New Territories Hong Kong SAR China.,Research Department of Policy and Practice University College London School of Pharmacy London UK
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25
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Brown E, Wilding JPH, Alam U, Barber TM, Karalliedde J, Cuthbertson DJ. The expanding role of SGLT2 inhibitors beyond glucose-lowering to cardiorenal protection. Ann Med 2021; 53:2072-2089. [PMID: 33107349 PMCID: PMC8592607 DOI: 10.1080/07853890.2020.1841281] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 10/12/2020] [Indexed: 12/17/2022] Open
Abstract
The kidney plays a major physiological role in glucose homeostasis but also contributes to the pathophysiology of type 2 diabetes (T2D), mediated by renal sodium glucose cotransporters (SGLTs). This recognition led to the development of SGLT2 inhibitors that inhibit proximal renal tubular renal glucose and sodium reabsorption. The glucoretic and natriuretic effect of SGLT2 inhibitors is associated with reductions in HbA1c levels, body weight, systolic blood pressure and triglycerides. Major vascular complications of T2D include cardiovascular disease and chronic kidney disease (CKD). Results from several cardiovascular outcome trials (CVOTs) with these drugs have highlighted benefits in reducing major adverse cardiovascular events by 11%, reducing the risk of cardiovascular death or hospitalization for heart failure (HF) by 23% and reducing the risk of progression of renal disease by 45%. Their cardiorenal benefits are apparent across a range of eGFRs (within CKD1-3 groups) and the presence or absence of ischaemic heart disease, HF or T2D. In patients with HF with reduced ejection fraction (HFrEF), similar risk reductions in cardiovascular death and HF events are also seen; results from studies in patients with HF with preserved ejection fraction (HFpEF) are awaited. Cardiorenal benefits have been recently reported in patients with CKD, regardless of the presence or absence of T2D. Indications for use of SGLT2 inhibitors have extended beyond glucose-lowering to a central role in cardiorenal protection. This review will first explore the mechanisms by which glycaemic control, weight loss and cardiovascular risk factors are modulated therapeutically with SGLT2 inhibitors. Subsequently, we outline putative mechanisms underpinning the cardiorenal benefits seen, including in HF and CKD, in the context of completed and ongoing clinical studies. Treatment strategies with SGLT2 inhibitors in individuals with CKD or HF, with and/or without T2D are increasingly appealing. Combination therapy with complementary therapeutic agents is also explored.
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Affiliation(s)
- Emily Brown
- Department of Metabolic and Cardiovascular Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - John P. H. Wilding
- Department of Metabolic and Cardiovascular Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Uazman Alam
- Department of Metabolic and Cardiovascular Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Division of Diabetes, Endocrinology and Gastroenterology, Institute of Human Development, University of Manchester, Manchester, UK
| | - Thomas M. Barber
- Human Metabolism Research Unit, University of Warwick, Coventry, UK
- University Hospital Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Janaka Karalliedde
- School of Cardiovascular Medicine & Sciences, King’s College London, London, UK
| | - Daniel J. Cuthbertson
- Department of Metabolic and Cardiovascular Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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26
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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: 18] [Impact Index Per Article: 6.0] [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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27
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Lin FJ, Wang CC, Hsu CN, Yang CY, Wang CY, Ou HT. Renoprotective effect of SGLT-2 inhibitors among type 2 diabetes patients with different baseline kidney function: a multi-center study. Cardiovasc Diabetol 2021; 20:203. [PMID: 34620182 PMCID: PMC8499571 DOI: 10.1186/s12933-021-01396-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 10/01/2021] [Indexed: 01/10/2023] Open
Abstract
Background To assess the effect of sodium glucose cotransporter-2 inhibitors (SGLT-2is) for type 2 diabetes on kidney outcomes stratified by patient baseline estimated glomerular filtration rate (eGFR) levels (i.e., eGFR ≤ 60, 60 < eGFR ≤ 90, and eGFR > 90 mL/min/1.73 m2). Methods Patients from three large healthcare delivery systems in Taiwan who had initiated SGLT-2is or other glucose-lowering drugs (oGLDs) between May 2016 and December 2017 were included. Main outcomes were the times to 30%, 40%, and 50% eGFR reduction after treatment initiation. One-to-one propensity score matching in the overall study cohort and in each eGFR subgroup between SGLT-2i and oGLD users was applied to ensure between-group comparability in baseline characteristics. Results There were 13,666 matched pairs of SGLT-2is and oGLD users in the overall cohort. While a sustained eGFR decline was revealed in oGLD-treated patients (mean values [standard errors] from 85.61 [0.43] to 82.49 [0.44] mL/min/1.73 m2 during the 12 months after treatment initiation), the mean eGFR values of SGLT-2i users decreased in the first 3 months (85.68 [0.37] to 79.71 [0.41] mL/min/1.73 m2) but then improved and sustained until the end of follow-up. There were 2300, 5705, and 5509 matched SGLT-2i and oGLD users in the eGFR ≤ 60, 60 < eGFR ≤ 90, and eGFR > 90 subgroups, respectively. Using SGLT-2is versus oGLDs was significantly associated with slower eGFR declines; hazard ratios (HRs) were 0.51 (95% CI 0.37–0.69), 0.51 (0.37–0.70), and 0.47 (0.31–0.71) for 40% eGFR reduction in the eGFR ≤ 60, 60 < eGFR ≤ 90, and eGFR > 90 subgroups, respectively. The renoprotective effect of SGLT-2is versus oGLDs was confirmed in the outcomes of 30% and 50% eGFR reduction across the three eGFR subgroups. Conclusions This study supports the renoprotective benefit of real-world SGLT-2i use irrespective of patient baseline kidney function. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-021-01396-2.
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Affiliation(s)
- Fang-Ju Lin
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan.,Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Chi-Chuan Wang
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan.,Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-Ning Hsu
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,College of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chen-Yi Yang
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Yuan Wang
- College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Huang-Tz Ou
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan. .,Department of Pharmacy, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Wang FZ, Wei WB, Li X, Huo JY, Jiang WY, Wang HY, Qian P, Li ZZ, Zhou YB. The cardioprotective effect of the sodium-glucose cotransporter 2 inhibitor dapagliflozin in rats with isoproterenol-induced cardiomyopathy. Am J Transl Res 2021; 13:10950-10961. [PMID: 34650776 PMCID: PMC8506988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 08/07/2021] [Indexed: 06/13/2023]
Abstract
Sodium-glucose cotransporter 2 inhibitor (SGLT2i) has been reported to improve glycemic control. This study was designed to investigate the effects of SGLT2i dapagliflozin (dapa) on cardiomyopathy induced by isoproterenol (ISO) and its potential mechanisms. Fifty male Sprague Dawley rats were randomly assigned to the control (n=10) and the ISO (2.5 mg/kg/day)-treated groups (n=40). After 2 weeks, the 28 surviving rats with obvious left ventricular dysfunction in the ISO group were randomized into three medication groups, including the angiotensin receptor neprilysin inhibitor (ARNI) sacubitril/valsartan group (S/V, n=9), the dapa group (n=9), and the ISO group (n=10) for 4 weeks. Next, electrical programmed stimulation was performed in all the groups to evaluate their susceptibility to ventricular arrhythmias (VAs). Compared to the ISO rats, the dapa administration not only effectively reduced the cumulative risk of death, the myocardial fibrosis, the plasma angiotensin II levels and its functional receptor AT1R protein expressions in the heart, and the proinflammatory cytokine levels in the cardiac tissue of the ISO-treated rats, but it also improved their cardiac function and inhibited oxidative stress. These effects were similar to S/V. However, dapa showed a greater efficacy than S/V in reducing the left ventricular end-diastolic volumes, lowing the heart rates and VAs, and decreasing the body weights and plasma glucose levels. The mechanisms by which dapa exerts protective effects on cardiomyopathy may be related to its indirect antioxidant capacity and direct hypoglycemic action.
