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Fatima K, Suri A, Rija A, Kalim S, Javaid S, Arif Z, Abedin MFE, Raza Y, Kalim N, Azam F, Musani S. The Effect of Sodium-Glucose Co-Transporter 2 Inhibitors on Stroke and Atrial Fibrillation: A Systematic Review and Meta-Analysis. Curr Probl Cardiol 2023; 48:101582. [PMID: 36584726 DOI: 10.1016/j.cpcardiol.2022.101582] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 12/23/2022] [Indexed: 12/29/2022]
Abstract
The effect of Sodium-glucose cotransporter-2 (SGLT2) inhibitors on the occurrence of AF and stroke remains unclear due to underpowered individual studies. We aim to conduct a meta-analysis including all studies that have evaluated the effects of SGLT2 inhibitors on the occurrence of AF and stroke. We queried electronic databases (PubMed, Cochrane CENTRAL and ClinicalTrials.gov) for randomized controlled trials assessing the effect of SGLT2 inhibitors. Trials were selected if they reported 1 or both of the pre-specified outcomes of stroke and AF. Results were pooled using a random-effects model. Subgroup analysis was conducted to study patients with T2DM, HF, CVD and CKD. 56 trials comprising 111,773 patients were included. SGLT2 inhibitors significantly reduced the incidence of AF across all studies (RR:0.87; 95%CI, [0.76-0.99], P=0.03, I^2=0%) especially when used as monotherapy (RR:0.87; 95%CI, [0.77-0.99], P=0.04, I^2=0%) and among T2DM patients (RR:0.83; 95%CI, [0.72-0.97], P=0.02, I^2=0%). The risk of stroke was not reduced after treatment with SGLT2 inhibitors (RR:0.97; 95%CI, [0.89-1.07], P=0.56, I^2=0%) and this was consistent when given as monotherapy (RR:0.98; 95%CI, [0.89-1.07], P=0.62, I^2=0%) or combination therapy (RR:0.58; 95%CI, [0.17-1.95], P=0.38, I^2=0%). This result was consistent among the 3 subpopulations: T2DM, CVD and HF, however benefit was seen in patients with CKD (eGFR<90) (RR:0.85; 95%CI, [0.75-0.97], P=0.02, I^2=0%). SGLT2 inhibitors significantly reduce the incidence of atrial fibrillation, and this effect is primarily seen when given as monotherapy and in patients with T2DM. However, they have no significant effect on the incidence of stroke, except for in patients with Stage 2 CKD and beyond (eGFR<90).
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Affiliation(s)
- Kaneez Fatima
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Azeema Suri
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Aiman Rija
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan.
| | - Sara Kalim
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Sarmad Javaid
- Department of Medicine, Jinnah Sindh Medical University, Karachi, Pakistan
| | - Zainab Arif
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Mariam Farhan Essa Abedin
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Yusra Raza
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Nimra Kalim
- Department of Medicine, Baqai Medical University, Karachi, Pakistan
| | - Fatima Azam
- Department of Medicine, Dow International Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Sarah Musani
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
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Li J, Ji C, Zhang W, Lan L, Ge W. Effect of new glucose-lowering drugs on stroke in patients with type 2 diabetes: A systematic review and Meta-analysis. J Diabetes Complications 2023; 37:108362. [PMID: 36462459 DOI: 10.1016/j.jdiacomp.2022.108362] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 11/20/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022]
Abstract
AIMS People with diabetes tend to face a higher risk of stroke. Randomized controlled trials (RCTs) have demonstrated the different outcomes of new glucose-lowering drugs marketed in recent years on cardiovascular outcome events. The effects of glucagon-like peptide-1 (GLP-1) agonists, sodium-glucose cotransporter-2 (SGLT-2) inhibitors, and dipeptidyl peptidase-4 (DPP-4) inhibitors on stroke risk were evaluated in published RCTs. METHODS A search of Embase, Cochrane Library, and PubMed databases identified studies with stroke as an outcome event up to 3 December 2021. Risk ratios for stroke outcomes were analyzed using a fixed-effects model. I2 was used to assess the heterogeneity of the study. RESULTS 19 RCTs with 155,027 participants with type 2 diabetes were identified. Pooled analysis showed that compared to placebo, GLP-1 agonists reduced non-fatal stroke by 15 % (RR = 0.85, 95%CI 0.77-0.94, P = 0.002, I2 = 0 %) and total stroke (RR = 0.84, 95%CI 0.77-0.93, P = 0.000, I2 = 0 %) by 16 %. SGLT-2 inhibitors and DPP-4 inhibitors were not significantly associated with lower stroke risk. CONCLUSIONS This meta-analysis indicates that GLP-1 agonists have potential benefits for stroke. However, further studies are needed if GLP-1 agonists are to be used to reduce the risk of stroke in patients with type 2 diabetes. More research is also needed to investigate the effects of new glucose-lowering drugs on different stroke subtypes. SYSTEMATIC REVIEW REGISTRATION This protocol was registered on the International Prospective Register of Systematic Reviews (https://www.crd.york.ac.uk/PROSPERO/; registration number: CRD42022326382).
