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Gami A, Blumenthal RS, McGuire DK, Sarkar S, Kohli P. New Perspectives in Management of Cardiovascular Risk Among People With Diabetes. J Am Heart Assoc 2024; 13:e034053. [PMID: 38879449 DOI: 10.1161/jaha.123.034053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/19/2024]
Abstract
Following the publication of results from multiple landmark cardiovascular outcome trials of antihyperglycemic medications over the past 8 years, there has been a major shift in the focus of care for people with type 2 diabetes, from control of hyperglycemia to managing cardiovascular risk. Multiple international cardiology and diabetes society guidelines and recommendations now endorse sodium-glucose cotransporter-2 inhibitors and glucagon-like protein-1 receptor agonists as first-line therapies to mitigate cardiovascular risk. The most recent publication is the 2023 European Society of Cardiology guideline on the management of cardiovascular disease in those with type 2 diabetes that, for the first time, recommends use of both classes of medications for the mitigation of cardiovascular risk for those with or at high risk for atherosclerotic cardiovascular disease, heart failure, and chronic kidney disease. Here, we review the evidence behind contemporary society guidelines and recommendations for the management of type 2 diabetes and cardiovascular risk.
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Affiliation(s)
- Abhishek Gami
- Department of Internal Medicine Johns Hopkins University School of Medicine Baltimore MD
| | - Roger S Blumenthal
- Division of Cardiology Johns Hopkins University School of Medicine Baltimore MD
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine University of Texas Southwestern Medical Center and Parkland Health Dallas TX
| | - Sudipa Sarkar
- Division of Endocrinology, Diabetes, and Metabolism Johns Hopkins University School of Medicine Baltimore MD
| | - Payal Kohli
- Department of Cardiology University of Colorado Anschutz Aurora CO
- Department of Cardiology Veterans Affairs Hospital Aurora CO
- Cherry Creek Heart Aurora CO
- Tegna Broadcasting Aurora CO
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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:2497-2604. [PMID: 38752899 DOI: 10.1016/j.jacc.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/23/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1313-e1410. [PMID: 38743805 DOI: 10.1161/cir.0000000000001251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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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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Lin YH, Lin CH, Lin YC, Huang YY, Tai AS, Fu SC, Lin SH. Sodium-Glucose Cotransporter 2 Inhibitors Reduce the Risk of Hospitalization for Heart Failure and Amputation Rate Compared With Incretin-Based Therapy in Patients With Diabetic Foot Disease: A Nationwide Population-Based Study. Endocr Pract 2024; 30:424-430. [PMID: 38325629 DOI: 10.1016/j.eprac.2024.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/09/2024] [Accepted: 01/29/2024] [Indexed: 02/09/2024]
Abstract
OBJECTIVE Major adverse cardiovascular event (MACE) outcomes associated with sodium-glucose cotransporter 2 inhibitor (SGLT2i) and glucagon-like peptide-1 receptor agonist (GLP-1 RA) therapies remain unclear in patients with type 2 diabetes and newly diagnosed diabetic foot complications (DFCs). This study examined the impact of SGLT2i and GLP-1 RA use on the rates of MACEs and amputations in patients with type 2 diabetes and without cardiovascular disease. METHODS Data from the Taiwan National Health Insurance Research Database (2004-2017) were analyzed, focusing on patients with type 2 diabetes without previous MACE and newly diagnosed DFCs. The primary outcome was the first MACE occurrence, and the secondary outcomes included MACE components, all-cause mortality, and lower extremity amputation (LEA) rates. RESULTS SGLT2i users showed a significant decrease in the MACE (hazard ratio [HR], 0.64; 95% confidence interval [CI], 0.46-0.88) and hospitalization for heart failure (HR, 0.54; 95% CI, 0.35-0.83) rates compared with dipeptidyl peptidase-4 inhibitor users. The amputation rates were also lower in SGLT2i users without LEA at the first DFC diagnosis (HR, 0.28; 95% CI, 0.10-0.75) and did not increase in those with a history of peripheral artery disease or LEA. No significant differences were observed between dipeptidyl peptidase-4 inhibitor and GLP-1 RA users in terms of the primary or secondary outcomes. CONCLUSION In patients with type 2 diabetes initially diagnosed with DFC, SGLT2i are effective in significantly reducing the hospitalization for heart failure and MACE rates. SGLT2i lower the amputation rates, especially in patients who have not previously had a LEA, than the dipeptidyl peptidase-4 inhibitor therapy.
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Affiliation(s)
- Yi-Hsuan Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chia-Hung Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan; Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan, Taiwan; Department of Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Chih Lin
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Yu-Yao Huang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan; Department of Medical Nutrition Therapy, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - An-Shun Tai
- Institute of Statistics, National Chiao Tung University, Hsinchu, Taiwan
| | - Shih-Chen Fu
- Institute of Statistics, National Chiao Tung University, Hsinchu, Taiwan
| | - Sheng-Hsuan Lin
- Institute of Statistics, National Chiao Tung University, Hsinchu, Taiwan.