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Affiliation(s)
- Fang-Zheng Wang
- Department of Physiology, Nanjing Medical UniversityNanjing 211166, Jiangsu, China
| | - Wen-Bo Wei
- Department of Cardiology, Nanjing BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical UniversityNanjing 210021, Jiangsu, China
| | - Xin Li
- Department of Cardiology, Nanjing BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical UniversityNanjing 210021, Jiangsu, China
| | - Jun-Yu Huo
- Department of Cardiology, First Affiliated Hospital of Nanjing Medical UniversityNanjing 210006, Jiangsu, China
| | - Wan-Ying Jiang
- Department of Cardiology, First Affiliated Hospital of Nanjing Medical UniversityNanjing 210006, Jiangsu, China
| | - Hong-Yu Wang
- Department of Physiology, Nanjing Medical UniversityNanjing 211166, Jiangsu, China
| | - Pei Qian
- Department of Physiology, Nanjing Medical UniversityNanjing 211166, Jiangsu, China
| | - Zhen-Zhen Li
- Department of Cardiology, Nanjing BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical UniversityNanjing 210021, Jiangsu, China
| | - Ye-Bo Zhou
- Department of Physiology, Nanjing Medical UniversityNanjing 211166, Jiangsu, China
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Gerstein HC, Sattar N, Rosenstock J, Ramasundarahettige C, Pratley R, Lopes RD, Lam CSP, Khurmi NS, Heenan L, Del Prato S, Dyal L, Branch K. Cardiovascular and Renal Outcomes with Efpeglenatide in Type 2 Diabetes. N Engl J Med 2021; 385:896-907. [PMID: 34215025 DOI: 10.1056/nejmoa2108269] [Citation(s) in RCA: 332] [Impact Index Per Article: 110.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Four glucagon-like peptide-1 (GLP-1) receptor agonists that are structurally similar to human GLP-1 have been shown to reduce the risk of adverse cardiovascular events among persons with type 2 diabetes. The effect of an exendin-based GLP-1 receptor agonist, efpeglenatide, on cardiovascular and renal outcomes in patients with type 2 diabetes who are also at high risk for adverse cardiovascular events is uncertain. METHODS In this randomized, placebo-controlled trial conducted at 344 sites across 28 countries, we evaluated efpeglenatide in participants with type 2 diabetes and either a history of cardiovascular disease or current kidney disease (defined as an estimated glomerular filtration rate of 25.0 to 59.9 ml per minute per 1.73 m2 of body-surface area) plus at least one other cardiovascular risk factor. Participants were randomly assigned in a 1:1:1 ratio to receive weekly subcutaneous injections of efpeglenatide at a dose of 4 or 6 mg or placebo. Randomization was stratified according to use of sodium-glucose cotransporter 2 inhibitors. The primary outcome was the first major adverse cardiovascular event (MACE; a composite of nonfatal myocardial infarction, nonfatal stroke, or death from cardiovascular or undetermined causes). RESULTS A total of 4076 participants were enrolled; 2717 were assigned to receive efpeglenatide and 1359 to receive placebo. During a median follow-up of 1.81 years, an incident MACE occurred in 189 participants (7.0%) assigned to receive efpeglenatide (3.9 events per 100 person-years) and 125 participants (9.2%) assigned to receive placebo (5.3 events per 100 person-years) (hazard ratio, 0.73; 95% confidence interval [CI], 0.58 to 0.92; P<0.001 for noninferiority; P = 0.007 for superiority). A composite renal outcome event (a decrease in kidney function or macroalbuminuria) occurred in 353 participants (13.0%) assigned to receive efpeglenatide and in 250 participants (18.4%) assigned to receive placebo (hazard ratio, 0.68; 95% CI, 0.57 to 0.79; P<0.001). Diarrhea, constipation, nausea, vomiting, or bloating occurred more frequently with efpeglenatide than with placebo. CONCLUSIONS In this trial involving participants with type 2 diabetes who had either a history of cardiovascular disease or current kidney disease plus at least one other cardiovascular risk factor, the risk of cardiovascular events was lower among those who received weekly subcutaneous injections of efpeglenatide at a dose of 4 or 6 mg than among those who received placebo. (Funded by Sanofi; AMPLITUDE-O ClinicalTrials.gov number, NCT03496298.).
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Affiliation(s)
- Hertzel C Gerstein
- From the Population Health Research Institute, Hamilton Health Sciences (H.C.G., C.R., L.H., L.D.), and McMaster University (H.C.G.) - both in Hamilton, ON, Canada; the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.); the Dallas Diabetes Research Center at Medical City, Dallas (J.R.); AdventHealth Translational Research Institute, Orlando, FL (R.P.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (R.D.L.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); Sanofi, Bridgewater, NJ (N.S.K.); the Section of Metabolic Diseases and Diabetes, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy (S.D.P.); and the Division of Cardiology, University of Washington, Seattle (K.B.)
| | - Naveed Sattar
- From the Population Health Research Institute, Hamilton Health Sciences (H.C.G., C.R., L.H., L.D.), and McMaster University (H.C.G.) - both in Hamilton, ON, Canada; the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.); the Dallas Diabetes Research Center at Medical City, Dallas (J.R.); AdventHealth Translational Research Institute, Orlando, FL (R.P.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (R.D.L.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); Sanofi, Bridgewater, NJ (N.S.K.); the Section of Metabolic Diseases and Diabetes, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy (S.D.P.); and the Division of Cardiology, University of Washington, Seattle (K.B.)
| | - Julio Rosenstock
- From the Population Health Research Institute, Hamilton Health Sciences (H.C.G., C.R., L.H., L.D.), and McMaster University (H.C.G.) - both in Hamilton, ON, Canada; the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.); the Dallas Diabetes Research Center at Medical City, Dallas (J.R.); AdventHealth Translational Research Institute, Orlando, FL (R.P.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (R.D.L.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); Sanofi, Bridgewater, NJ (N.S.K.); the Section of Metabolic Diseases and Diabetes, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy (S.D.P.); and the Division of Cardiology, University of Washington, Seattle (K.B.)
| | - Chinthanie Ramasundarahettige
- From the Population Health Research Institute, Hamilton Health Sciences (H.C.G., C.R., L.H., L.D.), and McMaster University (H.C.G.) - both in Hamilton, ON, Canada; the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.); the Dallas Diabetes Research Center at Medical City, Dallas (J.R.); AdventHealth Translational Research Institute, Orlando, FL (R.P.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (R.D.L.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); Sanofi, Bridgewater, NJ (N.S.K.); the Section of Metabolic Diseases and Diabetes, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy (S.D.P.); and the Division of Cardiology, University of Washington, Seattle (K.B.)
