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Chen X, Shu Y, Lin X. Impact of canagliflozin combined with metformin therapy on reducing cardiovascular risk in type 2 diabetes patients. Diabetol Metab Syndr 2024; 16:199. [PMID: 39153984 PMCID: PMC11330023 DOI: 10.1186/s13098-024-01438-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 08/05/2024] [Indexed: 08/19/2024] Open
Abstract
PURPOSE To investigate the impact and safety of canagliflozin combined with metformin on reducing cardiovascular risk in patients with type 2 diabetes mellitus (T2DM). METHODS A total of 258 patients with T2DM admitted to our hospital from March 2021 to March 2022 were selected and divided into a control group and an observation group using a random number table. The control group received metformin combined with a placebo, while the observation group received canagliflozin combined with metformin therapy. All patients received drug treatment for 52 weeks. The primary endpoint of the study was major adverse cardiovascular events (MACE), including myocardial infarction, ischemic stroke, and cardiovascular death. Other study parameters included safety after medication, severe adverse reactions, levels of glycated hemoglobin (HbA1c), body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and estimated glomerular filtration rate (eGFR). RESULTS After treatment, HbA1c, FPG, BMI, SBP, and DBP in both groups were lower than before treatment, and those indicators in the observation group were lower than those in the control group (P < 0.05). The eGFR, HDL-C, and LDL-C levels in both groups were higher than before treatment, with the eGFR in the observation group being higher than that in the control group (P < 0.05). The incidence of MACE (myocardial infarction, ischemic stroke, cardiovascular death) in the observation group (5.17%) was significantly lower than that in the control group (12.93%) (HR: 2.16, 95%CI:2.04-2.59, P < 0.05). There were no significant differences in the rates of hospitalization for heart failure (3.45% vs. 1.72%), renal adverse events (4.31% vs. 3.45%), non-cardiovascular death (1.72% vs. 0.86%), all-cause mortality (2.59% vs. 0.86%), and severe adverse reactions (12.07% vs. 9.48%) between the two groups (P > 0.05). CONCLUSION In patients with T2DM who received the canagliflozin combined with metformin, the mortality rate of cardiovascular causes was significantly reduced. Compared with metformin monotherapy, there is no significant difference in the incidence of serious adverse reactions, and the safety of medication is better, while the blood sugar, blood pressure, and weight of T2DM patients are more actively improved. For T2DM patients with high risk of cardiovascular disease, the combination of canagliflozin and metformin could have a higher benefit in cardiovascular outcomes.
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Affiliation(s)
- Xiaoyu Chen
- The Affiliated People's Hospital of Ningbo University General practice, Ningbo, China.
- , No.38, Lane 48, Yonggang North Road, Yinzhou District, Ningbo, Zhejiang, China.
| | - Yimin Shu
- The Affiliated People's Hospital of Ningbo University General practice, Ningbo, China
| | - Xuebo Lin
- The Affiliated People's Hospital of Ningbo University Endocrinology Department, Ningbo, China
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Pallarés-Carratalá V, Ruiz-García A, Serrano-Cumplido A, Fragoso AS, Fernández-Pascual V, Sánchez-Sánchez B, Cervera-Pérez MI, Alonso-Moreno FJ, Arranz-Martínez E, Barquilla-García A, Rey-Aldana D, García JP, Cinza-Sanjurjo S. Comparison of baseline clinical characteristics among people with type 2 diabetes on second-line therapy previously added with dapagliflozin or another oral glucose-lowering drug: AGORA study. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2024:S0214-9168(24)00043-3. [PMID: 38910079 DOI: 10.1016/j.arteri.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 05/13/2024] [Accepted: 05/23/2024] [Indexed: 06/25/2024]
Abstract
INTRODUCTION Type 2 diabetes mellitus (T2D) has acquired epidemic proportions worldwide. In recent years, new oral glucose-lowering drugs (OGLD) have emerged that improve the cardiovascular-kidney-metabolic control in T2D people. OBJECTIVES To compare the baseline clinical-biological characteristics among T2D people to whom had added-on dapagliflozin (DAPA group) or another OGLD (SOC group) second-line hypoglycaemic therapies among the AGORA study population. METHODS This is a multicentre cross-sectional observational study of the baseline characteristics of T2D people recruited through competitive sampling among 46 primary care health centres in Spain for the AGORA study. The inclusion and exclusion criteria of participants, and justification of the sample size are reported. After verifying the data necessary to be evaluated and informed consent, 317 subjects were included to the DAPA group and 288 to the SOC group. Both categorical and continuous variables were analysed and compared with the usual statistics. Cohen's d was used to assess the standardised difference in means. RESULTS Six hundred and five patients with T2D were assessed (mean age 63.5 [SD±8.1] years, 61.8% men), whom 17.4% were smokers, 47.6% had obesity, 74.8% hypertension, 87.3% dyslipidaemia, and 41.7% reported physical inactivity, with no significant differences between both comparison groups. The mean (SD) evolution time of T2D was 10.1 (5.6) years. Most baseline clinical-biological characteristics at recruitment were similar in both groups. However, DAPA group was younger (2.9 years), and had lower systolic blood pressure (SBP) (2.8mmHg), higher body weight (BW) (3.7kg), and higher glycated haemoglobin A1c (HbA1c) (0.3%) than SOC group. Only 11.5% of participants had poor glycaemic control (HbA1c>8%) at recruitment, 54.9% had good glycaemic control (HbA1c<7%), being significantly lower in the DAPA group (47.3%) than in the SOC group (63.4%). The percentage of T2D patients with high vascular risk (VR) was 46.3%, and 53.7% with very high VR, being significantly higher in the DAPA group (57.4%) than in the SOC group (49.6%). CONCLUSIONS Most baseline cardiovascular-kidney-metabolic characteristics were similar in T2D patients whom had added dapagliflozin on second-line hypoglycaemic therapy as those whom had added-on another OGLD. However, patients whom had added-on dapagliflozin had higher VR, lower SBP, higher BW, and slightly worse HbA1c control. Future research is necessary to explain the causes of these differences in cardiometabolic control.
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Affiliation(s)
| | - Antonio Ruiz-García
- Specialist in Family and Community Medicine, Pinto University Health Center, Lipids and Cardiovascular Prevention Unit, Pinto, Madrid, Spain; Department of Medicine, European University of Madrid, Villaviciosa de Odón, Madrid, Spain
| | | | | | | | | | | | | | | | | | - Daniel Rey-Aldana
- Specialist in Family and Community Medicine, A Estrada Health Center, Pontevedra, Spain
| | - José Polo García
- Specialist in Family and Community Medicine, Casar de Cáceres Health Center, Cáceres, Spain
| | - Sergio Cinza-Sanjurjo
- Milladoiro Health Centre, Health Area of Santiago de Compostela, Health Research Institute of Santiago de Compostela (IDIS), A Coruña, Spain; Networking Biomedical Research, Centre-Cardiovascular Diseases (CIBERCV), Santiago de Compostela, Spain
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Nyström T. Key results from observational studies and real-world evidence of sodium-glucose cotransporter-2 inhibitor effectiveness and safety in reducing cardio-renal risk. Diabetes Obes Metab 2024. [PMID: 38859661 DOI: 10.1111/dom.15696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/09/2024] [Accepted: 05/20/2024] [Indexed: 06/12/2024]
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors, originally designed to manage blood sugar levels in individuals with type 2 diabetes (T2D), have emerged as a crucial class of drugs for managing cardio-renal diseases. These drugs work by targeting the SGLT2 protein in the kidneys, promoting the excretion of glucose and influencing metabolic pathways beyond glucose control. The relationship between cardio-renal diseases and SGLT2 inhibitors has been explored through landmark trials and real-world evidence (RWE) studies, demonstrating significant reductions in cardio-renal complications. This review discusses the importance of RWE studies alongside randomized controlled trials in understanding the real-world effectiveness and safety of SGLT2 inhibitors. It outlines the advantages and disadvantages of RWE compared to RCTs, highlighting their complementary roles in providing comprehensive insights into treatment outcomes. By examining a range of RWE studies, the review underscores the cardio-renal benefits of SGLT2 inhibitors across various patient populations. Safety assessments indicate that SGLT2 inhibitors are generally well tolerated, with severe adverse events being rare. Common issues, such as genital mycotic infections and urinary tract infections, are acknowledged, alongside less frequent but significant adverse events including diabetic ketoacidosis, lower-limb amputations, and bone fractures. In summary, SGLT2 inhibitors show promising cardio-renal protective effects in real-world scenarios across diverse populations in T2D, indicating their potential as early intervention measures. Continued research is essential for gaining a thorough understanding of their long-term effects and safety profiles.
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Affiliation(s)
- Thomas Nyström
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
- Department of Internal Medicine, Section of Endocrinology and Diabetology, Södersjukhuset, Stockholm, Sweden
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Zafari Z, Park JE, Shah CH, dosReis S, Gorman EF, Hua W, Ma Y, Tian F. The State of Use and Utility of Negative Controls in Pharmacoepidemiologic Studies. Am J Epidemiol 2024; 193:426-453. [PMID: 37851862 DOI: 10.1093/aje/kwad201] [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] [Received: 12/16/2022] [Revised: 07/27/2023] [Accepted: 10/06/2023] [Indexed: 10/20/2023] Open
Abstract
Uses of real-world data in drug safety and effectiveness studies are often challenged by various sources of bias. We undertook a systematic search of the published literature through September 2020 to evaluate the state of use and utility of negative controls to address bias in pharmacoepidemiologic studies. Two reviewers independently evaluated study eligibility and abstracted data. Our search identified 184 eligible studies for inclusion. Cohort studies (115, 63%) and administrative data (114, 62%) were, respectively, the most common study design and data type used. Most studies used negative control outcomes (91, 50%), and for most studies the target source of bias was unmeasured confounding (93, 51%). We identified 4 utility domains of negative controls: 1) bias detection (149, 81%), 2) bias correction (16, 9%), 3) P-value calibration (8, 4%), and 4) performance assessment of different methods used in drug safety studies (31, 17%). The most popular methodologies used were the 95% confidence interval and P-value calibration. In addition, we identified 2 reference sets with structured steps to check the causality assumption of the negative control. While negative controls are powerful tools in bias detection, we found many studies lacked checking the underlying assumptions. This article is part of a Special Collection on Pharmacoepidemiology.
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Gokhale KM, Chandan JS, Sainsbury C, Tino P, Tahrani A, Toulis K, Nirantharakumar K. Using Repeated Measurements to Predict Cardiovascular Risk in Patients With Type 2 Diabetes Mellitus. Am J Cardiol 2024; 210:133-142. [PMID: 38682712 DOI: 10.1016/j.amjcard.2023.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 09/15/2023] [Accepted: 10/01/2023] [Indexed: 05/01/2024]
Abstract
The QRISK cardiovascular disease (CVD) risk assessment model is not currently optimized for patients with type 2 diabetes mellitus (T2DM). We aim to identify if the abundantly available repeatedly measured data for patients with T2D improves the predictive capability of QRISK to support the decision-making process regarding CVD prevention in patients with T2DM. We identified patients with T2DM aged 25 to 85, not on statin treatment and without pre-existing CVD from the IQVIA Medical Research Data United Kingdom primary care database and then followed them up until the first diagnosis of CVD, ischemic heart disease, or stroke/transient ischemic attack. We included traditional, nontraditional risk factors and relevant treatments for our analysis. We then undertook a Cox's hazards model accounting for time-dependent covariates to estimate the hazard rates for each risk factor and calculated a 10-year risk score. Models were developed for males and females separately. We tested the performance of our models using validation data and calculated discrimination and calibration statistics. The study included 198,835 (180,143 male with 11,976 outcomes and 90,466 female with 8,258 outcomes) patients. The 10-year predicted survival probabilities for females was 0.87 (0.87 to 0.87), whereas the observed survival estimates from the Kaplan-Meier curve for all female models was 0.87 (0.86 to 0.87). The predicted and observed survival estimates for males were 0.84 (0.84 to 0.84) and 0.84 (0.83 to 0.84) respectively. The Harrell's C-index of all female models and all male models were 0.71 and 0.69 respectively. We found that including time-varying repeated measures, only mildly improved CVD risk prediction for T2DM patients in comparison to the current practice standard. We advocate for further research using time-varying data to identify if the involvement of further covariates may improve the accuracy of currently accepted prediction models.
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Affiliation(s)
- Krishna M Gokhale
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom.
| | - Joht Singh Chandan
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Chris Sainsbury
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Peter Tino
- School of Computer Science, University of Birmingham, Birmingham, United Kingdom
| | - Abd Tahrani
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
| | - Konstantinos Toulis
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
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Wang Y, Su X, Zhang W, Zhou Y, Zhou X, Yang W, Li H, Ma J. Effects of a Novel Glucokinase Activator, Dorzagliatin, on Glycemic Control and Glucose Fluctuation in Drug-Naïve Patients with Type 2 Diabetes Mellitus. Int J Endocrinol 2023; 2023:4996057. [PMID: 38179187 PMCID: PMC10764651 DOI: 10.1155/2023/4996057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 11/18/2023] [Accepted: 12/12/2023] [Indexed: 01/06/2024] Open
Abstract
Aim The prevalence rate of type 2 diabetes mellitus (T2DM) has been increasing and a large proportion of patients still do not achieve adequate or sustainable glycemic control on the basis of previous hypoglycemic treatment. In this present study, we explored whether dorzagliatin, a novel glucokinase activator (GKA), could improve glycemic control and lessen glucose fluctuation in drug-naïve patients with T2DM. Methods A self-comparative observational study of 25 drug-naïve patients with T2DM (aged 18-75 years and HbA1c of 7.5%-11.0%) treated with dorzagliatin 75 mg twice daily for 52 weeks. Before and after dorzagliatin intervention, the serum levels of hemoglobin A1c (HbA1c), insulin, and C-peptide were measured repeatedly during fasting and after a mixed meal. The continuous glucose monitoring (CGM) device was also used to obtain 24-hour glucose profiles and assess the changes in glycemic variability parameters. Results After 52 weeks of treatment with dorzagliatin, a numerally greater reduction in HbA1c of 1.03% from the baseline was observed in patients with T2DM, accompanied by significant improvement in insulin resistance and insulin secretion. Moreover, the standard deviation of blood glucose (SDBG) and the mean amplitude of glycemic excursion (MAGE) derived from CGM data were significantly decreased after dorzagliatin therapy. The 24-h glucose variation profile showed that study patients had obviously lower mean glucose levels during the postprandial period from the baseline to week 52, an effect also demonstrated by the significant decrease in the incremental area under glucose concentration versus time curve for 2 h (iAUC0-2 h) after meals. Conclusions This study suggests that dorzagliatin therapy could effectively improve glycemic control and glucose fluctuation in drug-naïve patients with T2DM.
