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Wu L, Rodriguez M, El Hachem K, Krittanawong C. Diuretic Treatment in Heart Failure: A Practical Guide for Clinicians. J Clin Med 2024; 13:4470. [PMID: 39124738 PMCID: PMC11313642 DOI: 10.3390/jcm13154470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Revised: 07/25/2024] [Accepted: 07/26/2024] [Indexed: 08/12/2024] Open
Abstract
Congestion and fluid retention are the hallmarks of decompensated heart failure and the major reason for the hospitalization of patients with heart failure. Diuretics have been used in heart failure for decades, and they remain the backbone of the contemporary management of heart failure. Loop diuretics is the preferred diuretic, and it has been given a class I recommendation by clinical guidelines for the relief of congestion symptoms. Although loop diuretics have been used virtually among all patients with acute decompensated heart failure, there is still very limited clinical evidence to guide the optimized diuretics use. This is a sharp contrast to the rapidly growing evidence of the rest of the guideline-directed medical therapy of heart failure and calls for further studies. The loop diuretics possess a unique pharmacology and pharmacokinetics that lay the ground for different strategies to increase diuretic efficiency. However, many of these approaches have not been evaluated in randomized clinical trials. In recent years, a stepped and protocolized diuretics dosing has been suggested to have superior benefits over an individual clinician-based strategy. Diuretic resistance has been a major challenge to decongestion therapy for patients with heart failure and is associated with a poor clinical prognosis. Recently, therapy options have emerged to help overcome diuretic resistance to loop diuretics and have been evaluated in randomized clinical trials. In this review, we aim to provide a comprehensive review of the pharmacology and clinical use of loop diuretics in the context of heart failure, with attention to its side effects, and adjuncts, as well as the challenges and future direction.
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Affiliation(s)
- Lingling Wu
- Cardiovascular Division, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Mario Rodriguez
- John T. Milliken Department of Medicine, Division of Cardiovascular Disease, Section of Advanced Heart Failure and Transplant, Barnes-Jewish Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO 63110, USA
| | - Karim El Hachem
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY 10029, USA
| | - Chayakrit Krittanawong
- Section of Cardiology, Cardiology Division, NYU Langone Health and NYU School of Medicine, 550 First Avenue, New York, NY 10016, USA
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Asakura-Kinoshita M, Masuda T, Oka K, Ohara K, Miura M, Morinari M, Misawa K, Miyazawa Y, Akimoto T, Shimada K, Nagata D. Sodium-Glucose Cotransporter 2 Inhibitor Combined with Conventional Diuretics Ameliorate Body Fluid Retention without Excessive Plasma Volume Reduction. Diagnostics (Basel) 2024; 14:1194. [PMID: 38893720 PMCID: PMC11171863 DOI: 10.3390/diagnostics14111194] [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: 04/07/2024] [Revised: 05/28/2024] [Accepted: 06/04/2024] [Indexed: 06/21/2024] Open
Abstract
We previously reported that sodium-glucose cotransporter 2 (SGLT2) inhibitors exert sustained fluid homeostatic actions through compensatory increases in osmotic diuresis-induced vasopressin secretion and fluid intake. However, SGLT2 inhibitors alone do not produce durable amelioration of fluid retention. In this study, we examined the comparative effects of the SGLT2 inhibitor dapagliflozin (SGLT2i group, n = 53) and the combined use of dapagliflozin and conventional diuretics, including loop diuretics and/or thiazides (SGLT2i + diuretic group, n = 23), on serum copeptin, a stable, sensitive, and simple surrogate marker of vasopressin release and body fluid status. After six months of treatment, the change in copeptin was significantly lower in the SGLT2i + diuretic group than in the SGLT2i group (-1.4 ± 31.5% vs. 31.5 ± 56.3%, p = 0.0153). The change in the estimated plasma volume calculated using the Strauss formula was not significantly different between the two groups. Contrastingly, changes in interstitial fluid, extracellular water, intracellular water, and total body water were significantly lower in the SGLT2i + diuretic group than in the SGLT2i group. Changes in renin, aldosterone, and absolute epinephrine levels were not significantly different between the two groups. In conclusion, the combined use of the SGLT2 inhibitor dapagliflozin and conventional diuretics inhibited the increase in copeptin levels and remarkably ameliorated fluid retention without excessively reducing plasma volume and activating the renin-angiotensin-aldosterone and sympathetic nervous systems.