| | - Richard Pratley
- From the Population Health Research Institute, Hamilton Health Sciences (H.C.G., C.R., L.H., L.D.), and McMaster University (H.C.G.) - both in Hamilton, ON, Canada; the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.); the Dallas Diabetes Research Center at Medical City, Dallas (J.R.); AdventHealth Translational Research Institute, Orlando, FL (R.P.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (R.D.L.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); Sanofi, Bridgewater, NJ (N.S.K.); the Section of Metabolic Diseases and Diabetes, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy (S.D.P.); and the Division of Cardiology, University of Washington, Seattle (K.B.)
| | - Renato D Lopes
- From the Population Health Research Institute, Hamilton Health Sciences (H.C.G., C.R., L.H., L.D.), and McMaster University (H.C.G.) - both in Hamilton, ON, Canada; the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.); the Dallas Diabetes Research Center at Medical City, Dallas (J.R.); AdventHealth Translational Research Institute, Orlando, FL (R.P.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (R.D.L.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); Sanofi, Bridgewater, NJ (N.S.K.); the Section of Metabolic Diseases and Diabetes, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy (S.D.P.); and the Division of Cardiology, University of Washington, Seattle (K.B.)
| | - Carolyn S P Lam
- From the Population Health Research Institute, Hamilton Health Sciences (H.C.G., C.R., L.H., L.D.), and McMaster University (H.C.G.) - both in Hamilton, ON, Canada; the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.); the Dallas Diabetes Research Center at Medical City, Dallas (J.R.); AdventHealth Translational Research Institute, Orlando, FL (R.P.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (R.D.L.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); Sanofi, Bridgewater, NJ (N.S.K.); the Section of Metabolic Diseases and Diabetes, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy (S.D.P.); and the Division of Cardiology, University of Washington, Seattle (K.B.)
| | - Nardev S Khurmi
- From the Population Health Research Institute, Hamilton Health Sciences (H.C.G., C.R., L.H., L.D.), and McMaster University (H.C.G.) - both in Hamilton, ON, Canada; the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.); the Dallas Diabetes Research Center at Medical City, Dallas (J.R.); AdventHealth Translational Research Institute, Orlando, FL (R.P.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (R.D.L.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); Sanofi, Bridgewater, NJ (N.S.K.); the Section of Metabolic Diseases and Diabetes, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy (S.D.P.); and the Division of Cardiology, University of Washington, Seattle (K.B.)
| | - Laura Heenan
- From the Population Health Research Institute, Hamilton Health Sciences (H.C.G., C.R., L.H., L.D.), and McMaster University (H.C.G.) - both in Hamilton, ON, Canada; the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.); the Dallas Diabetes Research Center at Medical City, Dallas (J.R.); AdventHealth Translational Research Institute, Orlando, FL (R.P.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (R.D.L.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); Sanofi, Bridgewater, NJ (N.S.K.); the Section of Metabolic Diseases and Diabetes, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy (S.D.P.); and the Division of Cardiology, University of Washington, Seattle (K.B.)
| | - Stefano Del Prato
- From the Population Health Research Institute, Hamilton Health Sciences (H.C.G., C.R., L.H., L.D.), and McMaster University (H.C.G.) - both in Hamilton, ON, Canada; the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.); the Dallas Diabetes Research Center at Medical City, Dallas (J.R.); AdventHealth Translational Research Institute, Orlando, FL (R.P.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (R.D.L.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); Sanofi, Bridgewater, NJ (N.S.K.); the Section of Metabolic Diseases and Diabetes, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy (S.D.P.); and the Division of Cardiology, University of Washington, Seattle (K.B.)
| | - Leanne Dyal
- From the Population Health Research Institute, Hamilton Health Sciences (H.C.G., C.R., L.H., L.D.), and McMaster University (H.C.G.) - both in Hamilton, ON, Canada; the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.); the Dallas Diabetes Research Center at Medical City, Dallas (J.R.); AdventHealth Translational Research Institute, Orlando, FL (R.P.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (R.D.L.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); Sanofi, Bridgewater, NJ (N.S.K.); the Section of Metabolic Diseases and Diabetes, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy (S.D.P.); and the Division of Cardiology, University of Washington, Seattle (K.B.)
| | - Kelley Branch
- From the Population Health Research Institute, Hamilton Health Sciences (H.C.G., C.R., L.H., L.D.), and McMaster University (H.C.G.) - both in Hamilton, ON, Canada; the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.); the Dallas Diabetes Research Center at Medical City, Dallas (J.R.); AdventHealth Translational Research Institute, Orlando, FL (R.P.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (R.D.L.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); Sanofi, Bridgewater, NJ (N.S.K.); the Section of Metabolic Diseases and Diabetes, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy (S.D.P.); and the Division of Cardiology, University of Washington, Seattle (K.B.)
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van Ruiten CC, van der Aart‐van der Beek AB, IJzerman RG, Nieuwdorp M, Hoogenberg K, van Raalte DH, Heerspink HJL. Effect of exenatide twice daily and dapagliflozin, alone and in combination, on markers of kidney function in obese patients with type 2 diabetes: A prespecified secondary analysis of a randomized controlled clinical trial. Diabetes Obes Metab 2021; 23:1851-1858. [PMID: 33908691 PMCID: PMC8360098 DOI: 10.1111/dom.14410] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/15/2021] [Accepted: 04/26/2021] [Indexed: 12/16/2022]
Abstract
AIMS To evaluate the effects of separate and combined use of the sodium-glucose cotransporter-2 (SGLT2) inhibitor dapagliflozin and the glucagon-like peptide-1 receptor agonist (GLP-1RA) exenatide on measures of kidney function. METHODS In this prespecified secondary analysis of the DECREASE trial, we enrolled 66 obese patients with type 2 diabetes in a 16-week randomized double-blind placebo-controlled clinical trial to investigate the effects of dapagliflozin and exenatide twice daily, alone or in combination, versus placebo on 24-hour urinary albumin:creatinine ratio (UACR), creatinine and cystatin C-estimated glomerular filtration rate (GFR) and kidney injury molecule-1:creatinine ratio (KIM-1:Cr). RESULTS At week 16, the mean UACR change from baseline was -39.6% (95% confidence interval [CI] -58.6, -11.9; P = 0.001) in the combined exenatide-dapagliflozin group, -18.1% (95% CI -43.1, 18.0; P = 0.278) in the dapagliflozin group, -15.6% (95% CI -41.4, 21.6; P = 0.357) in the exenatide group and - 11.0% (95% CI -39.8, 31.5; P = 0.552) in the placebo group. Compared to placebo, UACR difference at week 16 in the exenatide-dapagliflozin group was -32.2% (95% CI -60.7, 16.9; P = 0.159). Effects were similar in 37 participants who were using angiotensin-converting enzyme inhibitors or angiotensin receptor blockers at baseline. Compared to placebo, in the exenatide-dapagliflozin group, an acute dip in estimated GFR was observed with creatinine-estimated GFR (-4.0 mL/min/1.73 m2 [95% CI -9.3, 1.2]; P = 0.129) and cystatin C-estimated GFR (-10.4 mL/min/1.73 m2 [95% CI -14.9, -5.8]; P < 0.001). The mean KIM-1:Cr difference in the combined treatment arm versus placebo was -43.8% (95% CI -73.5, 18.9; P = 0.129). CONCLUSION This prespecified secondary analysis suggests that combined therapy with exenatide and dapagliflozin may have synergistic effects on markers of kidney function compared to either therapy alone or placebo in obese patients with type 2 diabetes.