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Stachteas P, Patoulias D, Popovic DS, Athanasiadou P, Fragakis N. Bexagliflozin as an Adjunct Therapy to Diet and Exercise to Improve Glycaemic Control in Adults with Type 2 Diabetes. TOUCHREVIEWS IN ENDOCRINOLOGY 2024; 20:19-24. [PMID: 38812664 PMCID: PMC11132653 DOI: 10.17925/ee.2024.20.1.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/24/2023] [Indexed: 05/31/2024]
Abstract
Type 2 diabetes (T2D) is one of the leading causes of morbidity and mortality worldwide. Currently, over 10.5% of the adult population has been diagnosed with T2D, and almost 12% of total health expenditure is spent exclusively on T2D management globally. Sodium-glucose cotransporter-2 inhibitors are a relatively new class of oral antidiabetic agents that act by inhibiting renal sodium and glucose reabsorption. Except for their glucose-l owering effects, they have been associated with a more significant weight loss and blood pressure reduction and a lower risk of hypoglycaemia than other commonly prescribed antidiabetic drugs. On 20 January 2023, bexagliflozin became the fifth orally administered sodium-glucose transporter 2 inhibitor to be approved by the US Food and Drug Administration for the treatment of T2D as an adjunct therapy to diet and exercise in the USA after dapagliflozin, canagliflozin, empagliflozin and ertugliflozin. This review aims to discuss the current evidence on the efficacy and safety of bexagliflozin, which provides an important alternative treatment option for patients with T2D.
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Affiliation(s)
- Panagiotis Stachteas
- Second Department of Cardiology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Patoulias
- Outpatient Department of Cardiometabolic Medicine, Second Department of Cardiology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Djordje S Popovic
- Clinic for Endocrinology, Diabetes and Metabolic Disorders, Clinical Centre of Vojvodina, Medical Faculty, University of Novi Sad, Novi Sad, Serbia
| | - Polyxeni Athanasiadou
- Postgraduate Studies Program in Public Health, Laboratory of Primary Health Care, General Practice and Health Services Research, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nikolaos Fragakis
- Second Department of Cardiology, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Outpatient Department of Cardiometabolic Medicine, Second Department of Cardiology, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Omari MB, Naseri S, Hassan AJ. Drug Safety Evaluation of Sodium-Glucose Cotransporter 2 Inhibitors in Diabetic Comorbid Patients by Review of Systemic Extraglycemic Effects. Diabetes Metab Syndr Obes 2024; 17:1131-1141. [PMID: 38465348 PMCID: PMC10924842 DOI: 10.2147/dmso.s448670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 02/28/2024] [Indexed: 03/12/2024] Open
Abstract
Purpose The aim of this study is to evaluate the safety of this drug in diabetic patients with comorbidities of all systems. Method In this review, the beneficial effects of this drug and its mechanism on the disorders of every system of humans in relation to diabetes have been studied, and finally, its adverse effects have also been discussed. The search for relevant information is carried out in the PubMed and Google Scholar databases by using the following terms: diabetes mellitus type 2, SGLT, SGLT2 inhibitors, (SGLT2 inhibitors) AND (Pleiotropic effects). All English-published articles from 2016 to 2023 have been used in this study. It should be noted that a small number of articles published before 2016 have been used in the introduction and general informations. Results Its beneficial effects on improving cardiovascular disease risk factors and reducing adverse events caused by cardiovascular and renal diseases have proven in most large clinical studies that these effects are almost certain. It also has beneficial effects on other human systems such as the respiratory system, the gastrointestinal system, the circulatory system, and the nervous system; more of them are at the level of clinical and pre-clinical trials but have not been proven in large clinical trials or meta-analyses. Conclusion With the exception of a few adverse effects, this drug is considered a good choice and safe for all diabetic patients with comorbidities of all systems.
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Affiliation(s)
- Mohammad Belal Omari
- Department of Endocrinology, Hematology and Rheumatology, Ali Abad Teaching Hospital, Kabul University of Medical Sciences "Abu Ali Ibn Sina", Kabul, Afghanistan
| | - Shafiqullah Naseri
- Cardio-Pulmonary Department, Ali Abad Teaching Hospital, Kabul University of Medical Sciences "Abu Ali Ibn Sina", Kabul, Afghanistan
| | - Abdul Jalil Hassan
- Department of Infectious Disease and Tuberculosis, Ali Abad Teaching Hospital, Kabul University of Medical Sciences "Abu Ali Ibn Sina", Kabul, Afghanistan
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Eckert AJ, Zimny S, Altmeier M, Dugic A, Gillessen A, Bozkurt L, Götz G, Karges W, Wosch FJ, Kress S, Holl RW. Factors associated with diabetic foot ulcers and lower limb amputations in type 1 and type 2 diabetes supported by real-world data from the German/Austrian DPV registry. J Diabetes 2024; 16:e13531. [PMID: 38403299 PMCID: PMC10894714 DOI: 10.1111/1753-0407.13531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/09/2023] [Accepted: 12/27/2023] [Indexed: 02/27/2024] Open
Abstract
AIMS Diabetic foot ulcer (DFU) is a leading cause of lower limb amputations in people with diabetes. This study was aimed to retrospectively analyze factors affecting DFU using real-world data from a large, prospective central-European diabetes registry (DPV [Diabetes-Patienten-Verlaufsdokumentation]). MATERIALS AND METHODS We matched adults with type 1 (T1D) or type 2 diabetes (T2D) and DFU to controls without DFU by diabetes type, age, sex, diabetes duration, and treatment year to compare possible risk factors. Cox regression was used to calculate hazard ratios for amputation among those with DFU. RESULTS In our cohort (N = 63 464), male sex, taller height, and diabetes complications such as neuropathy, peripheral artery disease, nephropathy, and retinopathy were associated with DFU (all p < .001). Glycated hemoglobin (HbA1c) was related to DFU only in T1D (mean with 95% confidence interval [CI]: 7.8 [6.9-9.0] % vs 7.5 [6.8-8.5] %, p < .001). High triglycerides and worse low-density lipoprotein/high-density lipoprotein ratio were also associated with DFU in T1D, whereas smoking (14.7% vs 13.1%) and alcohol abuse (6.4% vs 3.8%, both p < .001) were associated with DFU in T2D. Male sex, higher Wagner grades, and high HbA1c in both diabetes types and insulin use in T2D were associated with increased hazard ratios for amputations. CONCLUSIONS Sex, body height, and diabetes complications were associated DFU risk in adults with T1D and T2D. Improvement in glycemic control and lipid levels in T1D and reduction of smoking and drinking in T2D may be appropriate interventions to reduce the risk for DFU or amputations.