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Affiliation(s)
- Maki Asakura-Kinoshita
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke 3290498, Japan; (M.A.-K.); (K.O.); (K.O.); (K.M.); (T.A.); (D.N.)
| | - Takahiro Masuda
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke 3290498, Japan; (M.A.-K.); (K.O.); (K.O.); (K.M.); (T.A.); (D.N.)
- Department of Nephrology, Shin-Oyama City Hospital, Oyama 3230827, Japan;
| | - Kentaro Oka
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke 3290498, Japan; (M.A.-K.); (K.O.); (K.O.); (K.M.); (T.A.); (D.N.)
- Department of Nephrology, Shin-Oyama City Hospital, Oyama 3230827, Japan;
| | - Ken Ohara
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke 3290498, Japan; (M.A.-K.); (K.O.); (K.O.); (K.M.); (T.A.); (D.N.)
| | - Marina Miura
- Department of Nephrology, Shin-Oyama City Hospital, Oyama 3230827, Japan;
| | - Masato Morinari
- Department of Internal Medicine, Nasu Minami Hospital, Nasu-Karasuyama 3210621, Japan; (M.M.); (Y.M.)
| | - Kyohei Misawa
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke 3290498, Japan; (M.A.-K.); (K.O.); (K.O.); (K.M.); (T.A.); (D.N.)
- Department of Nephrology, Shin-Oyama City Hospital, Oyama 3230827, Japan;
| | - Yasuharu Miyazawa
- Department of Internal Medicine, Nasu Minami Hospital, Nasu-Karasuyama 3210621, Japan; (M.M.); (Y.M.)
| | - Tetsu Akimoto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke 3290498, Japan; (M.A.-K.); (K.O.); (K.O.); (K.M.); (T.A.); (D.N.)
| | - Kazuyuki Shimada
- Department of Cardiology, Shin-Oyama City Hospital, Oyama 3230827, Japan;
| | - Daisuke Nagata
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke 3290498, Japan; (M.A.-K.); (K.O.); (K.O.); (K.M.); (T.A.); (D.N.)
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Jariwala P, Kulkarni GP, Punjani A, Boorugu H, Gude D. Role of Empagliflozin in heart failure with severe aortic stenosis before valve replacement: EASTER-HF study. Indian Heart J 2024; 76:207-209. [PMID: 38878965 PMCID: PMC11329009 DOI: 10.1016/j.ihj.2024.06.009] [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: 04/09/2023] [Revised: 03/24/2024] [Accepted: 06/12/2024] [Indexed: 06/18/2024] Open
Abstract
We evaluated empagliflozin in severe DAS patients with HF before AVR. HF patients with LVEF 30-80 % and NYHA functional class II-IV symptoms got empagliflozin 10 mg or not within 6 months before AVR, along with SOC. Adding empagliflozin to the SOC before AVR reduced HF death or HHF by 73 % after 6-months in a group of 20 patients (RR 0.27; p = 0.022). Improving LVEF (+3.48 %, p < 0.001) and NT-proBNP levels (-3974.6 pg/mL) with empagliflozin in SOC before AVR significantly reduced in-hospital and 6-month mortality in this patient group. In severe DAS and HF patients, empagliflozin improved symptoms and prognosis.
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Affiliation(s)
- Pankaj Jariwala
- Department of Cardiology, Yashoda Hospitals, Somajiguda, Raj Bhavan Road, Hyderabad, Telangana, 500082, India.
| | - Gururaj Pramod Kulkarni
- Department of Cardiology, Yashoda Hospitals, Somajiguda, Raj Bhavan Road, Hyderabad, Telangana, 500082, India.
| | - Arshad Punjani
- Department of Internal Medicine, Yashoda Hospitals, Somajiguda, Raj Bhavan Road, Hyderabad, Telangana, 500082, India.
| | - Harikishan Boorugu
- Department of Internal Medicine, Yashoda Hospitals, Somajiguda, Raj Bhavan Road, Hyderabad, Telangana, 500082, India.
| | - Dilip Gude
- Department of Internal Medicine, Yashoda Hospitals, Somajiguda, Raj Bhavan Road, Hyderabad, Telangana, 500082, India.