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Affiliation(s)
- Charlotte C. van Ruiten
- Diabetes Centre, Department of Internal MedicineAmsterdam UMC, Location VUMCAmsterdamThe Netherlands
| | | | - Richard G. IJzerman
- Diabetes Centre, Department of Internal MedicineAmsterdam UMC, Location VUMCAmsterdamThe Netherlands
| | - Max Nieuwdorp
- Diabetes Centre, Department of Internal MedicineAmsterdam UMC, Location VUMCAmsterdamThe Netherlands
| | - Klaas Hoogenberg
- Department of Internal MedicineMartini HospitalGroningenThe Netherlands
| | - Daniël H van Raalte
- Diabetes Centre, Department of Internal MedicineAmsterdam UMC, Location VUMCAmsterdamThe Netherlands
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Solis-Herrera C, Cersosimo E, Triplitt C. Antihyperglycemic Algorithms for Type 2 Diabetes: Focus on Nonglycemic Outcomes. Diabetes Spectr 2021; 34:248-256. [PMID: 34511851 PMCID: PMC8387619 DOI: 10.2337/ds20-0067] [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
Type 2 diabetes management continues to increase in complexity as more pharmacologic medication classes become available and high-quality clinical trials are completed. Because many antihyperglycemic agents could be appropriate for a given patient, expert treatment guidance is indispensable. Algorithms can help to guide clinicians toward initiating more evidence-based therapy and critically thinking about patient-centered factors that may influence their medication choices. High-quality cardiovascular, renal, and heart failure outcomes trials completed in the past several years have changed the paradigm of how we think about antihyperglycemic agents. Considerations for atherosclerotic cardiovascular disease, heart failure, and renal insufficiency now figure prominently in treatment algorithms for type 2 diabetes, and the results of recent outcomes trials have significantly transformed algorithmic guidelines published by diabetes, endocrinology, and cardiology associations.
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Affiliation(s)
- Carolina Solis-Herrera
- Division of Diabetes, University of Texas Health at San Antonio, San Antonio, TX
- MARC Diabetes Clinic, University of Texas Health at San Antonio, San Antonio, TX
- Clinical Research Center, Texas Diabetes Institute, University Health System, San Antonio, TX
| | - Eugenio Cersosimo
- Division of Diabetes, University of Texas Health at San Antonio, San Antonio, TX
- Clinical Research Center, Texas Diabetes Institute, University Health System, San Antonio, TX
| | - Curtis Triplitt
- Division of Diabetes, University of Texas Health at San Antonio, San Antonio, TX
- Clinical Research Center, Texas Diabetes Institute, University Health System, San Antonio, TX
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Abstract
Our understanding of nonalcoholic fatty liver disease pathophysiology continues to advance rapidly. Accordingly, the field has moved from describing the clinical phenotype through the presence of nonalcoholic steatohepatitis (NASH) and degree of fibrosis to deep phenotyping with a description of associated comorbidities, genetic polymorphisms and environmental influences that could be associated with disease progression. These insights have fuelled a robust therapeutic pipeline across a variety of new targets to resolve steatohepatitis or reverse fibrosis, or both. Additionally, some of these therapies have beneficial effects that extend beyond the liver, such as effects on glycaemic control, lipid profile and weight loss. In addition, emerging therapies for NASH cirrhosis would have to demonstrate either reversal of fibrosis with associated reduction in portal hypertension or at least delay the progression with eventual decrease in liver-related outcomes. For non-cirrhotic NASH, it is the expectation that reversal of fibrosis by one stage or resolution of NASH with no worsening in fibrosis will need to be accompanied by overall survival benefits. In this Review, we summarize NASH therapies that have progressed to phase II and beyond. We also discuss some of the potential clinical challenges with the use of these new therapies when approved.
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Clegg LE, Jing Y, Penland RC, Boulton DW, Hernandez AF, Holman RR, Vora J. Cardiovascular and renal safety of metformin in patients with diabetes and moderate or severe chronic kidney disease: Observations from the EXSCEL and SAVOR-TIMI 53 cardiovascular outcomes trials. Diabetes Obes Metab 2021; 23:1101-1110. [PMID: 33394543 DOI: 10.1111/dom.14313] [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: 10/19/2020] [Revised: 12/21/2020] [Accepted: 12/28/2020] [Indexed: 01/23/2023]
Abstract
AIM To provide evidence on the cardiovascular and renal safety of metformin in chronic kidney disease (CKD) stages 3 to 4. MATERIALS AND METHODS This post hoc analysis compared participants with an estimated glomerular filtration rate (eGFR) of 15 to 59 mL/min/1.73m2 in the Exenatide Study of Cardiovascular Event Lowering (EXSCEL) and the Saxagliptin and Cardiovascular Outcomes in Patients With Type 2 Diabetes Mellitus (SAVOR-TIMI 53) trials taking metformin, with those not exposed to metformin during these trials, using a propensity-matching approach. Adjusted Cox proportional hazards models were used to assess risk of major adverse cardiovascular events (MACE) and all-cause mortality (ACM). Metformin effect on eGFR slope was calculated using a mixed-model repeated measures analysis, and the number of lactic acidosis events was tabulated. RESULTS No strong trend for lower metformin doses with lower eGFR values was observed in either the EXSCEL or SAVOR-TIMI 53 trials. In the 1745 metformin-using participants matched to non-metformin users, metformin had neutral effects on MACE (hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.76-1.08; P = 0.28) and ACM (HR 0.86, 95% CI 0.70-1.07; P = 0.18), with no interaction by CKD stage, or with use of exenatide or saxagliptin. An improvement in eGFR slope was observed with metformin in the CKD stage 3B cohort in SAVOR-TIMI 53, but not in other groups. CONCLUSIONS This analysis of participants with CKD stages 3 to 4 from two cardiovascular outcomes trials supports the cardiorenal safety of metformin, but does not suggest a consistent benefit on MACE, ACM, or eGFR slope across this population.
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Affiliation(s)
- Lindsay E Clegg
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Gaithersburg, Maryland
| | - Yankang Jing
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert C Penland
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Boston, Massachusetts
| | - David W Boulton
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Gaithersburg, Maryland
| | - Adrian F Hernandez
- Duke University and Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Rury R Holman
- Diabetes Trials Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
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Naing S, Ramesh G, Garcha J, Poliyedath A, Khandelwal S, Mills PK. Is the stepping-down approach a better option than multiple daily injections in obese patients with poorly controlled Type 2 diabetes on advanced insulin therapy? Endocrinol Diabetes Metab 2021; 4:e00204. [PMID: 33855207 PMCID: PMC8029542 DOI: 10.1002/edm2.204] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/25/2020] [Accepted: 10/26/2020] [Indexed: 12/15/2022] Open
Abstract
Aim To determine whether de-escalating from advanced insulin therapy (AIT) to the combined use of metformin, an SGLT2 inhibitor, a GLP1 receptor agonist and basal insulin is the better option than multiple daily insulin injections (MDI) in obese patients with poorly controlled T2DM. Methods This was a 16-week, prospective, randomized, controlled trial. Twenty-two obese patients with T2DM on AIT were randomized to intervention (step-down) or control (MDI) group. In the intervention group, all prandial insulin injections were discontinued, but the patient remained on basal insulin and metformin, to which an SGLT2i and a GLP1 RA were added. In the control group, the patient remained on MDI. Results Compared to control group (n = 8), A1c was significantly lower at week 4 (9.54% vs 8.25%; p = .0088) and week 16 (9.7% vs 7.31%; p < .001) in intervention group (n = 10). In intervention group, compared to baseline, there was a significant decrease in weight (-16.38 pounds; p = .003), BMI (-3.06; p < .001), LDL cholesterol (-15.7 mg/dl; p = .0378), total cholesterol (-18.5 mg/dl; p = .0386), total daily insulin dose (-57.3 units; p < .001) and a significant improvement in DM-SAT patient satisfaction 0-100 scores: total score (+45.3; p < .001) and subscale scores (Convenience + 35.28, p = .019; Lifestyle + 35.8, p = .0052; Medical control + 51.3, p < .001; Wellbeing + 47.2, p = .0091) at week 16. Conclusion De-escalating from AIT to the combined use of metformin, SGLT2i, GLP1 RA and basal insulin in obese patients with poorly controlled T2DM on MDI resulted in significant improvement in glycaemic control, weight loss and significantly higher patient satisfaction. This stepping-down approach may be the better option than continuing MDI in these patients.