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Affiliation(s)
- Yuming Wang
- Department of Geriatrics, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu 210008, China
- Department of Endocrinology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210000, China
| | - Xiaofei Su
- Department of Endocrinology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210000, China
| | - Wenli Zhang
- Department of Endocrinology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210000, China
| | - Yunting Zhou
- Department of Endocrinology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210000, China
| | - Xiao Zhou
- Department of Endocrinology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210000, China
| | - Wei Yang
- Department of Pharmacy, Lai'an County People's Hospital, Chuzhou, Anhui 239200, China
| | - Huiqin Li
- Department of Endocrinology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210000, China
| | - Jianhua Ma
- Department of Endocrinology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210000, China
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Huang K, Wang Y, Sun S, Zhu Q, Zhou W, Liu J, Zhu D, Xie X. Cost–Effectiveness Analysis of Dapagliflozin Plus Standard Treatment for Patients With Type 2 Diabetes and High Risk of Cardiovascular Disease in China. Front Public Health 2022; 10:936703. [PMID: 35910934 PMCID: PMC9326075 DOI: 10.3389/fpubh.2022.936703] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 06/22/2022] [Indexed: 01/10/2023] Open
Abstract
Purpose To evaluate the long-term cost-effectiveness of dapagliflozin, in addition to standard treatment, for the treatment of adult patients with type 2 diabetes (T2DM) at high cardiovascular risk from the Chinese healthcare system perspective. Methods A decision-analytic Markov model with one-year cycles was developed to evaluate the health and economic outcomes in patients with T2DM and high risk of cardiovascular disease (CVD) treated with standard treatment and dapagliflozin plus standard treatment for 30 years. Clinical data, cost, and utility data were extracted from databases or published literature. Quality-adjusted life-years (QALYs), costs (€/¥ 2021) as well as incremental cost-effectiveness ratios (ICERs) were calculated. Deterministic and probabilistic sensitivity analyses were performed to assess the uncertainty in the results. Results Compared with standard treatment, dapagliflozin plus standard treatment was predicted to result in an additional 0.25 QALYs (12.26 QALYs vs. 12.01 QALYs) at an incremental cost of €4,435.81 (¥33,875.83) per patient. The ICER for dapagliflozin plus standard treatment vs. standard treatment was €17,742.07 (¥135,494.41) per QALY gained, which was considered cost-effective in China compared to three times the GDP per capita in 2021 (€31,809.77/¥242,928). The deterministic and probabilistic sensitivity analyses showed the base-case results to be robust. Conclusions The study suggests that, from the perspective of the Chinese health system, dapagliflozin plus standard treatment is a cost-effective option for patients with T2DM at high cardiovascular risk. These findings may help clinicians make the best treatment decisions for patients with T2DM at high cardiovascular risk.
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Affiliation(s)
- Kaiyu Huang
- Key Laboratory of Anti-inflammatory and Immunopharmacology, Department of Clinical Pharmacy, Ministry of Education, Anhui Medical University, Hefei, China
- The Key Laboratory of Major Autoimmune Diseases, Anhui Institute of Innovative Drugs, School of Pharmacy, Anhui Medical University, Hefei, China
| | - Yao Wang
- Key Laboratory of Anti-inflammatory and Immunopharmacology, Department of Clinical Pharmacy, Ministry of Education, Anhui Medical University, Hefei, China
- The Key Laboratory of Major Autoimmune Diseases, Anhui Institute of Innovative Drugs, School of Pharmacy, Anhui Medical University, Hefei, China
| | - Sijia Sun
- Key Laboratory of Anti-inflammatory and Immunopharmacology, Department of Clinical Pharmacy, Ministry of Education, Anhui Medical University, Hefei, China
- The Key Laboratory of Major Autoimmune Diseases, Anhui Institute of Innovative Drugs, School of Pharmacy, Anhui Medical University, Hefei, China
| | - Qian Zhu
- Key Laboratory of Anti-inflammatory and Immunopharmacology, Department of Clinical Pharmacy, Ministry of Education, Anhui Medical University, Hefei, China
| | - Weifeng Zhou
- Department of Clinical Medicine, Anhui Medical College, Hefei, China
| | - Jiatao Liu
- Department of Pharmacy, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Dongchun Zhu
- Department of Pharmacy, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xuefeng Xie
- Key Laboratory of Anti-inflammatory and Immunopharmacology, Department of Clinical Pharmacy, Ministry of Education, Anhui Medical University, Hefei, China
- The Key Laboratory of Major Autoimmune Diseases, Anhui Institute of Innovative Drugs, School of Pharmacy, Anhui Medical University, Hefei, China
- *Correspondence: Xuefeng Xie
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Wood SJ, Bell JS, Magliano DJ, Shaw JE, Cesari M, Ilomaki J. Effectiveness of Sodium-Glucose Cotransporter-2 Inhibitors vs. Dipeptidyl Peptidase-4 Inhibitors in Frail People With Diabetes Who Were Recently Hospitalized. Front Pharmacol 2022; 13:886834. [PMID: 35903329 PMCID: PMC9315378 DOI: 10.3389/fphar.2022.886834] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 06/20/2022] [Indexed: 12/02/2022] Open
Abstract
Introduction: Sodium-glucose cotransporter-2 inhibitors (SGLT-2Is) reduce heart failure (HF) hospitalizations and major adverse cardiovascular events (MACE) in general type 2 diabetes populations. The objective of this study was to determine whether SGLT-2Is vs. dipeptidyl peptidase-4 inhibitors (DPP-4Is) are associated with reductions in MACE, HF hospitalizations and mortality in frail people with type 2 diabetes. Methods: We conducted a cohort study of all patients aged ≥30 years with type 2 diabetes discharged from a hospital in Victoria, Australia between January 2014 and March 2018 who received SGLT-2Is or DPP-4Is within 60 days of discharge. Follow-up commenced 60 days after initial discharge, and MACE, HF hospitalization and mortality were recorded. Cox proportional hazards regression with competing risks and stabilized inverse probability of treatment weights (IPTWs), was used to generate subdistribution hazard ratios (sHRs) with 95% confidence intervals (CIs). Analyses were stratified into frailty quartiles according to Hospital Frailty Risk Scores (HFRS). Results: Of the 32,043 patients, (41.9% female and 5.9% ≥80 years) in the cohort, 5,152 (16.1%) received SGLT-2Is. Overall, SGLT-2I versus DPP-4I recipients had lower rates of MACE (sHR 0.51; 95% CI 0.46–0.56), HF hospitalization (sHR 0.42; 95% CI 0.36–0.49) and mortality (HR 0.38; 95% CI 0.33–0.43). People with HFRSs in the fourth quartile who received SGLT-2Is versus DPP-4Is also had reduced rates of MACE (sHR 0.37; 95% CI 0.29–0.46), HF hospitalization (sHR 0.43; 95% CI 0.33–0.56) and mortality (HR 0.32; 95% CI 0.25–0.41). Conclusion: SGLT-2Is may be preferred to DPP-4Is for preventing MACE, HF hospitalizations and mortality in frail people with type 2 diabetes.
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Affiliation(s)
- Stephen J Wood
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
- *Correspondence: Stephen J Wood,
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- National Health and Medical Research Council Centre of Research Excellence in Frailty and Healthy Ageing, Adelaide, SA, Australia
| | - Dianna J Magliano
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Jonathan E Shaw
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Matteo Cesari
- National Health and Medical Research Council Centre of Research Excellence in Frailty and Healthy Ageing, Adelaide, SA, Australia
- IRCCS Istituti Clinici Scientifici Maugeri, University of Milan, Milan, Italy
| | - Jenni Ilomaki
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Rhee JJ, Han J, Montez-Rath ME, Kim SH, Cullen MR, Stafford RS, Winkelmayer WC, Chertow GM. Cardiovascular outcomes associated with prescription of sodium-glucose co-transporter-2 inhibitors versus dipeptidyl peptidase-4 inhibitors in patients with diabetes and chronic kidney disease. Diabetes Obes Metab 2022; 24:928-937. [PMID: 35118793 PMCID: PMC8986594 DOI: 10.1111/dom.14657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 01/14/2022] [Accepted: 01/30/2022] [Indexed: 12/22/2022]
Abstract
AIM To determine the association with cardiovascular (CV) outcomes of sodium-glucose co-transporter-2 (SGLT-2) inhibitors compared with dipeptidyl peptidase-4 (DPP-4) inhibitors in patients with type 2 diabetes (T2D) and chronic kidney disease (CKD). MATERIALS AND METHODS We conducted a population-based cohort study of new users of SGLT-2 inhibitors and DPP-4 inhibitors with T2D and CKD using data from Optum Clinformatics DataMart. We assembled three cohorts: T2D/no CKD, T2D/CKD 1-2, and T2D/CKD 3a. The study outcomes were (a) time to first heart failure (HF) hospitalization and (b) time to a composite CV endpoint comprised of non-fatal myocardial infarction (MI) or stroke. After inverse probability of treatment weighting, we used proportional hazards regression to estimate hazard ratios (HR) and 95% confidence intervals (CI). RESULTS New users of SGLT-2 inhibitors versus DPP-4 inhibitors had lower risks of HF hospitalization in the T2D/no CKD (HR, 0.76; 95% CI, 0.70, 0.82) and T2D/CKD 1-2 (HR, 0.63; 95% CI, 0.48, 0.84) cohorts, but no significant association was present in the T2D/CKD 3a cohort. Compared with prescription of DPP-4 inhibitors, SGLT-2 inhibitors were associated with lower risks of non-fatal MI or stroke of 23% (HR, 0.77; 95% CI, 0.70, 0.85) in the T2D/no CKD cohort, but no significant associations were present in the T2D/CKD 1-2 and T2D/CKD 3a cohorts. CONCLUSIONS Incident prescription of SGLT-2 inhibitors was associated with lower risks of HF hospitalization but not with non-fatal MI or stroke despite suggesting benefit, relative to prescription of DPP-4 inhibitor across different stages of CKD.
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Affiliation(s)
- Jinnie J. Rhee
- Division of Nephrology, Stanford University School of Medicine, Stanford, CA, United States
- Stanford Diabetes Research Center, Stanford University School of Medicine, Stanford, CA, United States
| | - Jialin Han
- Division of Nephrology, Stanford University School of Medicine, Stanford, CA, United States
| | - Maria E. Montez-Rath
- Division of Nephrology, Stanford University School of Medicine, Stanford, CA, United States
| | - Sun H. Kim
- Division of Endocrinology, Gerontology, and Metabolism, Stanford University School of Medicine, Stanford, CA, United States
- Stanford Diabetes Research Center, Stanford University School of Medicine, Stanford, CA, United States
| | - Mark R. Cullen
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, United States
| | - Randall S. Stafford
- Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA, United States
| | - Wolfgang C. Winkelmayer
- Section of Nephrology and Selzman Institute for Kidney Health, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Glenn M. Chertow
- Division of Nephrology, Stanford University School of Medicine, Stanford, CA, United States
- Stanford Diabetes Research Center, Stanford University School of Medicine, Stanford, CA, United States
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Wright AK, Carr MJ, Kontopantelis E, Leelarathna L, Thabit H, Emsley R, Buchan I, Mamas MA, van Staa TP, Sattar N, Ashcroft DM, Rutter MK. Primary Prevention of Cardiovascular and Heart Failure Events With SGLT2 Inhibitors, GLP-1 Receptor Agonists, and Their Combination in Type 2 Diabetes. Diabetes Care 2022; 45:909-918. [PMID: 35100355 DOI: 10.2337/dc21-1113] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 01/09/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess associations between current use of sodium-glucose cotransporter 2 inhibitors (SGLT2is), glucagon-like peptide 1 receptor agonists (GLP-1RAs), and their combination and risk for major adverse cardiac and cerebrovascular events (MACCE) and heart failure (HF) in people with type 2 diabetes. RESEARCH DESIGN AND METHODS In three nested case-control studies involving patients with type 2 diabetes in England and Wales (primary care data from the Clinical Practice Research Datalink and Secure Anonymised Information Linkage Databank with linkage to hospital and mortality records), we matched each patient experiencing an event with up to 20 control subjects. Adjusted odds ratios (ORs) for MACCE and HF among patients receiving SGLT2i or GLP-1RA regimens versus other combinations were estimated using conditional logistic regression and pooled using random-effects meta-analysis. RESULTS Among 336,334 people with type 2 diabetes and without cardiovascular disease, 18,531 (5.5%) experienced a MACCE. In a cohort of 411,206 with type 2 diabetes and without HF, 17,451 (4.2%) experienced an HF event. Compared with other combination regimens, the adjusted pooled OR and 95% CI for MACCE associated with SGLT2i regimens was 0.82 (0.73, 0.92), with GLP-1RA regimens 0.93 (0.81, 1.06), and with the SGLT2i/GLP-1RA combination 0.70 (0.50, 0.98). Corresponding data for HF were SGLT2i 0.49 (0.42, 0.58), GLP-1RA 0.82 (0.71, 0.95), and SGLT2i/GLP-1RA combination 0.43 (0.28, 0.64). CONCLUSIONS SGLT2i and SGLT2i/GLP-1RA combination regimens may be beneficial in primary prevention of MACCE and HF and GLP-1RA for HF. These data call for primary prevention trials using these agents and their combination.
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Affiliation(s)
- Alison K Wright
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, University of Manchester, Manchester, U.K.,Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, U.K
| | - Matthew J Carr
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, U.K.,National Institute for Health Research Greater Manchester Patient Safety Translational Research Centre, School of Health Sciences, University of Manchester, Manchester, U.K
| | - Evangelos Kontopantelis
- Division of Population Health, Health Services and Primary Care, School of Health Sciences, University of Manchester, Manchester, U.K
| | - Lalantha Leelarathna
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, University of Manchester, Manchester, U.K.,Diabetes, Endocrinology and Metabolism Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, U.K
| | - Hood Thabit
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, University of Manchester, Manchester, U.K.,Diabetes, Endocrinology and Metabolism Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, U.K
| | - Richard Emsley
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, U.K
| | - Iain Buchan
- Institute of Population Health, University of Liverpool, Liverpool, U.K
| | - Mamas A Mamas
- Keele Cardiovascular Group, Centre for Prognosis Research, Keele University, Keele, U.K
| | - Tjeerd P van Staa
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, University of Manchester, Manchester, U.K
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, U.K
| | - Darren M Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, U.K.,National Institute for Health Research Greater Manchester Patient Safety Translational Research Centre, School of Health Sciences, University of Manchester, Manchester, U.K
| | - Martin K Rutter
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, University of Manchester, Manchester, U.K.,Diabetes, Endocrinology and Metabolism Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, U.K
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11
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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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12
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Fadini GP, Del Prato S, Avogaro A, Solini A. Challenges and opportunities in real-world evidence on the renal effects of sodium-glucose cotransporter-2 inhibitors. Diabetes Obes Metab 2022; 24:177-186. [PMID: 34747123 PMCID: PMC9298781 DOI: 10.1111/dom.14599] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/27/2021] [Accepted: 11/04/2021] [Indexed: 12/25/2022]
Abstract
With increasing population aging and prevalence of type 2 diabetes (T2D) worldwide, prevention of diabetic complications remains a major unmet need. While cardiovascular outcomes of diabetes are improving over time, diabetic kidney disease (DKD) still leads to an exceedingly high rate of end-stage kidney disease (ESKD). A game-changing opportunity is offered by treatment with sodium-glucose cotransporter-2 (SGLT2) inhibitors. Randomized controlled trials (RCTs) have indisputably shown that SGLT2 inhibitors reduce the rate of DKD progression, the decline in estimated glomerular filtration rate (eGFR), and the development of ESKD. In parallel, SGLT2 inhibitors improve cardiovascular outcomes, especially the risk of hospitalization for heart failure. Real-world studies (RWSs) have largely confirmed the findings of RCTs in broader populations of subjects with T2D followed under routine care. In the present paper, we review RWSs exploring the renal effects of SGLT2 inhibitors and highlight the most critical challenges that can be encountered in designing and conducting such studies. Channelling bias (confounding by indication), time-lag bias, conditioning on the future, database heterogeneity, linearity of eGFR change over time, and duration of observation are critical issues that may undermine the robustness of RWS findings. We then elaborate on the new opportunities to overcome such limitations by describing the design and objectives of the DARWIN (DApagliflozin Real-World evIdeNce)-Renal study, a new RWS promoted by the Italian Diabetes Society. Fine-tuning of methods for comparative observational research will improve evidence derived from RWSs on the renal effects of SGLT2 inhibitors, aiding the evolving discussion regarding the place of SGLT2 inhibitors in T2D treatment algorithms in different stages of DKD.