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Affiliation(s)
- Alexander J Eckert
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany
- German Center for Diabetes Research (DZD), Munich, Germany
| | - Stefan Zimny
- Department of General Internal Medicine, Endocrinology and Diabetology, Helios Clinic Schwerin, Schwerin, Germany
| | - Marcus Altmeier
- Klinik für Diabetologie, Klinikum Dortmund, Dortmund, Deutschland
| | - Ana Dugic
- Medical Clinic I, Klinikum Bayreuth Friedrich-Alexander-University Erlangen-Nürnberg, Bayreuth, Germany
| | - Anton Gillessen
- Department of Internal Medicine, Herz-Jesu-Hospital, Muenster, Germany
| | - Latife Bozkurt
- Department of Internal Medicine III and Karl Landsteiner Institute for Metabolic Disorders and Nephrology, Clinic Hietzing, Vienna Health Care Group, Vienna, Austria
| | - Gabriele Götz
- Department of Internal Medicine, Diabetes, Gastroenterology, Tumor Medicine, and Palliative Care, Academic Teaching Hospital Nürtingen, Tübingen, Germany
| | - Wolfram Karges
- Clinic for Gastroenterology, Metabolic Disorders and Internal Intensive Medicine (Medical Clinic III), Department of Endocrinology and Diabetology, University Hospital Aachen, Aachen, Germany
| | | | - Stephan Kress
- Diabetes, Sport and Physical Activity Working Group of the DDG, Unna, Germany
- Department of Internal Medicine I, Vinzentius Hospital Landau, Landau, Germany
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany
- German Center for Diabetes Research (DZD), Munich, Germany
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Zhang Q, Deng Z, Li T, Chen K, Zeng Z. SGLT2 inhibitor improves the prognosis of patients with coronary heart disease and prevents in-stent restenosis. Front Cardiovasc Med 2024; 10:1280547. [PMID: 38274313 PMCID: PMC10808651 DOI: 10.3389/fcvm.2023.1280547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 12/27/2023] [Indexed: 01/27/2024] Open
Abstract
Coronary heart disease is a narrowing or obstruction of the vascular cavity caused by atherosclerosis of the coronary arteries, which leads to myocardial ischemia and hypoxia. At present, percutaneous coronary intervention (PCI) is an effective treatment for coronary atherosclerotic heart disease. Restenosis is the main limiting factor of the long-term success of PCI, and it is also a difficult problem in the field of intervention. Sodium-glucose cotransporter 2 (SGLT2) inhibitor is a new oral glucose-lowering agent used in the treatment of diabetes in recent years. Recent studies have shown that SGLT2 inhibitors can effectively improve the prognosis of patients after PCI and reduce the occurrence of restenosis. This review provides an overview of the clinical studies and mechanisms of SGLT2 inhibitors in the prevention of restenosis, providing a new option for improving the clinical prognosis of patients after PCI.
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Affiliation(s)
| | | | | | | | - Zhihuan Zeng
- Department of Cardiovascular Diseases, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, Guangdong Province, China
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Avula V, Sharma G, Kosiborod MN, Vaduganathan M, Neilan TG, Lopez T, Dent S, Baldassarre L, Scherrer-Crosbie M, Barac A, Liu J, Deswal A, Khadke S, Yang EH, Ky B, Lenihan D, Nohria A, Dani SS, Ganatra S. SGLT2 Inhibitor Use and Risk of Clinical Events in Patients With Cancer Therapy-Related Cardiac Dysfunction. JACC. HEART FAILURE 2024; 12:67-78. [PMID: 37897456 DOI: 10.1016/j.jchf.2023.08.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 07/10/2023] [Accepted: 08/28/2023] [Indexed: 10/30/2023]
Abstract
BACKGROUND Certain antineoplastic therapies are associated with an increased risk of cardiomyopathy and heart failure (HF). Sodium glucose co-transporter 2 (SGLT2) inhibitors improve outcomes in patients with HF. OBJECTIVES This study aims to examine the efficacy of SGLT2 inhibitors in patients with cancer therapy-related cardiac dysfunction (CTRCD) or HF. METHODS The authors conducted a retrospective cohort analysis of deidentified, aggregate patient data from the TriNetX research network. Patients aged ≥18 years with a history of type 2 diabetes mellitus, cancer, and exposure to potentially cardiotoxic antineoplastic therapies, with a subsequent diagnosis of cardiomyopathy or HF between January 1, 2013, and April 30, 2020, were identified. Patients with ischemic heart disease were excluded. Patients receiving guideline-directed medical therapy were divided into 2 groups based on SGLT2 inhibitor use. After propensity score matching, odds ratios (ORs) and Cox proportional HRs were used to compare outcomes over a 2-year follow-up period. RESULTS The study cohort included 1,280 patients with CTRCD/HF (n = 640 per group; mean age: 67.6 years; 41.6% female; 68% White). Patients on SGLT2 inhibitors in addition to conventional guideline-directed medical therapy had a lower risk of acute HF exacerbation (OR: 0.483 [95% CI: 0.36-0.65]; P < 0.001) and all-cause mortality (OR: 0.296 [95% CI: 0.22-0.40]; P = 0.001). All-cause hospitalizations or emergency department visits (OR: 0.479; 95% CI: 0.383-0.599; P < 0.001), atrial fibrillation/flutter (OR: 0.397 [95% CI: 0.213-0.737]; P = 0.003), acute kidney injury (OR: 0.486 [95% CI: 0.382-0.619]; P < 0.001), and need for renal replacement therapy (OR: 0.398 [95% CI: 0.189-0.839]; P = 0.012) were also less frequent in patients on SGLT2 inhibitors. CONCLUSIONS SGLT2 inhibitor use is associated with improved outcomes in patients with CTRCD/HF.