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Affiliation(s)
- Soe Naing
- Division of EndocrinologyUniversity of California San Francisco, Fresno Medical Education ProgramFresnoCAUSA
| | - Geeta Ramesh
- Department of Family & Community MedicineUniversity of California San Francisco, Fresno Medical Education ProgramFresnoCAUSA
| | - Jasmine Garcha
- Department of Family & Community MedicineUniversity of California San Francisco, Fresno Medical Education ProgramFresnoCAUSA
| | - Anupama Poliyedath
- Department of Internal MedicineSt Agnes Internal Medicine Residency ProgramFresnoCAUSA
| | - Stutee Khandelwal
- Department of Internal MedicineUniversity of California San Francisco, Fresno Medical Education ProgramFresnoCAUSA
| | - Paul K. Mills
- Department of Internal MedicineUniversity of California San Francisco, Fresno Medical Education ProgramFresnoCAUSA
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Lee JF, Berzan E, Sridhar VS, Odutayo A, Cherney DZ. Cardiorenal Protection in Diabetic Kidney Disease. Endocrinol Metab (Seoul) 2021; 36:256-269. [PMID: 33873265 PMCID: PMC8090466 DOI: 10.3803/enm.2021.987] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 03/26/2021] [Indexed: 12/21/2022] Open
Abstract
Over the last 5 years there have been many new developments in the management of diabetic kidney disease. Glucagon-like peptide-1 receptor agonists (GLP-1 RA) and sodium-glucose cotransporter-2 (SGLT2) inhibitors were initially used for glycemic control, but more recent studies have now shown that their benefits extend to cardiovascular and kidney outcomes. The recent addition of data on the novel mineralocorticoid receptor antagonist (MRA) gives us another approach to further decrease the residual risk of diabetic kidney disease progression. In this review we describe the mechanism of action, key studies, and possible adverse effects related to these three classes of medications. The management of type 2 diabetes now includes an increasing number of medications for the management of comorbidities in a patient population at significant risk of cardiovascular disease and progression of chronic kidney disease. It is from this perspective that we seek to outline the rationale for the sequential and/or combined use of SGLT2 inhibitors, GLP-1 RA and MRAs in patients with type 2 diabetes for heart and kidney protection.
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Affiliation(s)
- Jason F. Lee
- Toronto General Hospital Research Institute, University Health Network, ON, Canada
- Division of Nephrology, Department of Medicine, University of Toronto, ON, Canada
| | - Ecaterina Berzan
- Toronto General Hospital Research Institute, University Health Network, ON, Canada
- Division of Nephrology, Department of Medicine, University of Toronto, ON, Canada
| | - Vikas S. Sridhar
- Toronto General Hospital Research Institute, University Health Network, ON, Canada
- Division of Nephrology, Department of Medicine, University of Toronto, ON, Canada
- Banting and Best Diabetes Centre, University of Toronto, ON, Canada
| | - Ayodele Odutayo
- Division of Nephrology, Department of Medicine, University of Toronto, ON, Canada
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael’s Hospital, ON, Canada
| | - David Z.I. Cherney
- Toronto General Hospital Research Institute, University Health Network, ON, Canada
- Division of Nephrology, Department of Medicine, University of Toronto, ON, Canada
- Banting and Best Diabetes Centre, University of Toronto, ON, Canada
- Department of Physiology, University of Toronto, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
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Cahn A, Wiviott SD, Mosenzon O, Murphy SA, Goodrich EL, Yanuv I, Rozenberg A, Wilding JPH, Leiter LA, Bhatt DL, McGuire DK, Litwak L, Kooy A, Gause-Nilsson IAM, Fredriksson M, Langkilde AM, Sabatine MS, Raz I. Cardiorenal outcomes with dapagliflozin by baseline glucose-lowering agents: Post hoc analyses from DECLARE-TIMI 58. Diabetes Obes Metab 2021; 23:29-38. [PMID: 32844557 DOI: 10.1111/dom.14179] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 08/20/2020] [Accepted: 08/20/2020] [Indexed: 02/06/2023]
Abstract
AIM To assess the associations between baseline glucose-lowering agents (GLAs) and cardiorenal outcomes with dapagliflozin versus placebo in the DECLARE-TIMI 58 study. MATERIALS AND METHODS DECLARE-TIMI 58 assessed the cardiorenal outcomes of dapagliflozin versus placebo in patients with type 2 diabetes. This post hoc analysis elaborates the efficacy and safety outcomes by baseline GLA for treatment effect and GLA-based treatment interaction. RESULTS At baseline, 14 068 patients (82.0%) used metformin, 7322 (42.7%) sulphonylureas, 2888 (16.8%) dipeptidyl peptidase-4 inhibitors, 750 (4.4%) glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and 7013 (40.9%) insulin. Dapagliflozin reduced the composite of cardiovascular death (CVD) and hospitalization for heart failure (HHF) versus placebo regardless of baseline GLA, with greater benefit in the small group of patients with baseline use of GLP-1 RAs (HR [95% CI] 0.37 [0.18, 0.78] vs. 0.86 [0.75, 0.98] in GLP-1 RA users vs. non-users, Pinteraction = .03). The overall HR for major adverse cardiovascular events (CVD, myocardial infarction or ischaemic stroke) was 0.93 (95% CI 0.84, 1.03) with dapagliflozin versus placebo, with no interaction by baseline GLA (Pinteraction > .05). The renal-specific outcome was reduced with dapagliflozin versus placebo in the overall cohort (HR [95%CI] 0.53[0.43-0.66]), with no interaction by baseline GLA (Pinteraction > .05). All of these outcomes were similar in those with versus those without baseline metformin use. CONCLUSIONS The effects of dapagliflozin on cardiorenal outcomes were generally consistent regardless of baseline GLA, with consistent benefits regardless of baseline metformin use. The potential clinical benefit of combining sodium-glucose co-transporter-2 inhibitors with GLP-1 RAs, given some evidence of cardiovascular risk reduction with both classes, should be explored further.