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Preda A, Montecucco F, Carbone F, Camici GG, Lüscher TF, Kraler S, Liberale L. SGLT2 inhibitors: from glucose-lowering to cardiovascular benefits. Cardiovasc Res 2024; 120:443-460. [PMID: 38456601 DOI: 10.1093/cvr/cvae047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/03/2024] [Accepted: 02/05/2024] [Indexed: 03/09/2024] Open
Abstract
An increasing number of individuals are at high risk of type 2 diabetes (T2D) and its cardiovascular complications, including heart failure (HF), chronic kidney disease (CKD), and eventually premature death. The sodium-glucose co-transporter-2 (SGLT2) protein sits in the proximal tubule of human nephrons to regulate glucose reabsorption and its inhibition by gliflozins represents the cornerstone of contemporary T2D and HF management. Herein, we aim to provide an updated overview of the pleiotropy of gliflozins, provide mechanistic insights and delineate related cardiovascular (CV) benefits. By discussing contemporary evidence obtained in preclinical models and landmark randomized controlled trials, we move from bench to bedside across the broad spectrum of cardio- and cerebrovascular diseases. With landmark randomized controlled trials confirming a reduction in major adverse CV events (MACE; composite endpoint of CV death, non-fatal myocardial infarction, and non-fatal stroke), SGLT2 inhibitors strongly mitigate the risk for heart failure hospitalization in diabetics and non-diabetics alike while conferring renoprotection in specific patient populations. Along four major pathophysiological axes (i.e. at systemic, vascular, cardiac, and renal levels), we provide insights into the key mechanisms that may underlie their beneficial effects, including gliflozins' role in the modulation of inflammation, oxidative stress, cellular energy metabolism, and housekeeping mechanisms. We also discuss how this drug class controls hyperglycaemia, ketogenesis, natriuresis, and hyperuricaemia, collectively contributing to their pleiotropic effects. Finally, evolving data in the setting of cerebrovascular diseases and arrhythmias are presented and potential implications for future research and clinical practice are comprehensively reviewed.
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Affiliation(s)
- Alberto Preda
- Department of Clinical Cardiology, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Fabrizio Montecucco
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132 Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, Genoa, Italy
| | - Federico Carbone
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132 Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, Genoa, Italy
| | - Giovanni G Camici
- Center for Molecular Cardiology, University of Zürich, Schlieren, Switzerland
- Department of Research and Education, University Hospital Zurich, Zurich, Switzerland
| | - Thomas F Lüscher
- Center for Molecular Cardiology, University of Zürich, Schlieren, Switzerland
- Royal Brompton and Harefield Hospitals and Imperial College and King's College, London, United Kingdom
| | - Simon Kraler
- Center for Molecular Cardiology, University of Zürich, Schlieren, Switzerland
- Department of Internal Medicine, Cantonal Hospital Baden, Baden, Switzerland
| | - Luca Liberale
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132 Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, Genoa, Italy
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Marton A, Saffari SE, Rauh M, Sun RN, Nagel AM, Linz P, Lim TT, Takase-Minegishi K, Pajarillaga A, Saw S, Morisawa N, Yam WK, Minegishi S, Totman JJ, Teo S, Teo LLY, Ng CT, Kitada K, Wild J, Kovalik JP, Luft FC, Greasley PJ, Chin CWL, Sim DKL, Titze J. Water Conservation Overrides Osmotic Diuresis During SGLT2 Inhibition in Patients With Heart Failure. J Am Coll Cardiol 2024; 83:1386-1398. [PMID: 38599715 DOI: 10.1016/j.jacc.2024.02.020] [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: 12/06/2023] [Revised: 02/08/2024] [Accepted: 02/08/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Sodium-glucose cotransporter 2 inhibitors are believed to improve cardiac outcomes due to their osmotic diuretic potential. OBJECTIVES The goal of this study was to test the hypothesis that vasopressin-driven urine concentration overrides the osmotic diuretic effect of glucosuria induced by dapagliflozin treatment. METHODS DAPA-Shuttle1 (Hepato-renal Regulation of Water Conservation in Heart Failure Patients With SGLT-2 Inhibitor Treatment) was a single-center, double-blind, randomized, placebo-controlled trial, in which patients with chronic heart failure