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Affiliation(s)
- Vennela Avula
- Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Garima Sharma
- Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; University of Missouri, Kansas City, Missouri, USA
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Tomas G Neilan
- Cardio-Oncology Program, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Teresa Lopez
- Department of Cardiology, La Paz University Hospital, Madrid, Spain
| | - Susan Dent
- Duke Cancer Institute, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Lauren Baldassarre
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Marielle Scherrer-Crosbie
- Division of Cardiology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ana Barac
- Cardio-Oncology Program, Division of Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Jennifer Liu
- Cardio-Oncology Program, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sumanth Khadke
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, Massachusetts, USA
| | - Eric H Yang
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | - Bonnie Ky
- Division of Cardiology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel Lenihan
- International Cardio-Oncology Society, Tampa, Florida, USA; St. Francis Healthcare, Cape Girardeau, Missouri, USA
| | - Anju Nohria
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sourbha S Dani
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, Massachusetts, USA
| | - Sarju Ganatra
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, Massachusetts, USA.
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Palanca A, Ampudia-Blasco FJ, Calderón JM, Sauri I, Martinez-Hervás S, Trillo JL, Redón J, Real JT. Comparison of GLP-1 receptor agonists and other Glucose-Lowering agents on cardiovascular outcomes in individuals with type 2 diabetes and Obesity: A Spanish Real-World Population-Based study. Diabetes Res Clin Pract 2024; 207:111071. [PMID: 38142748 DOI: 10.1016/j.diabres.2023.111071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/10/2023] [Accepted: 12/18/2023] [Indexed: 12/26/2023]
Abstract
AIMS Assess the impact of glucagon-like peptide receptor agonists (GLP-1RA) compared to other glucose-lowering agents on cardiovascular outcomes in individuals with type 2 diabetes and obesity in a Spanish metropolitan area. METHODS A retrospective population-based type 2 diabetes cohort was identified from the Valencia Clinic-Malvarrosa Department electronic databases (2014-2019). Study groups included GLP-1RA, sodium-glucose co-transporter-2 inhibitors (SGLT2i), Insulin, and Miscellany (other glucose-lowering agents). 1:1:1:1 propensity score matching was conducted. The primary outcome was a composite of major adverse cardiovascular events (4-point MACE) comprising myocardial infarction, stroke, all-cause mortality, and heart failure. Secondary outcomes included individual 4-point MACE components. Hazard ratios were estimated using Cox regression analyses against the Miscellany group. RESULTS From 26,944 subjects, 1,848 adults were selected per group. GLP-1RA did not show a significant reduction in 4-point MACE risk (HR 1.05 [95%CI 0.82-1.34]). SGLT2i significantly reduced the risk of heart failure (HR 0.16 [95%CI 0.05-0.54]) and atrial fibrillation (HR 0.58, [95%CI 0.35-0.95]). The Insulin group exhibited a higher risk for 4-point MACE and most individual outcomes compared to GLP-1RA and SGLT2i. CONCLUSIONS Our findings do not provide evidence of a reduced cardiovascular risk, as assessed by 4-point MACE, with GLP-1RA. In contrast, SGLT2i demonstrated protective effects against heart failure and atrial fibrillation.
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Affiliation(s)
- Ana Palanca
- INCLIVA Biomedical Research Institute, Valencia, Spain; CIBERDEM, CIBER of Diabetes and Associated Metabolic Diseases, Madrid, Spain.
| | - F Javier Ampudia-Blasco
- INCLIVA Biomedical Research Institute, Valencia, Spain; CIBERDEM, CIBER of Diabetes and Associated Metabolic Diseases, Madrid, Spain; Department of Endocrinology & Nutrition, Clinic University Hospital of Valencia, Spain; Department of Medicine, Medicine Faculty, University of Valencia (UV), Spain.