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Affiliation(s)
| | - Stefano Del Prato
- Department of Clinical and Experimental Medicine, Section of Metabolic Diseases and DiabetesUniversity of PisaPisaItaly
| | | | - Anna Solini
- Department of Surgical, Medical, Molecular and Critical Area PathologyUniversity of PisaPisaItaly
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13
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Caruso I, Giorgino F. SGLT-2 inhibitors as cardio-renal protective agents. Metabolism 2022; 127:154937. [PMID: 34808144 DOI: 10.1016/j.metabol.2021.154937] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/09/2021] [Accepted: 11/10/2021] [Indexed: 12/19/2022]
Abstract
Despite remarkable advances in diabetes care, patients with type 2 diabetes are still burdened by higher morbidity and mortality than non-diabetic individuals. Atherosclerotic cardiovascular disease, heart failure, and chronic kidney disease represent the most relevant causes of morbidity and mortality and sustain each other in a vicious circle. Cardiovascular diseases are the main cause of death in patients with chronic kidney disease, and, in turn, chronic kidney disease is a significant contributor to the risk of major cardiovascular events and hospitalization for heart failure. Cardiovascular outcome trials with SGLT-2 inhibitors in type 2 diabetes yielded unprecedented results on prevention of worsening heart failure and renal disease progression and mortality, further confirmed by randomized controlled trials in patients with baseline heart failure and chronic kidney disease, with or without diabetes, and observations from the real-world setting. However, the evidence regarding SGLT-2 inhibitors benefit on atherosclerotic cardiovascular events is conflicting. Hence, SGLT-2 inhibitors represent a remarkably valuable weapon in diabetes management, to be used in the context of a multi-targeted treatment strategy to address the many issues of this multifaceted disease.
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Affiliation(s)
- Irene Caruso
- Department of Emergency and Organ Transplantation, Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, Bari, Italy
| | - Francesco Giorgino
- Department of Emergency and Organ Transplantation, Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, Bari, Italy.
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14
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Joseph JJ, Deedwania P, Acharya T, Aguilar D, Bhatt DL, Chyun DA, Di Palo KE, Golden SH, Sperling LS. Comprehensive Management of Cardiovascular Risk Factors for Adults With Type 2 Diabetes: A Scientific Statement From the American Heart Association. Circulation 2022; 145:e722-e759. [PMID: 35000404 DOI: 10.1161/cir.0000000000001040] [Citation(s) in RCA: 191] [Impact Index Per Article: 95.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cardiovascular disease remains the leading cause of death in patients with diabetes. Cardiovascular disease in diabetes is multifactorial, and control of the cardiovascular risk factors leads to substantial reductions in cardiovascular events. The 2015 American Heart Association and American Diabetes Association scientific statement, "Update on Prevention of Cardiovascular Disease in Adults With Type 2 Diabetes Mellitus in Light of Recent Evidence," highlighted the importance of modifying various risk factors responsible for cardiovascular disease in diabetes. At the time, there was limited evidence to suggest that glucose-lowering medications reduce the risk of cardiovascular events. At present, several large randomized controlled trials with newer antihyperglycemic agents have been completed, demonstrating cardiovascular safety and reduction in cardiovascular outcomes, including cardiovascular death, myocardial infarction, stroke, and heart failure. This AHA scientific statement update focuses on (1) the evidence and clinical utility of newer antihyperglycemic agents in improving glycemic control and reducing cardiovascular events in diabetes; (2) the impact of blood pressure control on cardiovascular events in diabetes; and (3) the role of newer lipid-lowering therapies in comprehensive cardiovascular risk management in adults with diabetes. This scientific statement addresses the continued importance of lifestyle interventions, pharmacological therapy, and surgical interventions to curb the epidemic of obesity and metabolic syndrome, important precursors of prediabetes, diabetes, and comorbid cardiovascular disease. Last, this scientific statement explores the critical importance of the social determinants of health and health equity in the continuum of care in diabetes and cardiovascular disease.
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15
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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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16
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Bagepally BS, Chaikledkaew U, Youngkong S, Anothaisintawee T, Thavorncharoensap M, Dejthevaporn C, Thakkinstian A. Cost-Utility Analysis of Dapagliflozin Compared to Sulfonylureas for Type 2 Diabetes as Second-Line Treatment in Indian Healthcare Payer's Perspective. CLINICOECONOMICS AND OUTCOMES RESEARCH 2021; 13:897-907. [PMID: 34712053 PMCID: PMC8548256 DOI: 10.2147/ceor.s328433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 09/07/2021] [Indexed: 11/23/2022] Open
Abstract
Background Type 2 diabetes mellitus (T2DM) is a leading health issue, causing economic burden in India. Pharmacotherapy is a major cost driver in diabetic care usually funded through out of pocket expenditure; however, there has been a very limited economic evaluation evidence to guide the choice of diabetes pharmacotherapy in India. Therefore, this study aims to evaluate the long-term cost-effectiveness of dapagliflozin (sodium glucose transporter 2 inhibitor) compared to commonly used sulfonylureas as second-line drugs in Indian patients with T2DM. Methods Cost-utility analysis was employed to estimate the costs and health outcomes using a Markov model with 1-year cycle length during a lifetime horizon based on an Indian payer’s perspective. A treatment pathway with dapagliflozin as second-line therapy was compared to sulfonylureas after failure of initial metformin therapy. Clinical and cost data were collected from literature reviews and available secondary data sources. Both costs and outcomes were discounted at a 3% annual discount rate. The results were presented as the incremental cost-effectiveness ratio (ICER). One-way and probabilistic sensitivity analyses were performed to test parameter uncertainties. Results Compared to sulfonylurea, dapagliflozin was estimated to incur an additional cost of ₹182,632 (US$2,446) with an expected 3.49 life years (LY) or 1.72 quality adjusted life years (QALY) gained, resulting in an ICER of ₹52,270 (US$699) per LY gained, or ₹106,133 (US$1,421) per QALY gained. Uncertainty analyses showed that the ICER values were not sensitive to changes in most parameters. Conclusion Dapagliflozin would be cost-effective compared to sulfonylureas as the second line added to metformin for T2DM patients based on an Indian payer’s perspective.
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Affiliation(s)
- Bhavani Shankara Bagepally
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand.,Department of Non-Communicable Diseases, ICMR-National Institute of Epidemiology, Chennai, India
| | - Usa Chaikledkaew
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand.,Social and Administrative Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Sitaporn Youngkong
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand.,Social and Administrative Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Thunyarat Anothaisintawee
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand.,Department of Family Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Montarat Thavorncharoensap
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand.,Social and Administrative Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | | | - Ammarin Thakkinstian
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand.,Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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17
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Krogh J, Hjorthøj C, Kristensen SL, Selmer C, Haugaard SB. The effect of sodium-glucose transport protein 2 inhibitors on mortality and heart failure in randomized trials versus observational studies. Diabet Med 2021; 38:e14600. [PMID: 33991127 DOI: 10.1111/dme.14600] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 05/10/2021] [Indexed: 12/26/2022]
Abstract
AIM Randomized clinical trials (RCTs) allocating type 2 diabetes patients to treatment with sodium-glucose transport protein 2 (SGLT-2) inhibitors or placebo have found significant effects on the risk of heart failure and modest effects on mortality. In the wake of the first trials, a number of observational studies have been conducted, some of these reporting a mortality reduction of 50% compared to active comparators. In this review, we systematically assess and compare the results on all-cause mortality, cardiovascular mortality and heart failure hospitalization observed in RCTs with the results obtained in observational studies. METHOD We performed a systematic bibliographical search including cardiovascular outcome trials and observational studies assessing the effect of SGLT-2 inhibitors on mortality and heart failure. RESULTS Seven RCTs and 23 observational studies were included in the current review. The observed heterogeneity between study results for all-cause mortality (p-interaction < 0.001) and cardiovascular mortality (p-interaction < 0.001) was explained by study type, whereas this was not the case for heart failure (p-interaction = 0.18). CONCLUSION Methodological considerations such as the omission of important confounders, immortal-time bias and residual confounding such as unmeasured social economic inequality may be the cause of the inflated results observed in observational studies and that calls for caution when observational studies are used to guide treatment of patients with type 2 diabetes.
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Affiliation(s)
- Jesper Krogh
- Department of Endocrinology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Carsten Hjorthøj
- Copenhagen Research Center for Mental Health-Core, Mental Health Centre Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Public Health, Section of Epidemiology, University of Copenhagen, Copenhagen, Denmark
| | - Søren L Kristensen
- Department of Cardiology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Christian Selmer
- Department of Endocrinology, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Steen B Haugaard
- Department of Endocrinology, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
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18
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Real J, Vlacho B, Ortega E, Vallés JA, Mata-Cases M, Castelblanco E, Wittbrodt ET, Fenici P, Kosiborod M, Mauricio D, Franch-Nadal J. Cardiovascular and mortality benefits of sodium-glucose co-transporter-2 inhibitors in patients with type 2 diabetes mellitus: CVD-Real Catalonia. Cardiovasc Diabetol 2021; 20:139. [PMID: 34243779 PMCID: PMC8272340 DOI: 10.1186/s12933-021-01323-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 06/23/2021] [Indexed: 02/06/2023] Open
Abstract
Background Evidence from prospective cardiovascular (CV) outcome trials in type 2 diabetes (T2DM) patients supports the use of sodium–glucose co-transporter-2 inhibitors (SGLT2i) to reduce the risk of CV events. In this study, we compared the risk of several CV outcomes between new users of SGLT2i and other glucose-lowering drugs (oGLDs) in Catalonia, Spain. Methods CVD-REAL Catalonia was a retrospective cohort study using real-world data routinely collected between 2013 and 2016. The cohorts of new users of SGLT2i and oGLDs were matched by propensity score on a 1:1 ratio. We compared the incidence rates and hazard ratio (HR) for all-cause death, hospitalization for heart failure, chronic kidney disease, and modified major adverse CV event (MACE; all-cause mortality, myocardial infarction, or stroke). Results After propensity score matching, 12,917 new users were included in each group. About 27% of users had a previous history of CV disease. In the SGLT2i group, the exposure time was 60% for dapagliflozin, 26% for empagliflozin and 14% for canagliflozin. The use of SGLT2i was associated with a lower risk of heart failure (HR: 0.59; 95% confidence interval [CI] 0.47–0.74; p < 0.001), all-cause death (HR = 0.41; 95% CI 0.31–0.54; p < 0.001), all-cause death or heart failure (HR = 0.55; 95% CI 0.47–0.63; p < 0.001), modified MACE (HR = 0.62; 95% CI 0.52–0.74; p < 0.001), and chronic kidney disease (HR = 0.66; 95% CI 0.54–0.80; p < 0.001). Conclusions In this large, retrospective observational study of patients with T2DM from a Catalonia, initiation of SGLT-2i was associated with lower risk of mortality, as well as heart failure and CKD. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-021-01323-5.
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Affiliation(s)
- Jordi Real
- DAP‑Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain.,CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Bogdan Vlacho
- DAP‑Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Emilio Ortega
- Department of Endocrinology and Nutrition, Institut d'Investigacions Biomèdiques August Pi i Suñer, Hospital Clinic, Barcelona, Spain.,CIBER of Physiopathology of Obesity and Nutrition (CIBEROBN), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Joan Antoni Vallés
- DAP‑Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain.,Drug Area, Gerència d'Atenció Primaria, Institut Català de la Salut, Barcelona, Spain
| | - Manel Mata-Cases
- DAP‑Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain.,CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain.,Primary Health Care Center La Mina, Gerència d'Àmbit d'Atenció Primària Barcelona Ciutat, Institut Català de la Salut, Sant Adrià de Besòs, Spain
| | - Esmeralda Castelblanco
- DAP‑Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain.,CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | | | - Peter Fenici
- Cardiovascular Renal Metabolisms, BioPharmaceuticals Global Medical, AstraZeneca, Cambridge, UK
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, MO, USA
| | - Dídac Mauricio
- DAP‑Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain. .,CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain. .,Department of Endocrinology and Nutrition, Hospital Universitari de la Santa Creu i Sant Pau, Autonomous Universtity of Barcelona, Sant Quintí, 89, 08041, Barcelona, Spain. .,Departament of Medicine, University of Vic-Central University of Catalonia, Vic, Barcelona, Spain.
| | - Josep Franch-Nadal
- DAP‑Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain. .,CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain. .,Primary Health Care Center Raval Sud, Gerència d'Atenció Primaria, Institut Català de la Salut, Av. Drassanes, 17-21, 08001, Barcelona, Spain.
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Parretti HM, Subramanian A, Adderley NJ, Abbott S, Tahrani AA, Nirantharakumar K. Post-bariatric surgery nutritional follow-up in primary care: a population-based cohort study. Br J Gen Pract 2021; 71:e441-e449. [PMID: 33824163 PMCID: PMC8041293 DOI: 10.3399/bjgp20x714161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/15/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Bariatric surgery is the most effective treatment for severe obesity. However, without recommended follow-up it has long-term risks. AIM To investigate whether nutritional and weight monitoring in primary care meets current clinical guidance, after patients are discharged from specialist bariatric care. DESIGN AND SETTING Retrospective cohort study in primary care practices contributing to IQVIA Medical Research Data in the UK (1 January 2000 to 17 January 2018). METHOD Participants were adults who had had bariatric surgery with a minimum of 3 years' follow-up post-surgery, as this study focused on patients discharged from specialist care (at 2 years post-surgery). Outcomes were the annual proportion of patients from 2 years post-surgery with a record of recommended nutritional screening blood tests, weight measurement, and prescription of nutritional supplements, and the proportions with nutritional deficiencies based on blood tests. RESULTS A total of 3137 participants were included in the study, and median follow-up post-surgery was 5.7 (4.2-7.6) years. Between 45% and 59% of these patients had an annual weight measurement. The greatest proportions of patients with a record of annual nutritional blood tests were for tests routinely conducted in primary care, for example, recorded haemoglobin measurement varied between 44.9% (n = 629/1400) and 61.2% (n = 653/1067). Annual proportions of blood tests specific to bariatric surgery were low, for example, recorded copper measurement varied between 1.2% (n = 10/818) and 1.5% (n = 16/1067) where recommended. Results indicated that the most common deficiency was anaemia. Annual proportions of patients with prescriptions for recommended nutritional supplements were low. CONCLUSION This study suggests that patients who have bariatric surgery are not receiving the recommended nutritional monitoring after discharge from specialist care. GPs and patients should be supported to engage with follow-up care. Future research should aim to understand the reasons underpinning these findings.