NYHA functional classes I/II and reduced ejection fraction were randomly assigned to receive dapagliflozin 10 mg daily or placebo (1:1) for 4 weeks. The primary endpoint was change from baseline in urine osmolyte concentration. Secondary endpoints included changes in copeptin levels and solute free water clearance. RESULTS Thirty-three randomized, sodium-glucose cotransporter 2 inhibitor-naïve participants completed the study, 29 of whom (placebo: n = 14; dapagliflozin: n = 15) provided accurate 24-hour urine collections (mean age 59 ± 14 years; left ventricular ejection fraction 31% ± 9%). Dapagliflozin treatment led to an isolated increase in urine glucose excretion by 3.3 mmol/kg/d (95% CI: 2.51-4.04; P < 0.0001) within 48 hours (early) which persisted after 4 weeks (late; 2.7 mmol/kg/d [95% CI: 1.98-3.51]; P < 0.0001). Dapagliflozin treatment increased serum copeptin early (5.5 pmol/L [95% CI: 0.45-10.5]; P < 0.05) and late (7.8 pmol/L [95% CI: 2.77-12.81]; P < 0.01), leading to proportional reductions in free water clearance (early: -9.1 mL/kg/d [95% CI: -14 to -4.12; P < 0.001]; late: -11.0 mL/kg/d [95% CI: -15.94 to -6.07; P < 0.0001]) and elevated urine concentrations (late: 134 mmol/L [95% CI: 39.28-229.12]; P < 0.01). Therefore, urine volume did not significantly increase with dapagliflozin (mean difference early: 2.8 mL/kg/d [95% CI: -1.97 to 7.48; P = 0.25]; mean difference late: 0.9 mL/kg/d [95% CI: -3.83 to 5.62]; P = 0.70). CONCLUSIONS Physiological-adaptive water conservation eliminated the expected osmotic diuretic potential of dapagliflozin and thereby prevented a glucose-driven increase in urine volume of approximately 10 mL/kg/d · 75 kg = 750 mL/kg/d. (Hepato-renal Regulation of Water Conservation in Heart Failure Patients With SGLT-2 Inhibitor Treatment [DAPA-Shuttle1]; NCT04080518).
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Affiliation(s)
- Adriana Marton
- Programme in Cardiovascular and Metabolic Disorders, Duke-NUS Medical School, Singapore; Department of Internal Medicine 4-Nephrology and Hypertension, Paracelsus Private Medical School Nuremberg, Nuremberg, Germany.
| | | | - Manfred Rauh
- Research Laboratory, Division of Paediatrics, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Ruo-Ning Sun
- Clinical Imaging Research Centre, Centre for Translational Medicine, Singapore
| | - Armin M Nagel
- Institute of Radiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg (FAU), Erlangen, Germany; German Cancer Research Center (DKFZ), Division of Medical Physics in Radiology, Heidelberg, Germany
| | - Peter Linz
- Institute of Radiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Tzy Tiing Lim
- Programme in Cardiovascular and Metabolic Disorders, Duke-NUS Medical School, Singapore
| | | | | | - Sharon Saw
- Department of Laboratory Medicine, National University Hospital, Singapore
| | - Norihiko Morisawa
- Programme in Cardiovascular and Metabolic Disorders, Duke-NUS Medical School, Singapore
| | - Wan Keat Yam
- Programme in Cardiovascular and Metabolic Disorders, Duke-NUS Medical School, Singapore
| | - Shintaro Minegishi
- Programme in Cardiovascular and Metabolic Disorders, Duke-NUS Medical School, Singapore
| | - John J Totman
- Clinical Imaging Research Centre, Centre for Translational Medicine, Singapore; Radiography and Medical Imaging Department, Fatima College of Health Sciences, Abu Dhabi, United Arab Emirates
| | - Serena Teo
- Clinical Imaging Research Centre, Centre for Translational Medicine, Singapore
| | - Louis L Y Teo
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Choon Ta Ng
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Kento Kitada
- Department of Pharmacology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Johannes Wild
- Center for Cardiology, Cardiology I, Johannes Gutenberg-University, Mainz, Germany
| | - Jean-Paul Kovalik
- Programme in Cardiovascular and Metabolic Disorders, Duke-NUS Medical School, Singapore
| | - Friedrich C Luft
- Experimental and Clinical Research Center, Max-Delbrück Center for Molecular Medicine, Medical Faculty of the Charité, Berlin, Germany
| | - Peter J Greasley
- Early Discovery and Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Calvin W L Chin
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - David K L Sim
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Jens Titze
- Programme in Cardiovascular and Metabolic Disorders, Duke-NUS Medical School, Singapore; III. Department of Medicine and Hamburg Center for Kidney Health (HCKH), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Nephrology, Duke University Medical Center, Durham, North Carolina, USA.