| | | | | | - Sergio Martinez-Hervás
- INCLIVA Biomedical Research Institute, Valencia, Spain; CIBERDEM, CIBER of Diabetes and Associated Metabolic Diseases, Madrid, Spain; Department of Endocrinology & Nutrition, Clinic University Hospital of Valencia, Spain; Department of Medicine, Medicine Faculty, University of Valencia (UV), Spain
| | - José Luis Trillo
- Department of Health of Valencia Clínico-Malvarrosa, Valencia, Spain
| | - Josep Redón
- INCLIVA Biomedical Research Institute, Valencia, Spain
| | - José T Real
- INCLIVA Biomedical Research Institute, Valencia, Spain; CIBERDEM, CIBER of Diabetes and Associated Metabolic Diseases, Madrid, Spain; Department of Endocrinology & Nutrition, Clinic University Hospital of Valencia, Spain; Department of Medicine, Medicine Faculty, University of Valencia (UV), Spain
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12
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Alkabbani W, Shah BR, Zongo A, Eurich DT, Alsabbagh MW, Gamble JM. Post-initiation predictors of discontinuation of the sodium-glucose cotransporter-2 inhibitors: A comparative cohort study from the United Kingdom. Diabetes Obes Metab 2023; 25:3490-3500. [PMID: 37563767 DOI: 10.1111/dom.15241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 07/22/2023] [Accepted: 07/25/2023] [Indexed: 08/12/2023]
Abstract
AIMS To assess post-initiation predictors of discontinuation of sodium-glucose cotransporter-2 (SGLT2) inhibitors compared to dipeptidyl-peptidase-4 (DPP-4) inhibitors in the United Kingdom. MATERIALS AND METHODS We conducted a comparative population-based retrospective cohort study using primary care data from the UK Clinical Practice Research Datalink (CPRD) with linked data to hospital and death records. We included new metformin users who initiated either SGLT2 inhibitors or DPP-4 inhibitors between January 2013 and October 2019. The main outcome was treatment discontinuation, defined as the first 90-day gap after the estimated treatment end date. We used a series of extended Cox models to assess which time-dependent predictors were associated with treatment discontinuation. To test if the hazard ratio of discontinuation for each predictor was statistically different between SGLT2 and DPP-4 inhibitors, an exposure-predictor interaction term was added to each model. RESULTS There were 2550 new users of SGLT2 inhibitors and 8195 new users of DPP-4 inhibitors. Approximately 69% of SGLT2 inhibitor and 74% of DPP-4 inhibitor users had discontinued treatment by the end of follow-up. Occurrence of fractures after treatment initiation was a significant predictor of discontinuation of SGLT2 inhibitors (hazard ratio [HR] 4.13, 95% confidence interval [CI] 2.12-8.06) but not DPP-4 inhibitors (HR 0.93, 95% CI 0.79-1.11). The rate of treatment discontinuation was significantly higher for those with low estimated glomerular filtration rate and minimal contact with the healthcare system. Efficacy endpoints, such as heart failure and glycated haemoglobin level, were not associated with treatment discontinuation. CONCLUSIONS Our findings reflect some discrepancy between the available evidence and prescribing behaviour for SGLT2 inhibitors.
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Affiliation(s)
- Wajd Alkabbani
- School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
| | - Baiju R Shah
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Endocrinology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Arsène Zongo
- Faculty of Pharmacy and CHU de Quebec Research Center-Université Laval, Quebec City, Quebec, Canada
| | - Dean T Eurich
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
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13
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Tawhari MH, Aldahash RA, Almutairi FM, Albogami MS, Rokon AE, Alsomali FA, Alanazi KH, Alshehri AA, Almutairi TH, Alharbi AD, Alghamdi RM, Tawhari IH, Salih SAB. Impact of sodium-glucose cotransporter-2 inhibitors on kidney outcomes in type 2 diabetes: A tertiary center experience. J Family Community Med 2023; 30:267-272. [PMID: 38044971 PMCID: PMC10688587 DOI: 10.4103/jfcm.jfcm_111_23] [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: 04/29/2023] [Revised: 07/12/2023] [Accepted: 08/05/2023] [Indexed: 12/05/2023] Open
Abstract
BACKGROUND Diabetic nephropathy (DN) is a complication of chronic hyperglycemia associated with diabetes mellitus (DM). Several studies have demonstrated the positive impact of sodium-glucose cotransporter-2 (SGLT2) inhibitors on kidney outcomes. The objective of the study was to evaluate the effects of dapagliflozin, an SGLT2 inhibitor, on kidney outcomes in Saudi patients with type 2 DM. MATERIALS AND METHODS Study included all Saudi patients with type 2 DM who visited our center from August 1, 2021, to July 31, 2022, and had been on dapagliflozin for at least 3 months. Data was abstracted through chart review for all patients included in the study. Paired t-test or Wilcoxon signed-rank test were used to compare the results before and after treatment for continuous variables and the McNemar test was used to compare the results for categorical data. RESULTS Study included 184 Saudi patients with type 2 diabetes with a mean age of 61.32 years (SD=9.37). Dapagliflozin 10 mg/day significantly reduced hemoglobin A1C (HbA1C) from a mean (SD) of 9.00 to 8.40 (P < 0.001). Among a subgroup of patients with significant proteinuria (n = 83), dapagliflozin significantly reduced ACR from a median of 93.1 to 64.9 mg/g (P = 0.001). Following treatment, the estimated glomerular filtration rate improved from a mean of 69.83 to 71.68 mL/min and the mean arterial pressure (MAP) fell from 90.03 to 89.06 mmHg, both were not statistically significant. Despite a statistically insignificant increase in the episodes of urinary tract infections (UTIs), the hospitalization rate declined. No episodes of amputations or ketoacidosis occurred during the study period. CONCLUSION SGLT2 inhibitors had beneficial effects among Saudi patients with type 2 diabetes by improving diabetic control and lowering proteinuria. Dapagliflozin did not result in significant harm, including UTIs, amputations, and ketoacidosis.