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Affiliation(s)
- Helen M Parretti
- Norwich Medical School, Faculty of Medicine and Health, University of East Anglia, Norwich
| | | | - Nicola J Adderley
- Institute of Applied Health Research, University of Birmingham, Birmingham
| | - Sally Abbott
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham; Department of Diabetes, Endocrinology and Weight Management, University Hospitals Birmingham NHS Foundation Trust, Birmingham
| | - Abd A Tahrani
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham; Centre for Endocrinology Diabetes and Metabolism (CEDAM), Birmingham Health Partners, Birmingham; Department of Diabetes, Endocrinology and Weight Management, University Hospitals Birmingham NHS Foundation Trust, Birmingham
| | - Krishnarajah Nirantharakumar
- Institute of Applied Health Research, University of Birmingham, Birmingham; CEDAM, Birmingham Health Partners, Birmingham; Department of Diabetes, Endocrinology and Weight Management, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Midlands Health Data Research UK
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20
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Kale S, Tahrani AA. Sodium-glucose co-transporter-2 inhibitors in patients with type 2 diabetes mellitus without established cardiovascular disease: Do they have a role in primary prevention? Metabol Open 2021; 10:100082. [PMID: 33817616 PMCID: PMC8010211 DOI: 10.1016/j.metop.2021.100082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 01/19/2021] [Indexed: 11/16/2022] Open
Abstract
Most guidelines and cardiovascular outcome trials (CVOTs) focus on secondary prevention of cardiovascular disease (CVD) in type 2 diabetes mellitus (T2DM). Patients with T2DM without established CVD (eCVD) also form a critical cohort, for whom primary prevention with timely pharmacological and non-pharmacological interventions can effectively prevent or delay the onset of CVD. Sodium-glucose co-transporter 2 inhibitors (SGLT2i) have demonstrated a promising role for primary prevention of CVD in CVOTs and real-world studies. The 2019 American College of Cardiology/American Heart Association guidelines on primary prevention of CVD recommend SGLT2i as one of the add-on treatment options to metformin for adults with T2DM and glycated hemoglobin >7% who have cardiovascular (CV) risk factors. The outcomes with maximal response to SGLT2i use in primary prevention are hospitalization for heart failure and chronic kidney disease. The cardiorenal benefits with SGLT2i are attributed to pleiotropic effects on CV risk factors, and interference with glucose and sodium handling in kidneys, independent of their glycemic benefits. Results therefore support a role for SGLT2i not only in patients with T2DM and eCVD but also in patients with T2DM without eCVD. This review examines the evidence for potential role of SGLT2i for primary prevention of CVD in T2DM.
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Affiliation(s)
- Shailaja Kale
- Dr Shailaja Kale’s Diabetes & Speciality Clinic, Pune, India
| | - Abd A Tahrani
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
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21
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Caparrotta TM, Greenhalgh AM, Osinski K, Gifford RM, Moser S, Wild SH, Reynolds RM, Webb DJ, Colhoun HM. Sodium-Glucose Co-Transporter 2 Inhibitors (SGLT2i) Exposure and Outcomes in Type 2 Diabetes: A Systematic Review of Population-Based Observational Studies. Diabetes Ther 2021; 12:991-1028. [PMID: 33665777 PMCID: PMC7994468 DOI: 10.1007/s13300-021-01004-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/13/2021] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Sodium-glucose co-transporter 2 inhibitors (SGLT2is) are licensed for the treatment of type 2 diabetes (T2D) and more recently for heart failure with or without diabetes. They have been shown to be safe (from the cardiovascular (CV) perspective) and effective (in terms of glycaemia, and in some cases, in reducing CV events) in extensive randomised controlled trials (RCTs). However, there remain concerns regarding the generalisability of these findings (to those ineligible for RCT participation) and about non-CV safety. For effectiveness, population-based pharmacoepidemiology studies can confirm and extend the findings of RCTs to broader populations and explore safety, for which RCTs are not usually powered, in more detail. METHODS A pre-planned and registered ((International PROSPEctive Register Of Systematic Reviews) PROSPERO registration CRD42019160792) systematic review of population-based studies investigating SGLT2i effectiveness and safety, following Meta-analyses Of Observational Studies in Epidemiology (MOOSE) guidelines was conducted. RESULTS A total of 37 studies were identified (total n = 1,300,184 adults; total follow-up 910,577 person-years; exposures: SGLT2i class, canagliflozin, dapagliflozin and empagliflozin) exploring CV disease (CVD) outcomes, acute kidney injury (AKI), lower limb amputation (LLA), diabetic ketoacidosis (DKA), bone fracture, urinary tract infection (UTI), genital mycotic infection (GMI), hypoglycaemia, pancreatitis and venous thromboembolism. For CV and mortality outcomes, studies confirmed the associated safety of these drugs and correlated closely with the findings from RCTs, which may extend to primary CVD prevention (major adverse cardiovascular events point estimate range (PER) hazard ratio (HR) 0.78-0.94; hospitalised heart failure PER HR 0.48-0.79). For safety outcomes, SGLT2i exposure was not associated with an increased risk of AKI (PER HR 0.40-0.96), fractures (PER HR 0.87-1.11), hypoglycaemia (PER HR 0.76-2.49) or UTI (PER HR 0.72-0.98). There was a signal for increased association for GMIs (PER HR 2.08-3.15), and possibly for LLA (PER HR 0.74-2.79) and DKA (PER HR 0.96-2.14), but with considerable uncertainty. CONCLUSION In T2D, SGLT2is appear safe from the CV perspective and may have associated benefit in primary as well as secondary CVD prevention. For safety, they may be associated with an increased risk of GMI, LLA and DKA, although longer follow-up studies are needed.
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Affiliation(s)
- Thomas M Caparrotta
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK.
- NHS Lothian, Edinburgh Royal Infirmary, Edinburgh, UK.
| | - Andrew M Greenhalgh
- NHS Lothian, Edinburgh Royal Infirmary, Edinburgh, UK
- Defence Medical Services, Whittington Barracks, Whittington, Lichfield, UK
| | - Karen Osinski
- NHS Lothian, Edinburgh Royal Infirmary, Edinburgh, UK
| | - Robert M Gifford
- NHS Lothian, Edinburgh Royal Infirmary, Edinburgh, UK
- Defence Medical Services, Whittington Barracks, Whittington, Lichfield, UK
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Queen's Medical Research Institute, Edinburgh, UK
| | - Svenja Moser
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Sarah H Wild
- Usher Institute, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh, UK
| | - Rebecca M Reynolds
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Queen's Medical Research Institute, Edinburgh, UK
| | - David J Webb
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Queen's Medical Research Institute, Edinburgh, UK
| | - Helen M Colhoun
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
- Department of Public Health, NHS Fife, Hayfield House, Hayfield Rd, Kirkcaldy, UK
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22
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Chang HY, Chou YY, Tang W, Chang GM, Hsieh CF, Singh S, Tung YC. Association of antidiabetic therapies with lower extremity amputation, mortality and healthcare cost from a nationwide retrospective cohort study in Taiwan. Sci Rep 2021; 11:7000. [PMID: 33772082 PMCID: PMC7997872 DOI: 10.1038/s41598-021-86516-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 03/15/2021] [Indexed: 12/17/2022] Open
Abstract
We compared risks of clinical outcomes, mortality and healthcare costs among new users of different classes of anti-diabetic medications. This is a population-based, retrospective, new-user design cohort study using the Taiwan National Health Insurance Database between May 2, 2015 and September 30, 2017. An individual was assigned to a medication group based on the first anti-diabetic prescription on or after May 1, 2016: SGLT-2 inhibitors, DPP-4 inhibitors, GLP-1 agonists or older agents (metformin, etc.). Clinical outcomes included lower extremity amputation, peripheral vascular disease, critical limb ischemia, osteomyelitis, and ulcer. We built three Cox proportional hazards models for clinical outcomes and mortality, and three regression models with a log-link function and gamma distribution for healthcare costs, all with propensity-score weighting and covariates. We identified 1,222,436 eligible individuals. After adjustment, new users of SGLT-2 inhibitors were associated with 73% lower mortality compared to those of DPP-4 inhibitors or users of older agents, while 36% lower total costs against those of GLP-1 agonists. However, there was no statistically significant difference in the risk of lower extremity amputation across medication groups. Our study suggested that SGLT-2 inhibitors is associated with lower mortality compared to DPP 4 inhibitors and lower costs compared to GLP-1 agonists.
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Affiliation(s)
- Hsien-Yen Chang
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Center for Population Health IT, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ying-Yi Chou
- Institute of Health Policy and Management, School of Public Health, National Taiwan University, Room 634, No.17, Xu-Zhou Road, Taipei, 100, Taiwan
| | - Wenze Tang
- Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA
| | - Guann-Ming Chang
- Department of Family Medicine, Chang-Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chi-Feng Hsieh
- School of Medicine for International Students, I- Shou University, Kaohsiung, Taiwan
| | - Sonal Singh
- Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, MA, USA
| | - Yu-Chi Tung
- Institute of Health Policy and Management, School of Public Health, National Taiwan University, Room 634, No.17, Xu-Zhou Road, Taipei, 100, Taiwan.
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23
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Li D, Liu Y, Hidru TH, Yang X, Wang Y, Chen C, Li KHC, Tang Y, Wei Y, Tse G, Xia Y. Protective Effects of Sodium-Glucose Transporter 2 Inhibitors on Atrial Fibrillation and Atrial Flutter: A Systematic Review and Meta- Analysis of Randomized Placebo-Controlled Trials. Front Endocrinol (Lausanne) 2021; 12:619586. [PMID: 33815278 PMCID: PMC8018283 DOI: 10.3389/fendo.2021.619586] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 02/15/2021] [Indexed: 12/14/2022] Open
Abstract
Background Hyperglycemia is associated with an increased risk of developing atrial fibrillation (AF) and atrial flutter (AFL). Sodium-glucose transporter 2 inhibitors (SGLT2i) have been reported to prevent AF/AFL in some studies, but not others. Therefore, a meta-analysis was performed to investigate whether SGLT2i use is associated with lower risks of AF/AFL. Methods PubMed, Scopus, Web of Science, Cochrane library databases were searched for randomized placebo-controlled trials comparing SGLT2i and placebo. Results A total of 33 trials involving 66,685 patients were included. The serious adverse events (SAEs) of AF/AFL occurrence were significantly lower in the SGLT2i group than the placebo group (0.96% vs. 1.19%; RR 0.83; 95% CI 0.71-0.96; P = 0.01; I2 25.5%). Similarly, the SAEs of AF occurrence was significantly lower in the SGLT2i group (0.82% vs. 1.06%; RR 0.81; 95% CI 0.69-0.95; P = 0.01; I2 10.2%). The subgroup analysis showed that the reduction in AF/AFL was significant only for dapagliflozin (1.02% vs. 1.49%; RR 0.73; 95% CI 0.59-0.89; P = 0.002; I2 0%), but not for canagliflozin (1.00% vs 1.08%; RR 0.83; 95% CI 0.62-1.12; P = 0.23; I2 0%), empagliflozin (0.88% vs 0.70%; RR 1.20; 95% CI 0.76-1.90; P = 0.43; I2 0%), ertugliflozin (1.01% vs 0.96%; RR 1.08; 95% CI 0.66-1.75; P = 0.76; I2 0%), and sotagliflozin (0.16% vs 0.10%; RR 1.09; 95% CI 0.13-8.86; P = 0.93; I2 0%). Conclusions SGLT2i use is associated with a 19.33% lower SAEs of AF/AFL compared with the placebo. Dapagliflozin users had the lowest SAEs of AF/AFL incidence. Further studies are needed to determine whether canagliflozin, empagliflozin, ertugliflozin, and sotagliflozin similarly exert protective effects against AF/AFL development.
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Affiliation(s)
- Daobo Li
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yingying Liu
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | | | - Xiaolei Yang
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yunsong Wang
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Cheng Chen
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | | | - Yuqi Tang
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yushan Wei
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Gary Tse
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yunlong Xia
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
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Li CX, Liang S, Gao L, Liu H. Cardiovascular outcomes associated with SGLT-2 inhibitors versus other glucose-lowering drugs in patients with type 2 diabetes: A real-world systematic review and meta-analysis. PLoS One 2021; 16:e0244689. [PMID: 33606705 PMCID: PMC7895346 DOI: 10.1371/journal.pone.0244689] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 12/15/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS Glucose lowering agents that reduce the risk of major adverse cardiovascular events (MACE) would be considered a major advance. The reduction of cardiovascular risk by sodium-glucose cotransporter 2 inhibitors (SGLT-2i) has been confirmed by some large-scale randomized controlled studies (RCTs) and systematic reviews of RCTs, but exact indicators of cardiovascular risk remained controversial. Whether consistent results can be obtained in clinical practice is unclear. Therefore, in this meta-analysis, we analyzed the real-world effect of SGLT-2i on cardiovascular outcome in patients with type 2 diabetes mellitus (T2DM). METHODS We did a real-world systematic review and meta-analysis of cardiovascular outcome of SGLT-2i in patients with T2DM. We searched PubMed and Embase for trials published up to October 23, 2019. Data search and extraction were completed with a standardized data form and any discrepancies were resolved by consensus. The primary outcome was MACE and all-cause mortality (ACM). Secondary outcomes were hospitalization for heart failure (HHF), atrial fibrillation (AF), myocardial infarction (MI), stroke, cardiovascular mortality (CVM), unstable angina (UA), heart failure (HF). Odds ratio (OR) with 95% CIs were pooled across trials, and cardiovascular outcomes were stratified by baseline incidence of cardiovascular disease (CVD), usage rate of cardiovascular benefit drug, follow-up period and region. RESULTS Fourteen trials enrolling 3,157,259 patients were included. SGLT-2i reduced MACE (OR, 0.71; 95% CI 0.67,0.75, P<0.001) and ACM (OR, 0.53; 95% CI 0.49,0.57, P<0.001) compared to other glucose lowering drugs (oGLD). Compared with oGLD, SGLT-2i had significantly lowered the risk of HHF (OR, 0.56; 95% CI 0.46,0.68, P<0.001), MI (OR, 0.77; 95% CI 0.73,0.81, P<0.001), stroke (OR, 0.75; 95% CI 0.72,0.78, P<0.001), CVM (OR, 0.58; 95% CI 0.49,0.69, P<0.001) and HF (OR, 0.56; 95% CI 0.48,0.67, P<0.001), but there was no benefit from UA or AF. SGLT-2i significantly reduced the risk of severe hypoglycemia (OR, 0.78; 95% CI 0.69,0.90, P<0.001) and lower limb amputation (OR, 0.83; 95% CI 0.71,0.98, P<0.001), but it may increase the risk of diabetic ketoacidosis. Subgroup analysis showed SGLT-2i reduced the risk of MACE, ACM, HHF, MI, stroke, CVM and HF with a similar benefit regardless of the incidence of CVD was (20-30)% or < 15%, (15-30)% or <15% have been treated with GLP-1 receptor agonists (GLP-1RA), >80% or <70% have been treated with statins or both GLP-1RA and statins. SGLT-2i reduced the risk of ACM in low-risk population (P<0.001). No inconsistencies were found when stratification was performed at 1 or (3-4) years of follow-up except for BKA followed up for 1 year. SGLT-2i showed similar cardiovascular benefits in the Nordic countries, Asia and the United States. CONCLUSIONS The predominant impact of SGLT-2i is on cardiovascular outcome driven predominantly by reduction in MACE, ACM, HHF, MI, stroke, CVM, HF, but not UA or AF. SGLT-2i has robust benefits on reducing MACE, ACM, HHF, MI, stroke, CVM and HF regardless of a history of usage rate of GLP-1RA and/or statins and /or metformin. SGLT-2i does not increase the risk of severe hypoglycemia and lower limb amputation.