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Van den Eynde J, Verbrugge FH. Renal Sodium Avidity in Heart Failure. Cardiorenal Med 2024; 14:270-280. [PMID: 38565080 DOI: 10.1159/000538601] [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: 01/28/2024] [Accepted: 03/22/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Increased renal sodium avidity is a hallmark feature of the heart failure syndrome. SUMMARY Increased renal sodium avidity refers to the inability of the kidneys to elicit potent natriuresis in response to sodium loading. This eventually causes congestion, which is a major contributor to hospital admissions and mortality in heart failure. KEY MESSAGES Important novel concepts such as the renal tamponade hypothesis, accelerated nephron loss, and the role of hypochloremia, the sympathetic nervous system, inflammation, the lymphatic system, and interstitial sodium buffers are involved in the pathophysiology of renal sodium avidity. A good understanding of these concepts is crucially important with respect to treatment recommendations regarding dietary sodium restriction, fluid restriction, rapid up-titration of guideline-directed medical therapies, combination diuretic therapy, natriuresis-guided diuretic therapy, use of hypertonic saline, and ultrafiltration.
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Affiliation(s)
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
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Oka K, Masuda T, Ohara K, Miura M, Morinari M, Misawa K, Miyazawa Y, Akimoto T, Shimada K, Nagata D. Fluid homeostatic action of dapagliflozin in patients with chronic kidney disease: the DAPA-BODY Trial. Front Med (Lausanne) 2023; 10:1287066. [PMID: 38155663 PMCID: PMC10753517 DOI: 10.3389/fmed.2023.1287066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/30/2023] [Indexed: 12/30/2023] Open
Abstract
Sodium glucose cotransporter 2 (SGLT2) inhibitors have both glucose-lowering and diuretic effects. We recently reported that the SGLT2 inhibitor dapagliflozin exerts short-term fluid homeostatic action in patients with chronic kidney disease (CKD). However, the long-term effects of SGLT2 inhibitors on body fluid status in patients with CKD remain unclear. This was a prospective, non-randomized, open-label study that included a dapagliflozin treatment group (n = 73) and a control group (n = 24) who were followed for 6 months. Body fluid volume was measured using a bioimpedance analysis device. The extracellular water-to-total body water ratio (ECW/TBW), a predictor of renal outcomes, was used as a parameter for body fluid status (fluid retention, 0.400 ≤ ECW/TBW). Six-month treatment with dapagliflozin significantly decreased ECW/TBW compared with the control group (-0.65% ± 2.03% vs. 0.97% ± 2.49%, p = 0.0018). Furthermore, dapagliflozin decreased the ECW/TBW in patients with baseline fluid retention, but not in patients without baseline fluid retention (-1.47% ± 1.93% vs. -0.01% ± 1.88%, p = 0.0017). Vasopressin surrogate marker copeptin levels were similar between the control and dapagliflozin groups at 6 months (32.3 ± 33.4 vs. 30.6 ± 30.1 pmol/L, p = 0.8227). However, dapagliflozin significantly increased the change in copeptin levels at 1 week (39.0% ± 41.6%, p = 0.0010), suggesting a compensatory increase in vasopressin secretion to prevent hypovolemia. Renin and aldosterone levels were similar between the control and dapagliflozin groups at 6 months, while epinephrine and norepinephrine (markers of sympathetic nervous system activity) were significantly lower in the dapagliflozin group than in the control group. In conclusion, the SGLT2 inhibitor dapagliflozin ameliorated fluid retention and maintained euvolemic fluid status in patients with CKD, suggesting that SGLT2 inhibitors exert sustained fluid homeostatic actions in patients with various fluid backgrounds. Clinical trial registration: https://www.umin.ac.jp/ctr/, identifier [UMIN000048568].