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Affiliation(s)
- Mohammed H. Tawhari
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Centre, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
- Department of Medicine, Division of Nephrology, King Abdulaziz Medical City, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Raed A. Aldahash
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Centre, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
- Department of Medicine, Division of Endocrinology, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Faisal M. Almutairi
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Mahdi S. Albogami
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Ahmad E. Rokon
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Faisal A. Alsomali
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Khaled H. Alanazi
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Abdulrahman A. Alshehri
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Talal H. Almutairi
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Abdulrahman D. Alharbi
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Rayan M. Alghamdi
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Ibrahim H. Tawhari
- Department of Internal Medicine, College of Medicine, King Khalid University, Abha, Saudi Arabia
| | - Salih A. Bin Salih
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Centre, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
- Department of Medicine, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
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Ramakrishnan P, Garg N, Pabich S, Mandelbrot DA, Swanson KJ. Sodium-glucose cotransporter-2 inhibitor use in kidney transplant recipients. World J Transplant 2023; 13:239-249. [PMID: 37746038 PMCID: PMC10514750 DOI: 10.5500/wjt.v13.i5.239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 04/19/2023] [Accepted: 06/14/2023] [Indexed: 09/15/2023] Open
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are novel oral hypoglycemic agents garnering much attention for their substantial benefits. These recent data have positioned SGLT2i at the forefront of diabetic chronic kidney disease (CKD) and heart failure management. SGLT2i use post-kidney transplant is an emerging area of research. Highlights from this mini review include the following: Empagliflozin is the most prescribed SGLT2i in kidney transplant recipients (KTRs), median time from transplant to initiation was 3 years (range: 0.88-9.6 years). Median baseline estimated glomerular filtration rate (eGFR) was 66.7 mL/min/1.73 m2 (range: 50.4-75.8). Median glycohemoglobin (HgbA1c) at initiation was 7.7% (range: 6.9-9.3). SGLT2i were demonstrated to be effective short-term impacting HgbA1c, eGFR, hemoglobin/hematocrit, serum uric acid, and serum magnesium levels. They are shown to be safe in KTRs with low rates of infections, hypoglycemia, euglycemic diabetic ketoacidosis, and stable tacrolimus levels. More data is needed to demonstrate long-term outcomes. SGLT2i appear to be safe, effective medications for select KTRs. Our present literature, though limited, is founded on precedent robust research in CKD patients with diabetes. Concurrent research/utilization of SGLT2i is vital to not only identify long-term patient, graft and cardiovascular outcomes of these agents, but also to augment management in KTRs.
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Affiliation(s)
- Pavithra Ramakrishnan
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, United States
| | - Neetika Garg
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, United States
| | - Samantha Pabich
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, United States
| | - Didier A Mandelbrot
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, United States
| | - Kurtis J Swanson
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, United States
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15
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Hayes KN, Berry SD, Munshi MN, Zullo AR. Adoption of sodium-glucose cotransporter-2 inhibitors among prescribers caring for nursing home residents. J Am Geriatr Soc 2023; 71:2585-2592. [PMID: 37078149 PMCID: PMC10528819 DOI: 10.1111/jgs.18360] [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: 12/01/2022] [Revised: 02/17/2023] [Accepted: 03/09/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Sodium-glucose cotransporter-2 inhibitor (SGLT2I) use has increased among community-dwelling populations, but little is known about how clinicians have prescribed them for US nursing home (NH) residents. We described the adoption of SGLT2Is by prescribers caring for long-stay NH residents by clinician specialty and over time, compared with sulfonylureas, an older diabetes medication class. METHODS We conducted a retrospective cohort study of prescribers of SGLT2Is and sulfonylureas for all long-stay US NH residents aged 65 years or older (2017-2019). Using 100% of Medicare Part D claims linked to prescriber characteristics data, we identified all dispensings of SGLT2Is and sulfonylureas for long-stay NH residents and their associated prescribers. We described the distribution of prescriber specialties for each drug class over time as well as the number of NH residents prescribed SGLT2s versus sulfonylureas. We estimated the proportions of prescribers who prescribed both drug classes versus only sulfonylureas or only SGLT2Is. RESULTS We identified 36,427 unique prescribers (SGLT2I: N = 5811; sulfonylureas: N = 35,443) for 117,667 NH residents between 2017 and 2019. For both classes, family medicine and internal medicine physicians accounted for most prescriptions (75%-81%). Most clinicians (87%) prescribed only sulfonylureas, 2% prescribed SGLT2Is only, and 11% prescribed both. Geriatricians were least likely to prescribe only SGLT2Is. We observed an increase in the number of residents with SGLT2I use from n = 2344 in 2017 to n = 5748 in 2019. CONCLUSIONS Among NH residents, most clinicians have not incorporated SGLT2Is into their prescribing for diabetes, but the extent of use is increasing. Family medicine and internal medicine physicians prescribed the majority of diabetes medications for NH residents, and geriatricians were the least likely to prescribe only SGLT2Is. Future research should explore provider concerns regarding SGLT2I prescribing, particularly adverse events.