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Affiliation(s)
- Chun-xing Li
- Department of Pharmacy, Aerospace Center Hospital, Beijing, China
| | - Shuo Liang
- Department of Pharmacy, Aerospace Center Hospital, Beijing, China
| | - Lingyan Gao
- Department of Pharmacy, Aerospace Center Hospital, Beijing, China
| | - Hua Liu
- Department of Pharmacy, Aerospace Center Hospital, Beijing, China
- * E-mail:
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25
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Kuchay MS, Farooqui KJ, Mishra SK, Mithal A. Glucose Lowering Efficacy and Pleiotropic Effects of Sodium-Glucose Cotransporter 2 Inhibitors. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1307:213-230. [PMID: 32006266 DOI: 10.1007/5584_2020_479] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In type 2 diabetes, the maladaptive upregulation of sodium-glucose cotransporter 2 (SGLT2) protein expression and activity contribute to the maintenance of hyperglycemia. By inhibiting these proteins, SGLT2 inhibitors increase urinary glucose excretion (UGE) that leads to fall in plasma glucose concentrations and improvement in all glycemic parameters. Clinical studies have demonstrated that in patients with type 2 diabetes, SGLT2 inhibitors resulted in sustained reductions in glycated hemoglobin (HbA1C), body weight, blood pressure and serum uric acid levels. Interestingly, the cardiovascular (CV) and renal outcome trials revealed the beneficial effects of SGLT2 inhibitors on CV and renal functions. Because the benefits were seen soon after initiation of SGLT2 inhibitors, these observations are explained by effects beyond their glucose lowering capacity. SGLT2 inhibitors also reduce liver fat in patients with nonalcoholic fatty liver disease (NAFLD) and type 2 diabetes. This chapter describes the basic information about SGLT2 inhibitors, current status of SGLT2 inhibitors in the management of type 2 diabetes and their beneficial effects in addition to glycemic control.
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Affiliation(s)
- Mohammad Shafi Kuchay
- Division of Endocrinology and Diabetes, Medanta The Medicity Hospital, Gurugram, Haryana, India.
| | - Khalid Jamal Farooqui
- Division of Endocrinology and Diabetes, Medanta The Medicity Hospital, Gurugram, Haryana, India
| | - Sunil Kumar Mishra
- Division of Endocrinology and Diabetes, Medanta The Medicity Hospital, Gurugram, Haryana, India
| | - Ambrish Mithal
- Division of Endocrinology and Diabetes, Medanta The Medicity Hospital, Gurugram, Haryana, India
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Singh P, Adderley N, Subramanian A, Gokhale K, Singhal R, Toulis KA, Bellary S, Nirantharakumar K, Tahrani AA. The Impact of Bariatric Surgery on Incident Microvascular Complications in Patients With Type 2 Diabetes: A Matched Controlled Population-Based Retrospective Cohort Study. Diabetes Care 2021; 44:116-124. [PMID: 33444160 PMCID: PMC7783931 DOI: 10.2337/dc20-0571] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 10/07/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess the impact of bariatric surgery (BS) on incident microvascular complications of diabetes-related foot disease (DFD), sight-threatening diabetic retinopathy (STDR), and chronic kidney disease (CKD) in patients with type 2 diabetes and obesity. RESEARCH DESIGN AND METHODS A retrospective matched, controlled population-based cohort study was conducted of adults with type 2 diabetes between 1 January 1990 and 31 January 2018 using IQVIA Medical Research Data (IMRD), a database of primary care electronic records. Each patient with type 2 diabetes who subsequently had BS (surgical group) was matched on the index date with up to two patients with type 2 diabetes who did not have BS (nonsurgical group) within the same general practice by age, sex, preindex BMI, and diabetes duration. RESULTS Included were 1,126 surgical and 2,219 nonsurgical participants. In the study population 2,261 (68%) were women. Mean (SD) age was 49.87 (9.3) years vs. 50.12 (9.3) years and BMI was 46.76 (7.96) kg/m2 vs. 46.14 (7.49) kg/m2 in the surgical versus nonsurgical group, respectively. In the surgical group, 22.1%, 22.7%, 52.2%, and 1.1% of patients had gastric band, sleeve gastrectomy, Roux-en-Y gastric bypass (RYGB), and duodenal switch, respectively. Over a median follow-up of 3.9 years (interquartile range 1.8-6.4), BS was associated with reduction in incident combined microvascular complications (adjusted hazard ratio 0.53, 95% CI 0.43-0.66, P < 0.001), DFD (0.61, 0.50-0.75, P < 0.001), STDR (0.66, 0.44-1.00, P = 0.048), and CKD (0.63, 0.51-0.78, P < 0.001). Analysis based on the type of surgery showed that all types of surgery were associated with a favorable impact on the incidence of composite microvascular complications, with the greatest reduction for RYGB. CONCLUSIONS BS was associated with a significant reduction in incident diabetes-related microvascular complications.
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Affiliation(s)
- Pushpa Singh
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, U.K.,Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, U.K
| | - Nicola Adderley
- Institute of Applied Health Research, University of Birmingham, Birmingham, U.K
| | | | - Krishna Gokhale
- Institute of Applied Health Research, University of Birmingham, Birmingham, U.K
| | - Rishi Singhal
- Department of Surgery, University Hospital Birmingham NHS Foundation Trust, Birmingham, U.K
| | - Konstantinos A Toulis
- Institute of Applied Health Research, University of Birmingham, Birmingham, U.K.,Department of Endocrinology, 424 General Army Training Hospital, Thessaloniki, Greece
| | - Srikanth Bellary
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, U.K.,School of Life and Health Sciences, Aston University, Birmingham, U.K
| | - Krishnarajah Nirantharakumar
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, U.K. .,Institute of Applied Health Research, University of Birmingham, Birmingham, U.K.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, U.K.,Midlands Health Data Research, Birmingham, U.K
| | - Abd A Tahrani
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, U.K.,Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, U.K.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, U.K
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Gokhale KM, Chandan JS, Toulis K, Gkoutos G, Tino P, Nirantharakumar K. Data extraction for epidemiological research (DExtER): a novel tool for automated clinical epidemiology studies. Eur J Epidemiol 2020; 36:165-178. [PMID: 32856160 PMCID: PMC7987616 DOI: 10.1007/s10654-020-00677-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/12/2020] [Indexed: 01/07/2023]
Abstract
The use of primary care electronic health records for research is abundant. The benefits gained from utilising such records lies in their size, longitudinal data collection and data quality. However, the use of such data to undertake high quality epidemiological studies, can lead to significant challenges particularly in dealing with misclassification, variation in coding and the significant effort required to pre-process the data in a meaningful format for statistical analysis. In this paper, we describe a methodology to aid with the extraction and processing of such databases, delivered by a novel software programme; the "Data extraction for epidemiological research" (DExtER). The basis of DExtER relies on principles of extract, transform and load processes. The tool initially provides the ability for the healthcare dataset to be extracted, then transformed in a format whereby data is normalised, converted and reformatted. DExtER has a user interface designed to obtain data extracts specific to each research question and observational study design. There are facilities to input the requirements for; eligible study period, definition of exposed and unexposed groups, outcome measures and important baseline covariates. To date the tool has been utilised and validated in a multitude of settings. There have been over 35 peer-reviewed publications using the tool, and DExtER has been implemented as a validated public health surveillance tool for obtaining accurate statistics on epidemiology of key morbidities. Future direction of this work will be the application of the framework to linked as well as international datasets and the development of standardised methods for conducting electronic pre-processing and extraction from datasets for research purposes.
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Affiliation(s)
- Krishna Margadhamane Gokhale
- School of Computer Science, College of Engineering and Physical Sciences, University of Birmingham, Birmingham, B152TT, UK.
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B152TT, UK.
- Health Data Research UK, Birmingham, UK.
| | - Joht Singh Chandan
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B152TT, UK
| | - Konstantinos Toulis
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B152TT, UK
| | - Georgios Gkoutos
- Chair of Clinical Bioinformatics, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B152TT, UK
- Health Data Research UK, Birmingham, UK
| | - Peter Tino
- School of Computer Science, College of Engineering and Physical Sciences, University of Birmingham, Birmingham, B152TT, UK
| | - Krishnarajah Nirantharakumar
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B152TT, UK.
- Health Data Research UK, Birmingham, UK.
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Qiu M, Ding LL, Zhang M, Lin JH, Gu JS, Zhou X, Tang YX, Wei XB, Liu SY. SGLT2 inhibitors for prevention of cardiorenal events in people with type 2 diabetes without cardiorenal disease: A meta-analysis of large randomized trials and cohort studies. Pharmacol Res 2020; 161:105175. [PMID: 32860942 DOI: 10.1016/j.phrs.2020.105175] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 08/20/2020] [Accepted: 08/22/2020] [Indexed: 12/21/2022]
Abstract
To investigate whether sodium glucose cotransporter 2 inhibitors (SGLT2is) can reduce important cardiorenal endpoints in type 2 diabetic adults without established cardiovascular disease (ECD), in those without heart failure (HF), and in those without chronic kidney disease (CKD). We searched PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL) and clinicaltrials.gov. Event-driven randomized controlled trials (RCTs) and cohort studies were included. We conducted random-effects meta-analysis, respectively based on RCTs and cohort studies, on eight cardiorenal endpoints in three type 2 diabetic subgroups. Thirteen large studies were included. Meta-analysis of RCTs showed the high quality evidences: compared with placebo, SGLT2is significantly reduced the risk of major adverse cardiovascular events, cardiovascular death or hospitalization for HF, and progression of CKD in type 2 diabetic adults without ECD [HRs (95 % CIs): 0.88 (0.82, 0.94), 0.76 (0.70, 0.82), and 0.59 (0.52, 0.66), respectively; risk differences (95 % CIs): -1.6 (-2.4, -0.8), -2.6 (-3.3, -2.0), and -2.4 (-2.8, -2.0) per 1000 patient-years, respectively], in those without HF [HRs (95 % CIs): 0.89 (0.82, 0.95), 0.74 (0.67, 0.81), and 0.61 (0.55, 0.67), respectively; risk differences (95 % CIs): -1.7 (-2.9, -0.8), -5.8 (-7.3, -4.2), and -2.3 (-2.6, -1.9) per 1000 patient-years, respectively], and in those without CKD [HRs (95 % CIs): 0.88 (0.82, 0.94), 0.77 (0.71, 0.83), and 0.63 (0.57, 0.70), respectively; risk differences (95 % CIs): -2.4 (-3.6, -1.2), -6.1 (-7.6, -4.5), and -2.2 (-2.6, -1.8) per 1000 patient-years, respectively]. Meta-analysis of cohort studies also showed the benefits of SGLT2is on the three composite outcomes in the three diabetic subgroups. SGLT2is also significantly reduced some other cardiorenal endpoints in these diabetic subgroups. SGLT2is can significantly reduce important cardiorenal events in type 2 diabetic adults without ECD, in those without HF, and in those without CKD; which supports SGLT2is used in these diabetic subpopulations to prevent cardiorenal events.
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Affiliation(s)
- Mei Qiu
- Department of General Medicine, Shenzhen Longhua District Central Hospital, Shenzhen, China.
| | - Liang-Liang Ding
- Department of Endocrinology, First Affiliated Hospital of Yangtze University, Jingzhou, China
| | - Miao Zhang
- Department of Nephrology, Shenzhen Hospital of Beijing University of Chinese Medicine, Shenzhen, China
| | - Jin-Hao Lin
- Department of Gastroenterology, Shenzhen Hospital of Beijing University of Chinese Medicine, Shenzhen, China
| | - Jin-Song Gu
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Xian Zhou
- Department of General Medicine, Yan'an Hospital Affiliated to Kunming Medical University, Kunming, China
| | - Ying-Xi Tang
- Department of Cardiology, The Central Hospital of Wuhan, Wuhan, China
| | - Xu-Bin Wei
- Department of Cardiology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Shu-Yan Liu
- Department of Endocrinology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
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Wilkinson S, Williamson E, Pokrajac A, Fogarty D, Stirnadel‐Farrant H, Smeeth L, Douglas IJ, Tomlinson LA. Comparative effects of sulphonylureas, dipeptidyl peptidase-4 inhibitors and sodium-glucose co-transporter-2 inhibitors added to metformin monotherapy: a propensity-score matched cohort study in UK primary care. Diabetes Obes Metab 2020; 22:847-856. [PMID: 31957254 PMCID: PMC7187358 DOI: 10.1111/dom.13970] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 01/10/2020] [Accepted: 01/15/2020] [Indexed: 12/13/2022]
Abstract
AIM To assess the comparative effects of sodium-glucose co-transporter-2 (SGLT2) inhibitors, sulphonylureas (SUs) and dipeptidyl peptidase-4 (DPP-4) inhibitors on cardiometabolic risk factors in routine care. MATERIALS AND METHODS Using primary care data on 10 631 new users of SUs, SGLT2 inhibitors or DPP-4 inhibitors added to metformin, obtained from the UK Clinical Practice Research Datalink, we created propensity-score matched cohorts and used linear mixed models to describe changes in glycated haemoglobin (HbA1c), estimated glomerular filtration rate (eGFR), systolic blood pressure (BP) and body mass index (BMI) over 96 weeks. RESULTS HbA1c levels fell substantially after treatment intensification for all drugs: mean change at week 12: SGLT2 inhibitors: -15.2 mmol/mol (95% confidence interval [CI] -16.9, -13.5); SUs: -14.3 mmol/mol (95% CI -15.5, -13.2); and DPP-4 inhibitors: -11.9 mmol/mol (95% CI -13.1, -10.6). Systolic BP fell for SGLT2 inhibitor users throughout follow-up, but not for DPP-4 inhibitor or SU users: mean change at week 12: SGLT2 inhibitors: -2.3 mmHg (95% CI -3.8, -0.8); SUs: -0.8 mmHg (95% CI -1.9, +0.4); and DPP-4 inhibitors: -0.9 mmHg (95% CI -2.1,+0.2). BMI decreased for SGLT2 inhibitor and DPP-4 inhibitor users, but not SU users: mean change at week 12: SGLT2 inhibitors: -0.7 kg/m2 (95% CI -0.9, -0.5); SUs: 0.0 kg/m2 (95% CI -0.3, +0.2); and DPP-4 inhibitors: -0.3 kg/m2 (95% CI -0.5, -0.1). eGFR fell at 12 weeks for SGLT2 inhibitor and DPP-4 inhibitor users. At 60 weeks, the fall in eGFR from baseline was similar for each drug class. CONCLUSIONS In routine care, SGLT2 inhibitors had greater effects on cardiometabolic risk factors than SUs. Routine care data closely replicated the effects of diabetes drugs on physiological variables measured in clinical trials.