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Affiliation(s)
- Jiaxi Li
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China; Department of Pharmacy, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Cheng Ji
- Department of Pharmacy, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Wen Zhang
- Department of Radiology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Linyan Lan
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China; Department of Pharmacy, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Weihong Ge
- Department of Pharmacy, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China.
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Rathmann W, Kostev K. Association of glucose-lowering drugs with incident stroke and transient ischaemic attacks in primary care patients with type 2 diabetes: disease analyzer database. Acta Diabetol 2022; 59:1443-1451. [PMID: 35933524 PMCID: PMC9519725 DOI: 10.1007/s00592-022-01943-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 07/10/2022] [Indexed: 11/28/2022]
Abstract
AIMS Previous observational studies on glucose-lowering drugs and risk of stroke in type 2 diabetes yielded conflicting results. The aim was to examine the association of glucose-lowering drugs with incident stroke and transient ischaemic attacks (TIA) in newly diagnosed type 2 diabetes. METHODS We conducted a retrospective cohort analysis of the disease analyzer, which comprises a representative panel of 1248 general and internal medicine practices throughout Germany (01/2000-12/2019: 9.8 million patients). Incident non-fatal stroke/TIA was defined based on ICD-10 codes (I63, I64; G45) in newly diagnosed type 2 diabetes. Cox regression models were fitted to obtain hazard ratios (HR; 95%CI) for stroke/TIA adjusting for potential confounders (age, sex, health insurance, coronary heart disease, myocardial infarction, heart failure, polyneuropathy, blood pressure, eGFR) and anthropometric and metabolic intermediators (BMI, HbA1c, HDL- and LDL-cholesterol, triglycerides, lipid-lowering drugs). RESULT 312,368 persons with newly diagnosed type 2 diabetes without previous stroke/TIA (mean age: 64 years; 52% males) were included. There were 16,701 events of non-fatal stroke/TIA corresponding to an incidence rate of 9.3 (95%CI 9.1-9.4) per 1000 person-years. Using Cox regression, adjusted HR for stroke/TIA (per 1 year of treatment) of 0.59 (0.54-0.64) for SGLT2 inhibitors and of 0.79 (0.74-0.85) for GLP-1 receptor agonists were estimated. DPP-4 inhibitors (0.84; 0.82-0.86), metformin (0.90; 0.89-0.91), insulin (0.92; 0.91-0.93) and sulfonylureas (0.98; 0.96-0.99) also showed moderately reduced HR for stroke/TIA. Sex-specific regression analyses yielded similar results (HR). CONCLUSIONS Treatment with SGLT2 inhibitors or GLP-1 receptor agonists might reduce non-fatal stroke/TIA in persons with newly diagnosed type 2 diabetes.
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Affiliation(s)
- Wolfgang Rathmann
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University, Auf'm Hennekamp 65, 40225, Düsseldorf, Germany.
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Safety and Effectiveness of Sodium-Glucose Cotransporter 2 Inhibitor Combined with Medical Nutrition Therapy for Hyperglycemia in Acute Stroke: A Retrospective Study. Metabolites 2021; 12:metabo12010025. [PMID: 35050147 PMCID: PMC8779243 DOI: 10.3390/metabo12010025] [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: 12/09/2021] [Revised: 12/24/2021] [Accepted: 12/24/2021] [Indexed: 11/16/2022] Open
Abstract
Hyperglycemia, a predictor of poor clinical outcomes in acute stroke, must be lowered safely and promptly. We investigated the safety and effectiveness of sodium-glucose cotransporter 2 inhibitors (SGLT2is) combined with medical nutrition therapy in lowering blood glucose levels. This retrospective study included stroke patients admitted between 2014 and 2019, who (1) had glycated hemoglobin ≥6.5%, blood glucose level ≥ 11.1 mmol/L at admission, (2) took their diet and drugs orally during hospitalization, (3) underwent SGLT2is pharmacotherapy after admission, and (4) underwent a fasting blood glucose (FBG) test on day 7. Patients were provided with a moderate-carbohydrate diet combined with total energy restriction. We assessed the achievement of FBG < 7 mmol/L on day 7 and the need for sulfonylurea or a long-acting insulin analog (LIA) treatment during hospitalization, which carries a risk of hypoglycemia. Fifty-one patients met our inclusion criteria. Of them, 33 (64.7%) achieved the target FBG on day 7. Only eight patients were treated with a small dose of LIA; however, no patients required sulfonylurea. No dehydration occurred. SGLT2is combined with a moderate carbohydrate- and energy-restricted diet achieved the target FBG level safely, effectively, and promptly in mild stroke patients with oral ingestion.