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Affiliation(s)
- Kaleen N. Hayes
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Graduate Department of Pharmaceutical Sciences, University of Toronto Leslie Dan Faculty of Pharmacy, Toronto, Ontario, Canada
| | - Sarah D. Berry
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Medha N. Munshi
- Harvard Medical School, Boston, Massachusetts, USA
- Joslin Diabetes Center, 1 Joslin Place, Boston, Massachusetts, USA
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Andrew R. Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
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16
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McNeil S, Waller K, Poy Lorenzo YS, Mateevici OC, Telianidis S, Qi S, Churilov I, MacIsaac RJ, Galligan A. Detection, management, and prevention of diabetes-related foot disease in the Australian context. World J Diabetes 2023; 14:942-957. [PMID: 37547594 PMCID: PMC10401446 DOI: 10.4239/wjd.v14.i7.942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/06/2023] [Accepted: 05/23/2023] [Indexed: 07/12/2023] Open
Abstract
Diabetes-related foot disease (DFD) is a widely feared complication among people who live with diabetes. In Australia and globally, rates of disability, cardio-vascular disease, lower extremity amputation, and mortality are significantly increased in patients with DFD. In order to understand and prevent these outcomes, we analyse the common pathogenetic processes of neuropathy, arterial disease, and infection. The review then summarises important management considerations through the interdisciplinary lens. Using Australian and international guidelines, we offer a stepwise, evidence-based practical approach to the care of patients with DFD.
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Affiliation(s)
- Scott McNeil
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
| | - Kate Waller
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Podiatry, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
| | - Yves S Poy Lorenzo
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Infectious Diseases Unit, Department of Medicine, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Pharmacy, St Vincent’s Hospital Melbourne, Fitzroy 3065, Australia
- Department of Medicine, St Vincent’s Hospital Melbourne, University of Melbourne, Fitzroy 3065, Victoria, Australia
| | - Olimpia C Mateevici
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Infectious Diseases Unit, Department of Medicine, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
| | - Stacey Telianidis
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Vascular Surgery, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
| | - Sara Qi
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Vascular Surgery, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
| | - Irina Churilov
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Medicine, St Vincent’s Hospital Melbourne, University of Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Rehabilitation Medicine, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
| | - Richard J MacIsaac
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Medicine, St Vincent’s Hospital Melbourne, University of Melbourne, Fitzroy 3065, Victoria, Australia
- the Australian Centre for Accelerating Diabetes Innovations, School of Medicine, University of Melbourne, Parkville 3010, Victoria, Australia
| | - Anna Galligan
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
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Werkman NCC, Driessen JHM, Stehouwer CDA, Vestergaard P, Schaper NC, van den Bergh JP, Nielen JTH. The use of sodium-glucose co-transporter-2 inhibitors or glucagon-like peptide-1 receptor agonists versus sulfonylureas and the risk of lower limb amputations: a nation-wide cohort study. Cardiovasc Diabetol 2023; 22:160. [PMID: 37386427 PMCID: PMC10311702 DOI: 10.1186/s12933-023-01897-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 06/20/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Numerous studies have investigated the potential association of sodium-glucose co-transporter-2 inhibitors (SGLT2-Is) with an increased risk of lower limb amputations (LLAs), but have produced conflicting results. Particularly studies comparing SGLT2-Is to glucagon-like peptide-1 receptor agonists (GLP1-RAs) seem to find a higher LLA risk with SGLT2-I use. This raises the question whether the results are driven by a protective GLP1-RA-effect rather than a harmful SGLT2-I-effect. GLP1-RAs could promote wound healing and therefore reduce the risk of LLAs, but the associations between both drug classes and LLA remain uncertain. Therefore, the aim of the current study was to investigate the risk of LLA and diabetic foot ulcer (DFU) with SGLT2-I use and GLP1-RA use versus sulfonylurea use. METHODS A retrospective population-based cohort study was conducted using data from the Danish National Health Service (2013-2018). The study population (N = 74,475) consisted of type 2 diabetes patients aged 18 + who received a first ever prescription of an SGLT2-I, GLP1-RA or sulfonylurea. The date of the first prescription defined the start of follow-up. Time-varying Cox proportional hazards models estimated the hazard ratios (HRs) of LLA and DFU with current SGLT2-I use and GLP1-RA use versus current SU use. The models were adjusted for age, sex, socio-economic variables, comorbidities and concomitant drug use. RESULTS Current SGLT2-I use was not associated with a higher risk of LLA versus sulfonylureas {adjusted HR 1.10 [95% confidence interval (CI) 0.71-1.70]}. Current GLP1-RA use, on the other hand, was associated with a lower risk of LLA [adjusted HR 0.57 (95%CI 0.39-0.84)] compared to sulfonylureas. The risk of DFU was similar to that with sulfonylureas with both exposures of interest. CONCLUSION SGLT2-I use was not associated with a higher risk of LLA, but GLP1-RAs with a lower risk of LLA. Previous studies reporting a higher risk of LLA with SGLT2-I use compared to GLP1-RA use might have been looking at a protective GLP1-RA effect, rather than a harmful SGLT2-I effect.