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Affiliation(s)
- Samantha Wilkinson
- Department of Non‐Communicable Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Elizabeth Williamson
- Department of Non‐Communicable Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
| | | | | | | | - Liam Smeeth
- Department of Non‐Communicable Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Ian J. Douglas
- Department of Non‐Communicable Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Laurie A. Tomlinson
- Department of Non‐Communicable Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
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Fadini GP, Tentolouris N, Caballero Mateos I, Bellido Castañeda V, Morales Portillo C. A Multinational Real-World Study on the Clinical Characteristics of Patients with Type 2 Diabetes Initiating Dapagliflozin in Southern Europe. Diabetes Ther 2020; 11:423-436. [PMID: 31863344 PMCID: PMC6995805 DOI: 10.1007/s13300-019-00744-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION A real-world study was performed to describe the clinical characteristics of patients who received dapagliflozin to better understand differences when initiating dapagliflozin in various countries and different prescribing settings. METHODS We assessed pooled data from observational studies carried out in Italy (n = 2484), Spain (n = 564) and Greece (n = 87). The primary objective was to compare the clinical profile of patients initiating dapagliflozin in the three countries. We also evaluated the percentage of patients who received dapagliflozin in clinical practice who satisfied DECLARE-TIMI 58 enrolment criteria. RESULTS In Italy and Spain, around 90% of patients were receiving metformin vs. 66% in Greece (p < 0.0001). Patients in Greece had lower levels of estimated glomerular filtration rate and lower prevalence rates of retinopathy, prior stroke, acute myocardial infarction, peripheral arterial disease and atherosclerotic cardiovascular disease. Grouping the cohorts by prescribing setting (primary vs. specialist care), baseline HbA1c was lower in primary care (8.4 ± 1.7 vs. 8.7 ± 1.5, respectively; p < 0.0001). Significantly more patients were receiving other medications for concomitant conditions in specialist care. A total of 1416 patients (48%) did not meet DECLARE inclusion criteria, while 1561 (52%) patients met the criteria (Greece 41.05%, Italy 53.19%, Spain 51.35%). CONCLUSIONS Significant differences were seen among patients initiating dapagliflozin in southern Europe. Our results suggest that dapagliflozin was being initiated at different stages of the disease according to the country and prescribing settings. Such geographic heterogeneity may have an impact upon effectiveness of dapagliflozin on glucose lowering, as well as cardiovascular and renal outcomes.
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Affiliation(s)
- Gian Paolo Fadini
- For the DARWIN-T2D Network of the Italian Diabetes Society, Department of Medicine, University of Padova, 35128, Padua, Italy.
| | - Nikolaos Tentolouris
- 1st Department of Propaedeutic Internal Medicine, Medical School, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Singh P, Subramanian A, Adderley N, Gokhale K, Singhal R, Bellary S, Nirantharakumar K, Tahrani AA. Impact of bariatric surgery on cardiovascular outcomes and mortality: a population-based cohort study. Br J Surg 2020; 107:432-442. [DOI: 10.1002/bjs.11433] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 09/04/2019] [Accepted: 10/28/2019] [Indexed: 12/29/2022]
Abstract
Abstract
Background
Cohort studies have shown that bariatric surgery may reduce the incidence of and mortality from cardiovascular disease (CVD), but studies using real-world data are limited. This study examined the impact of bariatric surgery on incident CVD, hypertension and atrial fibrillation, and all-cause mortality.
Methods
A retrospective, matched, controlled cohort study of The Health Improvement Network primary care database (from 1 January 1990 to 31 January 2018) was performed (approximately 6 per cent of the UK population). Adults with a BMI of 30 kg/m2 or above who did not have gastric cancer were included as the exposed group. Each exposed patient, who had undergone bariatric surgery, was matched for age, sex, BMI and presence of type 2 diabetes mellitus (T2DM) with two controls who had not had bariatric surgery.
Results
A total of 5170 exposed and 9995 control participants were included; their mean(s.d.) age was 45·3(10·5) years and 21·5 per cent (3265 of 15 165 participants) had T2DM. Median follow-up was 3·9 (i.q.r. 1·8– 6·4) years. Mean(s.d.) percentage weight loss was 20·0(13·2) and 0·8(9·5) per cent in exposed and control groups respectively. Overall, bariatric surgery was not associated with a significantly lower CVD risk (adjusted hazard ratio (HR) 0·80; 95 per cent c.i. 0·62 to 1·02; P = 0·074). Only in the gastric bypass group was a significant impact on CVD observed (HR 0·53, 0·34 to 0·81; P = 0·003). Bariatric surgery was associated with significant reduction in all-cause mortality (adjusted HR 0·70, 0·55 to 0·89; P = 0·004), hypertension (adjusted HR 0·41, 0·34 to 0·50; P < 0·001) and heart failure (adjusted HR 0·57, 0·34 to 0·96; P = 0·033). Outcomes were similar in patients with and those without T2DM (exposed versus controls), except for incident atrial fibrillation, which was reduced in the T2DM group.
Conclusion
Bariatric surgery is associated with a reduced risk of hypertension, heart failure and mortality, compared with routine care. Gastric bypass was associated with reduced risk of CVD compared to routine care.
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Affiliation(s)
- P Singh
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Endocrinology and Diabetes, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - A Subramanian
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - N Adderley
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - K Gokhale
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - R Singhal
- Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - S Bellary
- School of Life and Health Sciences, Aston University, Birmingham, UK
- Department of Endocrinology and Diabetes, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - K Nirantharakumar
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Department of Endocrinology and Diabetes, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Health Data Research UK, London, UK
| | - A A Tahrani
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Endocrinology and Diabetes, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Morieri ML, Avogaro A, Fadini GP. Long-Acting Injectable GLP-1 Receptor Agonists for the Treatment of Adults with Type 2 Diabetes: Perspectives from Clinical Practice. Diabetes Metab Syndr Obes 2020; 13:4221-4234. [PMID: 33204129 PMCID: PMC7665457 DOI: 10.2147/dmso.s216054] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 10/14/2020] [Indexed: 12/15/2022] Open
Abstract
Randomized controlled trials (RCTs) have consistently shown glycemic and extra-glycemic benefits of long-acting injectable glucagon-like-peptide-1 receptor agonists (GLP-1RAs, liraglutide, albiglutide, exenatide once-weekly, dulaglutide, and semaglutide) in terms of reduction in the rates of cardiovascular events and mortality among patients with type 2 diabetes. Recently, the analyses of large datasets collecting routinely-accumulated data from clinical practice (ie, real-world studies, RWS) have provided new opportunities to complement the information obtained from RCTs. In this narrative review, we addressed clinically relevant questions that might be answered by well-conducted RWS: are subjects treated with GLP-1RAs in the "real-world" similar to those included in RCTs? Is the performance of GLP-1RA observed in the RWS (effectiveness) similar to that described in RCTs (efficacy)? Is the effectiveness similar in population of patients generally under-represented in RCTs? Are the cardiovascular benefits of GLP-1RAs confirmed in RWS? We also describe a few comparisons currently un-explored by specific RCTs, such as direct comparison between different administration strategies (eg, fixed- versus flexible-combination with basal-insulin) or between GLP-1RAs versus dipeptidyl-peptidase-4 inhibitor (DDP4i) or versus sodium/glucose cotransporter-2 inhibitors (SGLT-2i) on hard cardio-renal outcomes. Altogether, RWS provide highly informative information on treatment with GLP-1RAs. On the one side, RWS showed different clinical characteristics between subjects enrolled in RCTs versus those attending real-world clinics and receiving a GLP-1RA. On the other hand, RWS showed that GLP-1RA effectiveness is overall consistent in subgroups of patients less represented in RCTs. In addition, RWS allowed the identification of modifiable factors (eg, titration or adherence) that might guide physicians towards better GLP-1RAs use. Finally, multiple RWS reported better cardio-renal outcomes with GLP-1RAs than with DPP-4i, while initial findings from RWS described a weaker cardiovascular protection compared to SGLT-2i. Therefore, there is the need for further RWS and RCTs comparing these different classes of glucose lowering medications.
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Affiliation(s)
- Mario Luca Morieri
- Department of Medicine, University of Padova, Padova35128, Italy
- Correspondence: Mario Luca Morieri Department of Medicine, University of Padova, Via Giustiniani 2, Padova35128, ItalyTel +39 049 8217094 Email
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Padova35128, Italy
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Woo VC. Cardiovascular Effects of Sodium-Glucose Cotransporter-2 Inhibitors in Adults With Type 2 Diabetes. Can J Diabetes 2019; 44:61-67. [PMID: 31839265 DOI: 10.1016/j.jcjd.2019.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 08/30/2019] [Accepted: 09/06/2019] [Indexed: 12/19/2022]
Abstract
Adults with type 2 diabetes mellitus can benefit from pharmacotherapies that lower their risk for cardiovascular disease. This review describes the salient findings from sodium-glucose cotransporter-2 (SGLT2) inhibitor cardiovascular outcome trials that serendipitously revealed the cardiorenal benefits of SGLT2 inhibitors in adults with type 2 diabetes mellitus who either have established cardiovascular disease or multiple cardiovascular risk factors. It also summarizes the findings from other phase 3 clinical studies that measured the cardiovascular effects of SGLT2 inhibitors and real-world evidence reports that compared the cardiovascular impact of SGLT2 inhibitors with other antihyperglycemic agents. The collective data indicate that SGLT2 inhibitors are pleiotropic agents that offer important cardiovascular, metabolic and renal benefits beyond glucose lowering with low incidences of hypoglycemia. Specifically, the placebo-controlled SGLT2 inhibitor cardiovascular outcome trials documented either fewer major adverse cardiac events (nonfatal myocardial infarction, nonfatal stroke and cardiovascular death) or a reduction in the composite endpoint of cardiovascular death or hospitalization for heart failure in participants with type 2 diabetes mellitus and established cardiovascular disease. Amongst those with type 2 diabetes mellitus who did not have established cardiovascular disease but did present with multiple risk factors, SGLT2 inhibitors lowered the combined endpoint of cardiovascular death or hospitalization for heart failure but had little impact on the occurrence of major adverse cardiac events. Ongoing clinical trials and subanalyses of the trials that have been reported should shed further light on the clinical benefits and utility of SGLT2 inhibitors.
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Affiliation(s)
- Vincent C Woo
- Section of Endocrinology and Metabolism, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
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Toulis KA, Viola D, Gkoutos G, Keerthy D, Boelaert K, Nirantharakumar K. Risk of incident circulatory disease in patients treated for differentiated thyroid carcinoma with no history of cardiovascular disease. Clin Endocrinol (Oxf) 2019; 91:323-330. [PMID: 30993728 DOI: 10.1111/cen.13990] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 04/04/2019] [Accepted: 04/15/2019] [Indexed: 12/12/2022]
Abstract
CONTEXT The incidence of differentiated thyroid cancer (DTC) is increasing, yet the prognosis is favourable and long-term survival is expected. Exogenous TSH suppression has been used for many years to prevent DTC recurrence and may be associated with increased risks of circulatory diseases. DESIGN Risks of circulatory disease in patients treated for DTC were compared to randomly matched patients without DTC (controls) up to a 1:5 ratio using age, sex, body mass index (BMI) and smoking as the matching parameters in a population-based, open cohort study using The Health Improvement Network. PATIENTS A total of 3009 patients treated for DTC with no pre-existing cardiovascular disease were identified and matched to 11 303 controls, followed up to median of 5 years. RESULTS A total of 1259 incident circulatory events were recorded during the observation period. No difference in the risk of ischaemic heart disease (IHD) (adjusted hazards ratio [aHR]: 1.04, 95% CI: 0.80-1.36) or heart failure (HF) (aHR: 1.27, 95% CI: 0.89-1.81) was detected. The risk of atrial fibrillation (AF) and stroke was significantly higher in patients with DTC (aHR: 1.71, 95% CI: 1.36-2.15 and aHR: 1.34, 95% CI: 1.05-1.72, respectively). In a sensitivity analysis limited to newly diagnosed patients with DTC, only the risk of AF was consistently elevated (aHR: 1.86, 95% CI: 1.33-2.60). CONCLUSIONS The increased risk of AF in patients who have undergone treatment for DTC but without pre-existing CVD may warrant periodic screening for this arrhythmia. Whereas no evidence of increased risk of IHD or HF was observed, the increased risk of stroke/TIA warrants further investigation.
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Affiliation(s)
- Konstantinos A Toulis
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Department of Endocrinology, 424 General Military Hospital, Thessaloniki, Greece
| | - David Viola
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - George Gkoutos
- Centre for Computational Biology, University of Birmingham, Birmingham, UK
| | - Deepiksana Keerthy
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Kristien Boelaert
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Krishnarajah Nirantharakumar
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Health Data Research UK, London, UK
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Thayakaran R, Perrins M, Gokhale KM, Kumaran S, Narendran P, Price MJ, Nirantharakumar K, Toulis KA. Impact of glycaemic control on fracture risk in 5368 people with newly diagnosed Type 1 diabetes: a time-dependent analysis. Diabet Med 2019; 36:1013-1019. [PMID: 30848519 DOI: 10.1111/dme.13945] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2019] [Indexed: 12/30/2022]
Abstract
AIMS To assess whether glycaemic control is associated with a lifelong increased risk of fracture in people with newly diagnosed Type 1 diabetes. METHODS People with newly diagnosed Type 1 diabetes between 1 January 1995 and 10 May 2016 were identified in The Health Improvement Network database. Longitudinal HbA1c measurements from diagnosis to fracture or study end or loss to follow-up were collected. A Cox proportional hazards model with HbA1c included as a time-dependent variable was fitted to these data. RESULTS Some 5368 people with newly diagnosed Type 1 diabetes were included. The estimated adjusted hazard ratio (aHR) for HbA1c was statistically significant [aHR 1.007; 95% confidence interval (CI) 1.002-1.011 (mmol/mol) and aHR 1.07; 95% CI 1.03-1.12 (%)]. An incremental higher risk of fracture was observed with increasing levels of HbA1c . CONCLUSIONS In people with newly diagnosed Type 1 diabetes, higher HbA1c is associated with an increased risk for fractures.