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Affiliation(s)
- Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Stephen D Wiviott
- Division of Cardiovascular Medicine, TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Sabina A Murphy
- Division of Cardiovascular Medicine, TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Erica L Goodrich
- Division of Cardiovascular Medicine, TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ilan Yanuv
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
| | - Aliza Rozenberg
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Lawrence A Leiter
- Department of Medicine, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, and Parkland Health and Hospital System, Dallas, Texas
| | - Leon Litwak
- Endocrinology Unit, Diabetes Section, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Adriaan Kooy
- University Medical Center Groningen and Bethesda Diabetes Research Center, Groningen, the Netherlands
| | | | | | | | - Marc S Sabatine
- Division of Cardiovascular Medicine, TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Israel
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Arnott C, Neuen BL, Heerspink HJ, Figtree GA, Kosiborod M, Lam CS, Cannon CP, Rosenthal N, Shaw W, Mahaffey KW, Jardine MJ, Perkovic V, Neal B. The effects of combination canagliflozin and glucagon-like peptide-1 receptor agonist therapy on intermediate markers of cardiovascular risk in the CANVAS program. Int J Cardiol 2020; 318:126-129. [DOI: 10.1016/j.ijcard.2020.06.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/02/2020] [Accepted: 06/09/2020] [Indexed: 02/07/2023]
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Sridhar VS, Dubrofsky L, Boulet J, Cherney DZ. Making a case for the combined use of SGLT2 inhibitors and GLP1 receptor agonists for cardiorenal protection. J Bras Nefrol 2020; 42:467-477. [PMID: 32926067 PMCID: PMC7860654 DOI: 10.1590/2175-8239-jbn-2020-0100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 06/24/2020] [Indexed: 02/08/2023] Open
Abstract
Sodium glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1RA) were initially approved to improve glycemic control in the treatment of type 2 diabetes. Clinical trials have also demonstrated beneficial effects with regards to cardiovascular and renal parameters. Beyond improving glycemic control, these therapies promote weight loss and lower blood pressure when used individually, and in an additive manner when used together. Accordingly, taking advantage of complementary mechanisms of action with the combined use of these two classes of agents to further improve cardiorenal outcomes is conceptually appealing, but has yet to be explored in detail in clinical trials. In this review, we discuss proposed mechanisms for renal protection, clinical benefits, and adverse events associated with the individual and combined use of SGLT2 inhibitors and GLP-1RA. The management of type 2 diabetes has significantly changed over the last few years, moving away from solely glycemic control towards the concurrent management of associated comorbidities in a patient population at significant risk of cardiovascular disease and progression of chronic kidney disease. It is from this perspective that we seek to outline the rationale for the sequential and/or combined use of SGLT2 inhibitors and GLP-1RA in patients with type 2 diabetes.
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Affiliation(s)
- Vikas S. Sridhar
- University of Toronto, Department of Medicine, Division of Nephrology, Toronto General Hospital, Toronto, Ontario, Canada
| | - Lisa Dubrofsky
- University of Toronto, Department of Medicine, Division of Nephrology, Toronto General Hospital, Toronto, Ontario, Canada
| | - Jacinthe Boulet
- University of Montreal, Department of Medicine, Division of Cardiology, Montreal, Quebec, Canada
| | - David Z. Cherney
- University of Toronto, Department of Medicine, Division of Nephrology, Toronto General Hospital, Toronto, Ontario, Canada
- University of Toronto, Banting and Best Diabetes Centre, Toronto, Ontario, Canada
- University of Toronto, Departments of Physiology and Pharmacology and Toxicology, Toronto, Ontario, Canada
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D'Andrea E, Kesselheim AS, Franklin JM, Jung EH, Hey SP, Patorno E. Heterogeneity of antidiabetic treatment effect on the risk of major adverse cardiovascular events in type 2 diabetes: a systematic review and meta-analysis. Cardiovasc Diabetol 2020; 19:154. [PMID: 32993654 PMCID: PMC7525990 DOI: 10.1186/s12933-020-01133-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 09/18/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND We explored whether clinically relevant baseline characteristics of patients with type 2 diabetes can modify the effect of glucagon-like peptide-1 receptor agonists (GLP-1 RA) or sodium-glucose cotransporter-2 inhibitors (SGLT-2i) on the risk of major adverse cardiovascular events (MACE). METHODS We investigated Medline and EMBASE through June 2019. We included randomized clinical trials reporting the effect of GLP-1 RA or SGLT-2i on MACE in subgroups of patients with type 2 diabetes, identified through key baseline factors: established cardiovascular disease; heart failure; chronic kidney disease; uncontrolled diabetes; duration of diabetes; hypertension; obesity; age; gender and race. Hazard ratios (HRs) and 95% confidence intervals (CIs) from trials were meta-analyzed using random-effects models. RESULTS Ten trials enrolling 89,790 patients were included in the analyses. Subgroup meta-analyses showed a 14% risk reduction of MACE in patients with established cardiovascular disease [GLP1-RA: HR, 0.86 (95% CI, 0.80-0.93); SGLT-2i: 0.86 (0.80-0.93)], and no effect in at-risk patients without history of cardiovascular events [GLP1-RA: 0.94 (0.82-1.07); SGLT-2i: 1.00 (0.87-1.16)]. We observed a trend toward larger treatment benefits with SGLT-2i among patients with chronic kidney disease [0.82 (0.69-0.97)], and patients with uncontrolled diabetes for both GLP1-RA or SGLT-2i [GLP1-RA: 0.82 (0.71-0.95); SGLT-2i: 0.84 (0.75-0.95)]. Uncontrolled hypertension, obesity, gender, age and race did not appear to modify the effect of these drugs. CONCLUSIONS In this exploratory analysis, history of cardiovascular disease appeared to modify the treatment effect of SGLT2i or GLP1-RA on MACE. Chronic kidney disease and uncontrolled diabetes should be further investigated as potential effect modifiers.
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Affiliation(s)
- Elvira D'Andrea
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
| | - Aaron S Kesselheim
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Center for Bioethics, Harvard Medical School, Boston, MA, USA
| | - Jessica M Franklin
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Emily H Jung
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Spencer Phillips Hey
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Center for Bioethics, Harvard Medical School, Boston, MA, USA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, USA
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Practical Considerations and Rationale for Glucagon-Like Peptide-1 Receptor Agonist Plus Sodium-Dependent Glucose Cotransporter-2 Inhibitor Combination Therapy in Type 2 Diabetes. Can J Diabetes 2020; 45:291-302. [PMID: 33189580 DOI: 10.1016/j.jcjd.2020.09.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/31/2020] [Accepted: 09/07/2020] [Indexed: 02/07/2023]
Abstract
Glucagon-like peptide-1 receptor agonists and sodium-dependent glucose cotransporter-2 inhibitors have demonstrated clinically significant benefits on glycated hemoglobin, weight, blood pressure and cardiorenal outcomes. The emerging evidence from clinical trials and meta-analyses that assessed the combination of these 2 classes of drugs has been promising. An expert forum that included individuals with expertise in endocrine, cardiology and nephrology issues was held in May 2020 to review the literature on the metabolic and cardiorenal benefits of these 2 classes, independently and in combination, in adults with type 2 diabetes mellitus. Although hard outcome data are not available, the group concluded that the combination of glucagon-like peptide-1 receptor agonists with sodium-dependent glucose cotransporter-2 inhibitors is an emerging option for managing adults with type 2 diabetes as long as cost is not a barrier. Ongoing research may offer further insights on hard cardiorenal outcomes for this therapeutic combination as well as provide direction on the potential of this approach in obesity, nonalcoholic fatty liver disease, nonalcoholic steatohepatitis and populations without diabetes.