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Tsai WH, Chuang SM, Liu SC, Lee CC, Chien MN, Leung CH, Liu SJ, Shih HM. Effects of SGLT2 inhibitors on stroke and its subtypes in patients with type 2 diabetes: a systematic review and meta-analysis. Sci Rep 2021; 11:15364. [PMID: 34321571 PMCID: PMC8319393 DOI: 10.1038/s41598-021-94945-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 07/19/2021] [Indexed: 02/07/2023] Open
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors have shown impressive effects in reducing major vascular events in several randomized controlled trials (RCTs). The purpose of this study was to perform a meta-analysis to evaluate the effect of SGLT2 inhibitors on the risk of stroke and its subtypes. All data from prospective RCTs up to 20 October 2020 involving SGLT2 inhibitors that reported stroke events as the primary endpoint or safety in subjects with type 2 diabetes were subjected to meta-analysis. Five eligible RCTs (EMPA-REG, CANVAS, DECLARE-TIMI 58, CREDENCE and VERTIS CV) involving 46,969 participants were included. Pooled analysis of the RCTs showed no significant effect of SGLT2 inhibitors on total stroke [risk ratio (RR) = 0.95; 95% confidence interval (CI) 0.79-1.13, P = 0.585]. Subgroup analysis indicated that SGLT2 inhibitors had no significant effect against fatal stroke, non-fatal stroke, ischemic stroke or transient ischemic attack. When only hemorrhagic stroke was included, SGLT2 inhibitors were associated with a significant 50% reduction compared with placebo (RR = 0.49, 95% CI 0.30-0.82, P = 0.007). This meta-analysis shows that SGLT2 inhibitors have a neutral effect on the risk of stroke and its subtypes but a potential protective effect against hemorrhagic stroke.
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Affiliation(s)
- Wen-Hsuan Tsai
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Taipei, 10449, Taiwan
| | - Shih-Ming Chuang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Taipei, 10449, Taiwan. .,Mackay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan. .,Department of Medicine, Mackay Medical Collage, New Taipei City, Taiwan.
| | - Sung-Chen Liu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Taipei, 10449, Taiwan.,Department of Medicine, Mackay Medical Collage, New Taipei City, Taiwan
| | - Chun-Chuan Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Taipei, 10449, Taiwan
| | - Ming-Nan Chien
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Taipei, 10449, Taiwan.,Department of Medicine, Mackay Medical Collage, New Taipei City, Taiwan
| | - Ching-Hsiang Leung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Taipei, 10449, Taiwan
| | - Shu-Jung Liu
- Medical Library, MacKay Memorial Hospital, Tamsui Branch, New Taipei City, Taiwan
| | - Hong-Mou Shih
- Division of Nephrology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan.,Graduate Institute of Physiology, College of Medicine, National Taiwan University, Taipei, Taiwan
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Sato K, Mano T, Iwata A, Toda T. Subtype-Dependent Reporting of Stroke With SGLT2 Inhibitors: Implications From a Japanese Pharmacovigilance Study. J Clin Pharmacol 2019; 60:629-635. [PMID: 31792991 DOI: 10.1002/jcph.1561] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 11/04/2019] [Indexed: 12/13/2022]
Abstract
Volume depletion as an adverse events (AE) caused by sodium-glucose cotransporter-2 inhibitors (SGLT2i) because of their diuretic effect may raise the concern about the risk of lacunar stroke; however, an earlier meta-analysis reported no significant increase in the incidence of stroke without clearly distinguishing stroke subtypes. Here, aiming to investigate subtype-wise reporting of stroke potentially related to SGLT2i treatment, we conducted a disproportionality analysis using the Japanese Adverse Drug Event Report database, which contains approximately 500 000 cases recorded between April 2004 and March 2019 to detect stroke as AE signals associated with SGLT2i treatment by calculating the reporting odds ratio (ROR). As a result, we identified 532 stroke event reports with the use of SGLT2i. The SGLT2i showed varying degrees of significantly higher reporting (lower 95% ROR > 1) for all ischemic stroke (ROR, 12.7), thrombosis (ROR, 21.7), lacunar infarction (ROR, 48.9), and embolism (ROR, 2.51), but no significantly higher reporting for hemorrhagic stroke. Current pharmacovigilance results showed that the RORs for stroke following SGLT2i use differ greatly depending on the stroke subtypes. It suggests the need for an observational cohort study to be conducted to investigate the incidence of each stroke subtype as the effect of SGLT2i.
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Affiliation(s)
- Kenichiro Sato
- Department of Neurology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Tatsuo Mano
- Department of Neurology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Atsushi Iwata
- Department of Neurology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Tatsushi Toda
- Department of Neurology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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