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Affiliation(s)
- R Thayakaran
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - M Perrins
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - K M Gokhale
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - S Kumaran
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - P Narendran
- Department of Diabetes, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Immunology and Immunotherapy, Birmingham, UK
| | - M J Price
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - K Nirantharakumar
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Department of Diabetes, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, Birmingham, UK
- Health Data Research UK Midlands, Birmingham, UK
| | - K A Toulis
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Ingelfinger JR, Rosen CJ. Clinical Credence - SGLT2 Inhibitors, Diabetes, and Chronic Kidney Disease. N Engl J Med 2019; 380:2371-2373. [PMID: 30990261 DOI: 10.1056/nejme1904740] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Julie R Ingelfinger
- From the Tufts University School of Medicine, Boston, and the Center for Clinical and Translational Research, Maine Medical Center Research Institute, Scarborough (C.J.R.)
| | - Clifford J Rosen
- From the Tufts University School of Medicine, Boston, and the Center for Clinical and Translational Research, Maine Medical Center Research Institute, Scarborough (C.J.R.)
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Singh AK, Unnikrishnan AG, Zargar AH, Kumar A, Das AK, Saboo B, Sinha B, Gangopadhyay KK, Talwalkar PG, Ghosal S, Kalra S, Joshi S, Sharma SK, Sriram U, Mohan V. Evidence-Based Consensus on Positioning of SGLT2i in Type 2 Diabetes Mellitus in Indians. Diabetes Ther 2019; 10:393-428. [PMID: 30706366 PMCID: PMC6437257 DOI: 10.1007/s13300-019-0562-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Indexed: 02/05/2023] Open
Abstract
The current diabetes management strategies not only aim at controlling glycaemic parameters but also necessitate continuous medical care along with multifactorial risk reduction through a comprehensive management concept. The sodium-glucose cotransporter 2 inhibitors (SGLT2i) are a group of evolving antidiabetic agents that have the potential to play a pivotal role in the comprehensive management of patients with diabetes due to their diverse beneficial effects. SGLT2i provide moderate glycaemic control, considerable body weight and blood pressure reduction, and thus have the ability to lower the risk of macrovascular and microvascular complications. Some of the unique characteristics associated with SGLT2i, such as reduction in body weight (more visceral fat mass loss than subcutaneous fat loss), reduction in insulin resistance and improvement in β-cell function, as measured by homeostatic model assessment-β (HOMA-β) could be potentially beneficial and help in overcoming some of the challenges faced by Indian patients with diabetes. In addition, a patient-centric approach with individualised treatment during SGLT2i therapy is inevitable in order to reduce diabetic complications and improve quality of life. Despite their broad benefits profile, the risk of genital tract infections, volume depletion, amputations and diabetic ketoacidosis associated with SGLT2i should be carefully monitored. In this compendium, we systematically reviewed the literature from Medline, Cochrane Library, and other relevant databases and attempted to provide evidence-based recommendations for the positioning of SGLT2i in the management of diabetes in the Indian population.Funding: AstraZeneca Pharma India Limited.
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Affiliation(s)
| | | | - Abdul H Zargar
- Advanced Centre for Diabetes and Endocrine Care, Srinagar, Jammu and Kashmir, India
| | - Ajay Kumar
- Diabetes Care and Research Centre, Patna, Bihar, India
| | - Ashok K Das
- Pondicherry Institute of Medical Sciences, Pondicherry, India
| | - Banshi Saboo
- Diacare-Diabetes Care & Hormone Clinic, Ahmedabad, Gujarat, India
| | | | | | | | - Samit Ghosal
- Nightingale Hospital, Kolkata, West Bengal, India
| | - Sanjay Kalra
- Bharti Hospital & B.R.I.D.E, Karnal, Haryana, India
| | - Shashank Joshi
- Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India
| | | | - Usha Sriram
- Clinical Endocrinology Education and Research (ACEER), Chennai, Tamil Nadu, India
| | - Viswanathan Mohan
- Dr Mohan's Diabetes Specialities Centre and Madras Diabetes Research Foundation, Chennai, Tamil Nadu, India
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Kumarendran B, Sumilo D, O’Reilly MW, Toulis KA, Gokhale KM, Wijeyaratne CN, Coomarasamy A, Arlt W, Tahrani AA, Nirantharakumar K. Increased risk of obstructive sleep apnoea in women with polycystic ovary syndrome: a population-based cohort study. Eur J Endocrinol 2019; 180:265-272. [PMID: 30763274 PMCID: PMC6410684 DOI: 10.1530/eje-18-0693] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 02/13/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Obesity is very common in patients with obstructive sleep apnoea (OSA) and polycystic ovary syndrome (PCOS). Longitudinal studies assessing OSA risk in PCOS and examining the role of obesity are lacking. Our objective was to assess the risk of OSA in women with vs without PCOS and to examine the role of obesity in the observed findings. DESIGN Population-based retrospective cohort study utilizing The Health Improvement Network (THIN), UK. METHODS 76 978 women with PCOS and 143 077 age-, BMI- and location-matched women without PCOS between January 2000 and May 2017 were identified. Hazard ratio (HR) for OSA among women with and without PCOS were calculated after controlling for confounding variables using multivariate Cox models. RESULTS Median patient age was 30 (IQR: 25-35) years; median follow-up was 3.5 (IQR: 1.4-7.1) years. We found 298 OSA cases in PCOS women vs 222 in controls, with incidence rates for OSA of 8.1 and 3.3 per 10 000 person years, respectively. Women with PCOS were at increased risk of developing OSA (adjusted HR = 2.26, 95% CI: 1.89-2.69, P < 0.001), with similar HRs for normal weight, overweight and obese PCOS women. CONCLUSIONS Women with PCOS are at increased risk of developing OSA compared to control women irrespective of obesity. Considering the significant metabolic morbidity associated with OSA, clinicians should have a low threshold to test for OSA in women with PCOS. Whether OSA treatment has an impact on PCOS symptoms and outcomes needs to be examined.
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Affiliation(s)
- Balachandran Kumarendran
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Department of Community and Family Medicine, Faculty of Medicine, University of Jaffna, Jaffna, Sri Lanka
| | - Dana Sumilo
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Michael W O’Reilly
- Institute of Metabolism and Systems Research, University of Birmingham
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | | | - Krishna M Gokhale
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Chandrika N Wijeyaratne
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Arri Coomarasamy
- Institute of Metabolism and Systems Research, University of Birmingham
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Abd A Tahrani
- Institute of Metabolism and Systems Research, University of Birmingham
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Krishnarajah Nirantharakumar
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Institute of Metabolism and Systems Research, University of Birmingham
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Health Data Research, Birmingham, UK
- Correspondence should be addressed to K Nirantharakumar;
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Cai X, Shi L, Yang W, Gu S, Chen Y, Nie L, Ji L. Cost-effectiveness analysis of dapagliflozin treatment versus metformin treatment in Chinese population with type 2 diabetes. J Med Econ 2019; 22:336-343. [PMID: 30663458 DOI: 10.1080/13696998.2019.1570220] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND OBJECTIVE Dapagliflozin is the first SGLT2 inhibitor available in China, where the disease burden of diabetes and its complications is very heavy. Because a new diabetes treatment strategy for diabetes should consider its cost-effectiveness, compared with an existing treatment, this study aimed to examine the cost-effectiveness between dapagliflozin and metformin treatment in China. METHODS The Cardiff Diabetes Model (CDM) was used to estimate cost effectiveness and macro- and micro-vascular outcomes of dapagliflozin vs metformin. The CDM effectiveness inputs were derived from indirect comparative efficacy data from meta-analysis of 71 studies comparing monotherapy and add-on therapy of dapagliflozin vs metformin: dapagliflozin or metformin monotherapy, add-on therapy with other oral hypoglycemic agents, and add-on therapy with insulin. Direct medication costs and medical costs on treating diabetes were calculated based on published and local sources. A discount rate of 3% was applied to both costs and health effects. Univariate and probabilistic sensitivity analyses (PSA) were performed to assess uncertainties. RESULTS The total healthcare costs accumulated over the lifetime on dapagliflozin treatment arm was 8,626 Chinese yuan higher than the metformin treatment arm for an individual patient, and the quality adjusted life years (QALYs) gained with dapagliflozin treatment was 0.8 more than metformin treatment. Therefore, an incremental cost-effectiveness ratio was 10,729 yuan per QALY gained for dapagliflozin treatment arm vs metformin treatment arm. The cost-effectiveness results were robust to various sensitivity analyses. CONCLUSION Dapagliflozin treatment was more cost-effective compared with metformin treatment for Chinese type 2 diabetes patients. However, the findings of favorable cost-effectiveness results for dapagliflozin are largely driven by the effects of favorable weight profile on clinical, utility, and costs in the Cardiff model.
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Affiliation(s)
- Xiaoling Cai
- a Department of Endocrinology & Metabolism , Peking University People's Hospital , Beijing , PR China
| | - Lizheng Shi
- b Department of Global Health Management and Policy , Tulane University School of Public Health and Tropical Medicine , New Orleans , LA , USA
| | - Wenjia Yang
- a Department of Endocrinology & Metabolism , Peking University People's Hospital , Beijing , PR China
| | - Shuyan Gu
- c Center for Health Policy Studies, School of Public Health , Zhejiang University School of Medicine , Hangzhou , PR China
| | - Yingyao Chen
- d School of Public Health , Fudan University , Shanghai , PR China
| | - Lin Nie
- e Department of Endocrinology & Metabolism , Beijing Airport Hospital , Beijing , PR China
| | - Linong Ji
- a Department of Endocrinology & Metabolism , Peking University People's Hospital , Beijing , PR China
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Singh AK, Singh R. Heart failure hospitalization with SGLT-2 inhibitors: a systematic review and meta-analysis of randomized controlled and observational studies. Expert Rev Clin Pharmacol 2019; 12:299-308. [PMID: 30817235 DOI: 10.1080/17512433.2019.1588110] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Heart failure (HF) in type 2 diabetes mellitus (T2DM) poses a significant increase in mortality. Until recently, anti-diabetic drugs have not been shown to reduce hospitalization due to heart failure (hHF). While thiazolidinedione class and saxagliptin has shown a significantly increased risk, sodium-glucose linked co-transporter 2 inhibitors (SGLT-2Is) have demonstrated a significant reduction in the risk of hHF. Areas covered: We systematically searched the database of PubMed, Embase, ClinicalTrials.gov, and International conference presentation up to 25 December 2018 and retrieved all the studies that were conducted for ≥24 weeks and explicitly reported hHF outcome. Subsequently, we conducted the meta-analysis to study the effect of SGLT-2Is on hHF outcome in randomized controlled trials (RCTs), observational studies, and both. Expert opinion: The meta-analysis of RCTs (N = 34,322), observational studies (N = 15,36,339), and both (N = 15,70,661) demonstrated a significant decrease in hHF (OR 0.70, 0.64, 0.66, respectively, all p = 0.000) with SGLT-2Is compared to placebo or other anti-diabetes drugs in T2DM. A significant benefit in hHF (OR 0.68, p = 0.000) is also observed in patients with established HF (N = 3891) in sub-group meta-analysis of RCTs. Ongoing dedicated HF trials will further enlighten the merits of SGLT-2Is in patients with established heart failure (preserved or reduced) with or without T2DM.
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Affiliation(s)
- Awadhesh Kumar Singh
- a Department of Endocrinology , GD Hospital & Diabetes Institute , Kolkata , India
| | - Ritu Singh
- b Department of Gynecology & Obstetrics , GD Hospital & Diabetes Institute , Kolkata , India
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Clegg LE, Heerspink HJL, Penland RC, Tang W, Boulton DW, Bachina S, Fox RD, Fenici P, Thuresson M, Mentz RJ, Hernandez AF, Holman RR. Reduction of Cardiovascular Risk and Improved Estimated Glomerular Filtration Rate by SGLT2 Inhibitors, Including Dapagliflozin, Is Consistent Across the Class: An Analysis of the Placebo Arm of EXSCEL. Diabetes Care 2019; 42:318-326. [PMID: 30523029 DOI: 10.2337/dc18-1871] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 11/08/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The sodium-glucose cotransporter 2 inhibitors (SGLT2i) empagliflozin and canagliflozin reduce the incidence of major adverse cardiovascular events (MACE), all-cause mortality (ACM), and renal events in cardiovascular outcomes trials, with observational real-world evidence suggesting class effect benefits that include dapagliflozin. We examined the placebo arm of the Exenatide Study of Cardiovascular Event Lowering (EXSCEL) to determine whether the effects of drop-in open-label dapagliflozin on MACE, ACM, and estimated glomerular filtration rate (eGFR) were consistent with the SGLT2i class as a whole. RESEARCH DESIGN AND METHODS SGLT2i drop-in therapy occurred in 10.6% of EXSCEL participants, with 5.2% taking dapagliflozin. Propensity-matched cohorts of SGLT2i users and nonusers (n = 709 per group) were generated on the basis of their characteristics before open-label SGLT2i drop-in or at baseline for participants taking SGLT2i at enrollment and an equivalent study visit for non-SGLT2i users. Time to first adjudicated MACE and ACM was analyzed using Cox regression. eGFR slopes were compared between matched cohorts using a mixed-model repeated-measures analysis. RESULTS In adjusted analyses, SGLT2i users (compared with nonusers) had a numerically lower risk of MACE (adjusted hazard ratio 0.79 [95% CI 0.49-1.28]), as did dapagliflozin users (0.55 [0.26-1.15]). SGLT2i users had a significantly lower ACM risk (0.51 [0.27-0.95]; dapagliflozin: 0.66 [0.25-1.72]). Compared with nonusers, eGFR slope was significantly better for SGLT2i users overall (+1.78 [95% CI 0.87-2.69] mL/min/1.73 m2 per year) and for dapagliflozin users (+2.28 [1.01-3.54] mL/min/1.73 m2 per year). CONCLUSIONS This post hoc analysis of the placebo arm of EXSCEL supports a beneficial class effect for all SGLT2i, including dapagliflozin, for reduced ACM and less eGFR decline.