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Affiliation(s)
- Kentaro Oka
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
- Department of Nephrology, Shin-Oyama City Hospital, Oyama, Tochigi, Japan
| | - Takahiro Masuda
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
- Department of Nephrology, Shin-Oyama City Hospital, Oyama, Tochigi, Japan
| | - Ken Ohara
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Marina Miura
- Department of Nephrology, Shin-Oyama City Hospital, Oyama, Tochigi, Japan
| | - Masato Morinari
- Department of Internal Medicine, Nasu Minami Hospital, Nasukarasuyama, Tochigi, Japan
| | - Kyohei Misawa
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
- Department of Nephrology, Shin-Oyama City Hospital, Oyama, Tochigi, Japan
| | - Yasuharu Miyazawa
- Department of Internal Medicine, Nasu Minami Hospital, Nasukarasuyama, Tochigi, Japan
| | - Tetsu Akimoto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Kazuyuki Shimada
- Department of Cardiology, Shin-Oyama City Hospital, Oyama, Tochigi, Japan
| | - Daisuke Nagata
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
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Beal B, Schutte AE, Neuen BL. Blood Pressure Effects of SGLT2 Inhibitors: Mechanisms and Clinical Evidence in Different Populations. Curr Hypertens Rep 2023; 25:429-435. [PMID: 37948021 DOI: 10.1007/s11906-023-01281-1] [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] [Accepted: 10/26/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE OF REVIEW Sodium glucose transporter 2 inhibitors (SGLT2 inhibitors) are increasingly prescribed due to their considerable benefits on clinical outcomes in people with diabetes, heart failure, and chronic kidney disease (CKD). Hypertension is a common comorbidity in each of these disease states, increasing risk of cardiovascular morbidity and mortality. We herein review the effects of SGLT2 inhibitors on blood pressure in different populations, proposed mechanisms of action, and the contribution of blood pressure lowering to end-organ protection. RECENT FINDINGS A recognised effect of SGLT2 inhibitors in recent clinical trials is blood pressure lowering, with multiple postulated mechanisms. This advantageous effect was first identified in populations with type 2 diabetes mellitus, prior to expansion of these trials to broader cohorts. On our review, we identified that the blood pressure lowering effect of SGLT2 inhibitors appears to be a dose-independent class-effect, with a magnitude of effect comparable to that seen with a low dose hydrochlorothiazide. There is considerable evidence demonstrating that this effect is observed across populations including those with type 2 diabetes mellitus, chronic kidney disease, and resistant hypertension.
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Affiliation(s)
- Bryony Beal
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Aletta E Schutte
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Level 5, 1 King St Newtown 2042, Sydney, Australia
- School of Population Health, University of New South Wales, Sydney, Australia
| | - Brendon L Neuen
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, Australia.
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Level 5, 1 King St Newtown 2042, Sydney, Australia.
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Bueno H, Packer M. Acetazolamide for acute heart failure: is ADVOR a riddle wrapped in a mystery inside an enigma? Eur Heart J 2023; 44:3683-3685. [PMID: 37623429 DOI: 10.1093/eurheartj/ehad560] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 08/18/2023] [Accepted: 08/21/2023] [Indexed: 08/26/2023] Open
Affiliation(s)
- Héctor Bueno
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Hospital Universitario 12 de Octubre, Melchor Fernández Almagro, 3, 28029 Madrid, Spain
- Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Madrid, Spain
- Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
- Imperial College, London, UK
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