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Alfayez OM, Almohammed OA, Alkhezi OS, Almutairi AR, Al Yami MS. Indirect comparison of glucagon like peptide-1 receptor agonists regarding cardiovascular safety and mortality in patients with type 2 diabetes mellitus: network meta-analysis. Cardiovasc Diabetol 2020; 19:96. [PMID: 32571416 PMCID: PMC7310317 DOI: 10.1186/s12933-020-01070-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 06/16/2020] [Indexed: 12/25/2022] Open
Abstract
Background The cardiovascular outcome trials (CVOTs) have shown that glucagon like peptide-1 receptor agonists (GLP1RAs) have varying degrees of cardiovascular (CV) safety in patients with type 2 diabetes mellitus (T2DM.) The lack of any head-to-head comparative trials among GLP1RAs urged the need for an indirect comparison of these agents. Therefore, this study was conducted to indirectly compare the CV safety and mortality effects among different GLP1RAs in patients with T2DM using network meta-analysis (NMA). Methods Medline was searched to identify GLP1RA CVOTs to date. The outcomes of interest were CV death, myocardial infarction (IM), stroke, and death from any cause. An NMA with binomial likelihood logit link model was used for the binary outcomes. We conducted both fixed effects and random effects models for each outcome, and selected the best model based on the deviance information and the average posterior residual deviance. This NMA was reported in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA-NMA). Results A total of seven GLP1RA CVOTs were included having 56,004 patients. The NMA results showed that oral semaglutide was statistically better than exenatide (OR 0.47, 95% CI 0.21–0.99), dulaglutide (OR 0.46, 95% CI 0.20–0.97), albiglutide (OR 0.45, 95% CI 0.19–0.97), lixisenatide (OR 0.43, 95% CI 0.19–0.92) in reducing CV death events. No significant differences were detected between most of the treatments regarding reducing death from any cause, MI and stroke events. The ranking results showed that oral semaglutide had the highest probability to be ranked first (> 90%) in reducing CV death and death from any cause. Moreover, once weekly semaglutide had the highest probability to be ranked first in reducing MI and stroke events. Conclusion The GLP1RAs have shown significant benefits in terms of CV safety. The indirect comparison and ranking probability results have shown that one weekly semaglutide and oral semaglutide seems to be the preferred option in patients with T2DM and established or at high risk of CVD. This result can aid health care providers, pharmacy and therapeutics committees in hospitals, and insurance companies when deciding which GLP1RA to start or add to their formulary.
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Affiliation(s)
- Osamah M Alfayez
- Department of Pharmacy Practice, College of Pharmacy, Qassim University, Qassim, Saudi Arabia
| | - Omar A Almohammed
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia.
| | - Omar S Alkhezi
- Department of Pharmacy Practice, College of Pharmacy, Qassim University, Qassim, Saudi Arabia
| | | | - Majed S Al Yami
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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Castellana M, Procino F, Sardone R, Trimboli P, Giannelli G. Generalizability of sodium-glucose co-transporter-2 inhibitors cardiovascular outcome trials to the type 2 diabetes population: a systematic review and meta-analysis. Cardiovasc Diabetol 2020; 19:87. [PMID: 32534590 PMCID: PMC7293778 DOI: 10.1186/s12933-020-01067-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/08/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Cardiovascular outcome trials of sodium-glucose co-transporter-2 inhibitors (SGLT2i CVOTs) found the agents to be associated with clinical benefits in terms of cardiovascular and renal outcomes. We performed a meta-analysis to assess and compare the overall prevalence of eligibility for the enrollment criteria of CANVAS, DECLARE-TIMI 58, EMPA-REG OUTCOME, and VERTIS-CV among unselected patients with type 2 diabetes. METHODS This meta-analysis was registered in PROSPERO (CRD42020172032). PubMed, CENTRAL, Scopus and Web of Science were researched in March 2020. Studies evaluating the prevalence of eligibility for each SGLT2i CVOT were selected. Endpoints were estimated using a random-effects model. RESULTS Five studies, evaluating 1,703,519 patients with type 2 diabetes, were included. Overall, the prevalence of eligible patients according to the enrollment criteria of CANVAS, DECLARE-TIMI 58, EMPA-REG OUTCOME, and VERTIS-CV was 36.4%, 49.5%, 17.0% and 19.0%, respectively. In head-to-head comparisons, DECLARE-TIMI 58 was associated with the highest odds of eligibility (1.74 versus CANVAS, 5.15 versus EMPA-REG OUTCOME and 4.81 versus VERTIS-CV), followed by CANVAS and EMPA-REG OUTCOME/VERTIS-CV. A high heterogeneity was found for all the outcomes. CONCLUSIONS The present review showed that a considerable number of patients counseled in clinical practice could have been eligible for SGLT2i CVOTs. Particularly, dapagliflozin was shown to be the SGLT2i with the largest generalizability of findings from its CVOT according to the odds ratio of eligibility for the enrollment criteria among unselected patients with type 2 diabetes. Further country- or region-specific studies are needed to confirm the applicability of our results.
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Affiliation(s)
- Marco Castellana
- Population Health Unit, National Institute of Gastroenterology "Saverio de Bellis", Research Hospital, Castellana Grotte, Bari, Italy.
| | - Filippo Procino
- Population Health Unit, National Institute of Gastroenterology "Saverio de Bellis", Research Hospital, Castellana Grotte, Bari, Italy
| | - Rodolfo Sardone
- Population Health Unit, National Institute of Gastroenterology "Saverio de Bellis", Research Hospital, Castellana Grotte, Bari, Italy
| | - Pierpaolo Trimboli
- Clinic for Nuclear Medicine and Competence Center for Thyroid Diseases, Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Scienze Biomediche, Università della Svizzera Italiana (USI), Lugano, Switzerland
| | - Gianluigi Giannelli
- National Institute of Gastroenterology "Saverio de Bellis", Research Hospital, Castellana Grotte, Bari, Italy
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Longato E, Di Camillo B, Sparacino G, Tramontan L, Avogaro A, Fadini GP. Better cardiovascular outcomes of type 2 diabetic patients treated with GLP-1 receptor agonists versus DPP-4 inhibitors in clinical practice. Cardiovasc Diabetol 2020; 19:74. [PMID: 32522260 PMCID: PMC7288543 DOI: 10.1186/s12933-020-01049-w] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 06/05/2020] [Indexed: 02/07/2023] Open
Abstract
Background Cardiovascular outcome trials in high-risk patients showed that some GLP-1 receptor agonists (GLP-1RA), but not dipeptidyl-peptidase-4 inhibitors (DPP-4i), can prevent cardiovascular events in type 2 diabetes (T2D). Since no trial has directly compared these two classes of drugs, we performed a comparative outcome analysis using real-world data. Methods From a database of ~ 5 million people from North-East Italy, we retrospectively identified initiators of GLP-1RA or DPP-4i from 2011 to 2018. We obtained two balanced cohorts by 1:1 propensity score matching. The primary outcome was the 3-point major adverse cardiovascular events (3P-MACE; a composite of death, myocardial infarction, or stroke). 3P-MACE components and hospitalization for heart failure were secondary outcomes. Results From 330,193 individuals with T2D, we extracted two matched cohorts of 2807 GLP-1RA and 2807 DPP-4i initiators, followed for a median of 18 months. On average, patients were 63 years old, 60% male; 15% had pre-existing cardiovascular disease. The rate of 3P-MACE was lower in patients treated with GLP-1RA compared to DPP4i (23.5 vs. 34.9 events per 1000 person-years; HR: 0.67; 95% C.I. 0.53–0.86; p = 0.002). Rates of myocardial infarction (HR 0.67; 95% C.I. 0.50–0.91; p = 0.011) and all-cause death (HR 0.58; 95% C.I. 0.35–0.96; p = 0.034) were lower among GLP-1RA initiators. The as-treated and intention-to-treat approaches yielded similar results. Conclusions Patients initiating a GLP-1RA in clinical practice had better cardiovascular outcomes than similar patients who initiated a DPP-4i. These data strongly confirm findings from cardiovascular outcome trials in a lower risk population.