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Affiliation(s)
- Lindsay E Clegg
- Quantitative Clinical Pharmacology, Early Clinical Development, IMED Biotech Unit, AstraZeneca, Gaithersburg, MD
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Robert C Penland
- Quantitative Clinical Pharmacology, Early Clinical Development, IMED Biotech Unit, AstraZeneca, Waltham, MA
| | - Weifeng Tang
- Quantitative Clinical Pharmacology, Early Clinical Development, IMED Biotech Unit, AstraZeneca, Gaithersburg, MD
| | - David W Boulton
- Quantitative Clinical Pharmacology, Early Clinical Development, IMED Biotech Unit, AstraZeneca, Gaithersburg, MD
| | - Srinivas Bachina
- Quantitative Clinical Pharmacology, Early Clinical Development, IMED Biotech Unit, AstraZeneca, Waltham, MA
| | - Robert D Fox
- Quantitative Clinical Pharmacology, Early Clinical Development, IMED Biotech Unit, AstraZeneca, Waltham, MA
| | | | | | - Robert J Mentz
- Duke University and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Adrian F Hernandez
- Duke University and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Rury R Holman
- Diabetes Trials Unit, University of Oxford, Oxford, U.K
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Dawwas GK, Smith SM, Park H. Cardiovascular outcomes of sodium glucose cotransporter-2 inhibitors in patients with type 2 diabetes. Diabetes Obes Metab 2019; 21:28-36. [PMID: 30039524 DOI: 10.1111/dom.13477] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 07/11/2018] [Accepted: 07/15/2018] [Indexed: 12/27/2022]
Abstract
AIMS To determine the association between cardiovascular diseases (CVD) and SGLT2 inhibitors compared to sulfonylureas and dipeptidyl peptidase-4 (DPP4) inhibitors and to examine within-class effects of SGLT2 inhibitors. METHODS A retrospective cohort analysis was conducted using Truven Health MarketScan. New users of SGLT2 inhibitors, sulfonylureas or DPP-4 inhibitors were included. Primary outcome was incident CVD, defined as non-fatal myocardial infarction or non-fatal stroke; secondary outcomes were hospitalization because of heart failure and lower extremity amputation. Proportional hazards models, after propensity score matching, were used to obtain hazard ratios (HR) and 95% confidence intervals (CI). RESULTS In fully adjusted models, use of SGLT2 inhibitors was associated with a decreased risk of developing CVD compared with use of sulfonylureas (HR, 0.50; 95% CI, 0.45, 0.55) and DPP-4 inhibitors (HR, 0.57; 95% CI, 0.52, 0.62), respectively. Analyses revealed no evidence of within-class effects: dapagliflozin vs sulfonylureas (HR, 0.55; 95% CI, 0.43, 0.70) or DPP-4 inhibitors (HR, 0.57; 95% CI, 0.46, 0.70); and canagliflozin vs sulfonylureas (HR, 0.61; 95% CI, 0.54, 0.69) or DPP-4 inhibitors (HR, 0.66; 95% CI, 0.54, 0.71). Additionally, SGLT2 inhibitors were associated with lower risk of hospitalization because of heart failure compared to both sulfonylureas and DPP-4 inhibitors, as well as lower risk of lower extremity amputation compared to sulfonylureas. CONCLUSION Using population-based data, incident use of SGLT-2 inhibitors was associated with a decreased incidence of CVD compared to use of sulfonylureas and DPP-4 inhibitors. These findings were consistent between dapagliflozin and canagliflozin, suggesting that CVD reduction is a class effect for SGLT2 inhibitors. In addition, SGLT2 inhibitors portended lower risk of hospitalization because of heart failure (vs sulfonylureas and DPP-4 inhibitors) and lower risk of lower extremity amputation (vs sulfonylureas).
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Affiliation(s)
- Ghadeer K Dawwas
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Steven M Smith
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida
- Department of Community Health and Family Medicine, College of Medicine, University of Florida, Gainesville, Florida
| | - Haesuk Park
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida
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O’Reilly MW, Glisic M, Kumarendran B, Subramanian A, Manolopoulos KN, Tahrani AA, Keerthy D, Muka T, Toulis KA, Hanif W, Thomas GN, Franco OH, Arlt W, Nirantharakumar K. Serum testosterone, sex hormone-binding globulin and sex-specific risk of incident type 2 diabetes in a retrospective primary care cohort. Clin Endocrinol (Oxf) 2019; 90:145-154. [PMID: 30256433 PMCID: PMC6334272 DOI: 10.1111/cen.13862] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 08/24/2018] [Accepted: 09/21/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Previous studies suggest that androgens have a sexually dimorphic impact on metabolic dysfunction. However, the sex-specific link between circulating androgens and risk of type 2 diabetes mellitus (T2DM) has not been examined in a large scale, longitudinal cohort, a task we undertook in this study. DESIGN A retrospective cohort study in a UK primary care database. PATIENTS We included men and women with available serum testosterone and sex hormone-binding globulin (SHBG) results. MEASUREMENTS We categorized serum concentrations according to clinically relevant cut-off points and calculated crude and adjusted T2DM Incidence Rate Ratios (IRRs and aIRRs). RESULTS Serum testosterone concentrations were available in 70 541 men and 81 889 women; serum SHBG was available in 15 907 men and 42 034 women. In comparison to a reference cohort with serum testosterone ≥20 nmol/L, men with lower serum testosterone had a significantly increased risk of T2DM, with the highest risk in those with serum testosterone <7 nmol/L (aIRR 2.71, 95% CI 2.34-3.14, P < 0.001). In women, the risk of T2DM started to increase significantly when serum testosterone concentrations exceeded 1.5 nmol/L, with the highest risk in women with serum testosterone ≥3.5 nmol/L (aIRR 1.98, 95% CI 1.55-2.52, P < 0.001). These observations were verified in a continuous rather than categorized analysis. The risk of T2DM increased in men and women with serum SHBG <40 and <50 nmol/L, respectively. CONCLUSIONS/INTERPRETATION In this longitudinal study, we found sexually dimorphic associations between serum testosterone and risk of incident T2DM. Androgen deficiency and excess should be considered important risk factors for diabetes in men and women, respectively.
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Affiliation(s)
- Michael W. O’Reilly
- Institute of Metabolism and Systems ResearchUniversity of BirminghamBirminghamUK
- Centre for Endocrinology, Diabetes and MetabolismBirmingham Health PartnersBirminghamUK
| | - Marija Glisic
- Department of EpidemiologyErasmus University Medical CentreRotterdamThe Netherlands
| | - Balachandran Kumarendran
- Institute of Applied Health ResearchUniversity of BirminghamBirminghamUK
- Department of Public Health, Faculty of MedicineUniversity of KelaniyaKelaniyaSri Lanka
| | | | - Konstantinos N. Manolopoulos
- Institute of Metabolism and Systems ResearchUniversity of BirminghamBirminghamUK
- Centre for Endocrinology, Diabetes and MetabolismBirmingham Health PartnersBirminghamUK
| | - Abd A. Tahrani
- Institute of Metabolism and Systems ResearchUniversity of BirminghamBirminghamUK
- Centre for Endocrinology, Diabetes and MetabolismBirmingham Health PartnersBirminghamUK
| | - Deepi Keerthy
- Institute of Applied Health ResearchUniversity of BirminghamBirminghamUK
| | - Taulant Muka
- Department of EpidemiologyErasmus University Medical CentreRotterdamThe Netherlands
| | | | - Wasim Hanif
- Centre for Endocrinology, Diabetes and MetabolismBirmingham Health PartnersBirminghamUK
| | - G. Neil Thomas
- Institute of Applied Health ResearchUniversity of BirminghamBirminghamUK
| | - Oscar H. Franco
- Department of EpidemiologyErasmus University Medical CentreRotterdamThe Netherlands
- Institute of Social and Preventive Medicine (ISPM)University of BernBernSwitzerland
| | - Wiebke Arlt
- Institute of Metabolism and Systems ResearchUniversity of BirminghamBirminghamUK
- Centre for Endocrinology, Diabetes and MetabolismBirmingham Health PartnersBirminghamUK
| | - Krishnarajah Nirantharakumar
- Centre for Endocrinology, Diabetes and MetabolismBirmingham Health PartnersBirminghamUK
- Institute of Applied Health ResearchUniversity of BirminghamBirminghamUK
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Ruiz-García A, Arranz-Martínez E, Morón-Merchante I, Pascual-Fuster V, Tamarit JJ, Trias-Villagut F, Pintó-Sala X, Ascaso JF. Consensus document of the Spanish Society of Arteriosclerosis (SEA) for the prevention and treatment of cardiovascular disease in type 2 diabetes mellitus. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS 2018; 30 Suppl 1:1-19. [PMID: 30053980 DOI: 10.1016/j.arteri.2018.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 06/16/2018] [Indexed: 01/16/2023]
Abstract
A consensus document of the Diabetes working group of the Spanish Society of Arteriosclerosis (SEA) is presented, based on the latest studies and conceptual changes that have appeared. It presents the cardiovascular risk in type 2 diabetes mellitus (T2DM) and the action guidelines for the prevention and treatment of cardiovascular disease (CVD) associated with T2DM. The importance of lipid control, based on the objective of LDL-C and non-HDL-C when there is hypertriglyceridemia, and the blood pressure control in the prevention and treatment of CVD is evaluated. The new hypoglycemic drugs and their effects on CVD are reviewed, as well as the treatment and control guidelines of hyperglycemia. Likewise, the use of antiplatelet agents is considered. Emphasis is placed on the importance of global and simultaneous action on all risk factors to achieve a significant reduction in cardiovascular events. This supplement is sponsored by Laboratorios Esteve, S.A.
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Affiliation(s)
- Antonio Ruiz-García
- Centro de Salud Universitario Pinto, Unidad de Lípidos y Prevención Cardiovascular, Universidad Europea de Madrid, Pinto, Madrid, España
| | | | | | | | - Juan J Tamarit
- Consorcio Hospital General Universitario, Valencia, España
| | | | | | - Juan F Ascaso
- Hospital Clínico-Universitat de València, INCLIVA Research Institute, CIBER de Diabetes y Enfermedades Metabólicas (CIBERDEM), ISCIII, Valencia, España
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Raschi E, Poluzzi E, Fadini GP, Marchesini G, De Ponti F. Observational research on sodium glucose co-transporter-2 inhibitors: A real breakthrough? Diabetes Obes Metab 2018; 20:2711-2723. [PMID: 30003655 PMCID: PMC6283243 DOI: 10.1111/dom.13468] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 07/04/2018] [Accepted: 07/10/2018] [Indexed: 12/14/2022]
Abstract
Sodium glucose co-transporter-2 inhibitors have attracted the interest of the scientific community following the results from dedicated cardiovascular outcome trials, which demonstrated remarkable reduction in all-cause mortality and other cardiovascular (CV) endpoints with empagliflozin and canagliflozin. These impressive results raised further expectations on real world data from large observational cohort studies. They were designed to address the possible existence of a class effect, and the uncertainty on whether this benefit can be extended from secondary to primary CV prevention of patients with type 2 diabetes. In this review, we collated data from existing observational studies (including the celebrated CVD-REAL cohorts) and critically appraised results and methodological issues with the aim of providing clinical insight, including unsettled aspects, and proposing a research agenda for future investigations.
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Affiliation(s)
- Emanuel Raschi
- Pharmacology Unit, Department of Medical and Surgical SciencesUniversity of BolognaBolognaItaly
| | - Elisabetta Poluzzi
- Pharmacology Unit, Department of Medical and Surgical SciencesUniversity of BolognaBolognaItaly
| | | | - Giulio Marchesini
- Unit of Metabolic Diseases & Clinical Dietetics, Department of Medical and Surgical SciencesUniversity of BolognaBolognaItaly
| | - Fabrizio De Ponti
- Pharmacology Unit, Department of Medical and Surgical SciencesUniversity of BolognaBolognaItaly
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Sodium-Glucose Cotransporter-2 Inhibition in Type 2 Diabetes Mellitus: A Review of Large-Scale Cardiovascular Outcome Studies and Possible Mechanisms of Benefit. Cardiol Rev 2018; 26:312-320. [PMID: 29608505 DOI: 10.1097/crd.0000000000000201] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cardiovascular (CV) disease remains the leading cause of morbidity and mortality in individuals with type 2 diabetes mellitus (T2DM). However, conventional antihyperglycemic medications seem to have minimal effect on lowering CV risk despite achieving excellent reductions in glycated hemoglobin A1c and associated reductions in microvascular risk. Sodium-glucose cotransporter 2 (SGLT2) inhibitors have emerged as noteworthy antihyperglycemic agents with concomitant CV and renal protection in T2DM patients. In this comprehensive review, we present the key CV findings from major large-scale outcome trials of SGLT2 inhibitors to date. We also review the mechanistic studies that might explain the CV benefits of SGLT2 inhibition in patients with T2DM.
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Sodium-glucose transporter 2 inhibition and cardiovascular events in patients with diabetes: information from clinical trials and observational real-world data. Clin Sci (Lond) 2018; 132:2003-2012. [DOI: 10.1042/cs20171374] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 08/11/2018] [Accepted: 08/15/2018] [Indexed: 01/10/2023]
Abstract
Cardiovascular (CV) disease (CVD) is the main cause of morbidity and mortality in patients with type 2 diabetes mellitus (T2DM). Despite optimal glycaemic control, standard antihyperglycaemic therapy failed to impact CV events in intervention trials; therefore, the U.S. Food and Drug Administration (FDA) and the European Medicines Agency (EMA) issued a guidance to the pharmaceutical industry to specifically assess the CV outcomes and safety of new glucose-lowering drugs. Amongst them, sodium-glucose transporter 2 (SGLT2) inhibitors proved to not only provide good tolerance, few adverse effects, and good glycometabolic control, but also striking reduction in the risk of CV events. In this review, data from the main randomised controlled trials are presented, including post-hoc analyses looking into several aspects of CV protection. Moreover, the main findings from observational real-world studies to date are described, overall reassuring as regards to CV safety and efficacy of SGLT2 inhibitors. Finally, several mechanisms which might contribute to the cardioprotective effect of SGLT2 inhibition are depicted, including findings from recent mechanistic studies.
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Goncalves E, Bell DSH. Combination Treatment of SGLT2 Inhibitors and GLP-1 Receptor Agonists: Symbiotic Effects on Metabolism and Cardiorenal Risk. Diabetes Ther 2018; 9:919-926. [PMID: 29623594 PMCID: PMC5984923 DOI: 10.1007/s13300-018-0420-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION When treating type 2 diabetes, drugs that cause hypoglycemia and weight gain should, if possible, be avoided. In addition, due to the increased incidence and prevalence of cardiovascular disease, cardiac events and heart failure, as well as the accelerated renal decompensation that may occur with type 2 diabetes, hypoglycemic agents that have the potential to lower cardiac and renal risk should be utilized as early as possible in the course of the disease. METHODS This is a literature review of the efficacy of combined treatment with a glucagon-like peptide 1 (GLP-1) agonist and a sodium glucose cotransporter-2 (SGLT2) inhibitor in lowering glycated hemoglobin (HbA1c) level, cardiac risk, cardiac events and renal decompensation. RESULTS Evidence is presented which shows that the efficacy of combined SGLT2 inhibitor/GLP-1 receptor agonist therapy is additive in lowering HbA1c level, systolic blood pressure and body weight. This combined therapy also has the potential to cause further reductions in major cardiovascular events and renal decompensation than those achieved with either drug used as monotherapy or in combination with other hypoglycemic agents. CONCLUSION The combination of a GLP-1 agonist and an SGLT2-inhibitor has additive effects on lowering HbA1c and systolic blood pressure, body weight and cardiac risk and has the potential to synergistically reduce cardiovascular events and decelerate renal decompensation. A large prospective study of this combination is needed to prove that this synergism, especially as it applies to cardiac risk factors, cardiac events and mortality and preservation of renal function, is proven.
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Affiliation(s)
- Edison Goncalves
- Diabetes & Thyroid Associates, 2022 Brookwood Medical Center Dr, Birmingham, 35209, AL, USA.
| | - David S H Bell
- Southside Endocrinology, Irondale, AL, USA
- University of Alabama at Birmingham, Birmingham, AL, USA
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