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Affiliation(s)
- Enrico Longato
- Department of Information Engineering, University of Padova, 35100, Padua, Italy
| | - Barbara Di Camillo
- Department of Information Engineering, University of Padova, 35100, Padua, Italy
| | - Giovanni Sparacino
- Department of Information Engineering, University of Padova, 35100, Padua, Italy
| | - Lara Tramontan
- Arsenàl.IT, Veneto's Research Centre for eHealth Innovation, 31100, Treviso, Italy
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Via Giustiniani 2, 35100, Padua, Italy
| | - Gian Paolo Fadini
- Department of Medicine, University of Padova, Via Giustiniani 2, 35100, Padua, Italy.
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Chen HY, Huang JY, Siao WZ, Jong GP. The association between SGLT2 inhibitors and new-onset arrhythmias: a nationwide population-based longitudinal cohort study. Cardiovasc Diabetol 2020; 19:73. [PMID: 32503541 PMCID: PMC7275510 DOI: 10.1186/s12933-020-01048-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 05/31/2020] [Indexed: 12/12/2022] Open
Abstract
Background Clinical trials have shown the cardiovascular protective effect of sodium–glucose cotransporter-2 (SGLT2) inhibitors and reduced hospitalization for heart failure. However, no study has investigated the association between SGLT2 inhibitors and the risk of arrhythmias. This study aimed to evaluate the risk of new-onset arrhythmias (NOA) and all-cause mortality with the use of SGLT2 inhibitors. Methods This was a population-based cohort study utilizing Taiwan’s National Health Insurance Research Database. Each patient aged 20 years and older who took SGLT2 inhibitors was assigned to the SGLT2 inhibitor group, whereas sex-, age-, diabetes mellitus duration-, drug index date-, and propensity score-matched randomly selected patients without SGLT2 inhibitors were assigned to the non-SGLT2 inhibitor group. The study outcome was all-cause mortality and NOA. Results A total of 399,810 patients newly diagnosed with type 2 DM were enrolled. A 1:1 matching propensity method was used to match 79,150 patients to 79,150 controls in the non-SGLT2 inhibitors group for analysis. The SGLT2 inhibitor group was associated with a lower risk of all-cause mortality [adjusted hazard ratio (aHR) 0.547; 95% confidence interval (CI) 0.482–0.621; P = 0.0001] and NOA (aHR 0.830; 95% CI 0.751–0.916; P = 0.0002). Conclusions Patients with type 2 DM prescribed with SGLT2 inhibitors were associated with a lower risk of all-cause mortality and NOA compared with those not taking SGLT2 inhibitors in real-world practice.
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Affiliation(s)
- Hung-Yi Chen
- Department of Pharmacy, China Medical University and China Medical University Beigang Hospital, Yunlin County, Taiwan, ROC
| | - Jing-Yang Huang
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan, ROC
| | - Wun-Zhih Siao
- Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital and Chung Shan Medical University, Taichung, Taiwan, ROC
| | - Gwo-Ping Jong
- Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital and Chung Shan Medical University, Taichung, Taiwan, ROC.
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Katsurada K, Nandi SS, Zheng H, Liu X, Sharma NM, Patel KP. GLP-1 mediated diuresis and natriuresis are blunted in heart failure and restored by selective afferent renal denervation. Cardiovasc Diabetol 2020; 19:57. [PMID: 32384887 PMCID: PMC7206815 DOI: 10.1186/s12933-020-01029-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 04/25/2020] [Indexed: 02/07/2023] Open
Abstract
Background Glucagon-like peptide-1 (GLP-1) induces diuresis and natriuresis. Previously we have shown that GLP-1 activates afferent renal nerve to increase efferent renal sympathetic nerve activity that negates the diuresis and natriuresis as a negative feedback mechanism in normal rats. However, renal effects of GLP-1 in heart failure (HF) has not been elucidated. The present study was designed to assess GLP-1-induced diuresis and natriuresis in rats with HF and its interactions with renal nerve activity. Methods HF was induced in rats by coronary artery ligation. The direct recording of afferent renal nerve activity (ARNA) with intrapelvic injection of GLP-1 and total renal sympathetic nerve activity (RSNA) with intravenous infusion of GLP-1 were performed. GLP-1 receptor expression in renal pelvis, densely innervated by afferent renal nerve, was assessed by real-time PCR and western blot analysis. In separate group of rats after coronary artery ligation selective afferent renal denervation (A-RDN) was performed by periaxonal application of capsaicin, then intravenous infusion of GLP-1-induced diuresis and natriuresis were evaluated. Results In HF, compared to sham-operated control; (1) response of increase in ARNA to intrapelvic injection of GLP-1 was enhanced (3.7 ± 0.4 vs. 2.0 ± 0.4 µV s), (2) GLP-1 receptor expression was increased in renal pelvis, (3) response of increase in RSNA to intravenous infusion of GLP-1 was enhanced (132 ± 30% vs. 70 ± 16% of the baseline level), and (4) diuretic and natriuretic responses to intravenous infusion of GLP-1 were blunted (urine flow 53.4 ± 4.3 vs. 78.6 ± 4.4 µl/min/gkw, sodium excretion 7.4 ± 0.8 vs. 10.9 ± 1.0 µEq/min/gkw). A-RDN induced significant increases in diuretic and natriuretic responses to GLP-1 in HF (urine flow 96.0 ± 1.9 vs. 53.4 ± 4.3 µl/min/gkw, sodium excretion 13.6 ± 1.4 vs. 7.4 ± 0.8 µEq/min/gkw). Conclusions The excessive activation of neural circuitry involving afferent and efferent renal nerves suppresses diuretic and natriuretic responses to GLP-1 in HF. These pathophysiological responses to GLP-1 might be involved in the interaction between incretin-based medicines and established HF condition. RDN restores diuretic and natriuretic effects of GLP-1 and thus has potential beneficial therapeutic implication for diabetic HF patients.
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Affiliation(s)
- Kenichi Katsurada
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, 985850 Nebraska Medical Center, Omaha, NE, 68198-5850, USA
| | - Shyam S Nandi
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, 985850 Nebraska Medical Center, Omaha, NE, 68198-5850, USA
| | - Hong Zheng
- Division of Basic Biomedical Sciences, Sanford School of Medicine of the University of South Dakota, Vermillion, SD, USA
| | - Xuefei Liu
- Division of Basic Biomedical Sciences, Sanford School of Medicine of the University of South Dakota, Vermillion, SD, USA
| | - Neeru M Sharma
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, 985850 Nebraska Medical Center, Omaha, NE, 68198-5850, USA
| | - Kaushik P Patel
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, 985850 Nebraska Medical Center, Omaha, NE, 68198-5850, USA.
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