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Affiliation(s)
- Nikki C. C. Werkman
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Johanna H. M. Driessen
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center+, Maastricht, The Netherlands
- School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | - Coen D. A. Stehouwer
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Internal Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Peter Vestergaard
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - Nicolaas C. Schaper
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Internal Medicine, Division of Endocrinology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Joop P. van den Bergh
- School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
- Department of Internal Medicine, Division of Rheumatology, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Internal Medicine, VieCuri Medical Center, Venlo, The Netherlands
| | - Johannes T. H. Nielen
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center+, Maastricht, The Netherlands
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Nani A, Carrara F, Paulesu CME, Dalle Fratte C, Padroni M, Enisci S, Bilancio MC, Romio MS, Bertuzzi F, Pintaudi B. Association of Sodium-Glucose Cotransporter 2 Inhibitors with Osteomyelitis and Other Lower Limb Safety Outcomes in Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis of Randomised Controlled Trials. J Clin Med 2023; 12:3958. [PMID: 37373652 DOI: 10.3390/jcm12123958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 06/04/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023] Open
Abstract
Our aim was to evaluate osteomyelitis and other major lower limb safety outcomes (i.e., peripheral artery disease or PAD, ulcers, atraumatic fractures, amputations, symmetric polyneuropathy, and infections) in patients affected by type 2 diabetes mellitus (T2DM) and treated with sodium-glucose cotransporter 2 inhibitors (SGLT2-is). We thus performed a systematic review and meta-analysis of randomised controlled trials (RCTs) comparing SGLT2-is at approved doses for T2DM with a placebo or standard of care. MEDLINE, Embase, and Cochrane CENTRAL were searched through August 2022. Separate intention-to-treat analyses were implemented for each molecule to calculate Mantel-Haenszel risk ratios (RRMH) with 95% confidence intervals (CIs) through a random-effects model. We processed data from 42 RCTs for a total of 29,491 and 23,052 patients, respectively assigned to SGLT2-i and comparator groups. SGLT2-is showed a pooled neutral effect on osteomyelitis, PAD, fractures, and symmetric polyneuropathy, whereas slightly deleterious sway on ulcers (RRMH 1.39 [1.01-1.91]), amputations (RRMH 1.27 [1.04-1.55]), and infections (RRMH 1.20 [1.02-1.40]). In conclusion, SGLT2-is appear to not significantly interfere with the onset of osteomyelitis, PAD, lower limb fractures, or symmetric polyneuropathy, even though the number of these events proved consistently higher in the investigational groups; otherwise, local ulcers, amputations, and overall infections may be favoured by their employment. This study is registered with the Open Science Framework (OSF).
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Affiliation(s)
- Alessandro Nani
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20133 Milan, Italy
| | - Federica Carrara
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20133 Milan, Italy
- Hospital Pharmacy, Humanitas Gavazzeni, 24125 Bergamo, Italy
| | | | - Chiara Dalle Fratte
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20133 Milan, Italy
| | - Matteo Padroni
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20133 Milan, Italy
| | - Silvia Enisci
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20133 Milan, Italy
| | - Maria Concetta Bilancio
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20133 Milan, Italy
| | - Maria Silvia Romio
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20133 Milan, Italy
| | | | - Basilio Pintaudi
- Department of Diabetology, Niguarda Hospital, 20162 Milan, Italy
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Deshpande R, Patel R, Regmi MR, Salih M, Kropp R, Al-Bast B, Sheikh MA, Sagalov A, Kulkarni A, Siddique M, Hegde S, Bhattarai M. Safety outcomes of sodium-glucose cotransporter-2 inhibitors in patients with type 2 diabetes and other risk factors for cardiovascular disease: a systematic review and meta-analysis. Cardiovasc Endocrinol Metab 2023; 12:e0284. [PMID: 37180737 PMCID: PMC10171571 DOI: 10.1097/xce.0000000000000284] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 02/22/2023] [Indexed: 05/16/2023]
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT2-Is) have emerged as standard therapy for heart failure. We aim to assess the safety of SGLT2-Is in patients with a high risk of cardiovascular disease. Areas covered An electronic database search was conducted for randomized control trials comparing SGLT2-Is to placebo in patients with a high risk of cardiac disease or heart failure. Data were pooled for outcomes using random-effect models. The odds ratio (OR) and 95% confidence interval (CI) were used to compare eight safety outcomes between the two groups. The analysis included ten studies with 71 553 participants, among whom 39 053 received SGLT2-Is; 28 809 were male and 15 655 were female (mean age, 65.2 years). The mean follow-up period was 2.3 years with the range being 0.8-4.2 years. The SGLT2-Is group had a significant reduction in AKI (OR = 0.8;95% CI 0.74-0.90) and serious adverse effects (OR = 0.9; 95% CI 0.83-0.96) as compared to placebo. No difference was found in fracture (OR = 1.1; 95% CI 0.91-1.24), amputation (OR = 1.1; 95% CI 1.00-1.29), hypoglycemia (OR 0.98;95% CI 0.83-1.15), and UTI (OR = 1.1; 95% CI 1.00-1.22). In contrast, DKA (OR = 2.4; 95% CI 1.65-3.60) and volume depletion (OR = 1.2; 95% CI 1.07-1.41) were higher in SGLT2-Is group. Expert opinion/commentary The benefits of SLGT2-Is outweigh the risk of adverse events. They may reduce the risk of AKI but are associated with an increased risk of DKA and volume depletion. Further studies are warranted to monitor a wider range of safety outcomes of SGLT2-Is.
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Affiliation(s)
- Radhika Deshpande
- Department of Internal Medicine, Southern Illinois University School of Medicine
| | - Raj Patel
- Division of Cardiology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Manjari R. Regmi
- Division of Cardiology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Mohsin Salih
- Division of Cardiology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Robert Kropp
- Department of Internal Medicine, Southern Illinois University School of Medicine
| | - Basma Al-Bast
- Division of Cardiology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Muhammad A. Sheikh
- Division of Cardiology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Andrew Sagalov
- Department of Internal Medicine, Southern Illinois University School of Medicine
| | - Abhishek Kulkarni
- Division of Cardiology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Momin Siddique
- Division of Cardiology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Shruti Hegde
- Division of Cardiology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Mukul Bhattarai
- Division of Cardiology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
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Khan MS, Rashid AM, Shafi T, Ferreira JP, Butler J. Management of Heart Failure With Reduced Ejection Fraction in Patients With Diabetes Mellitus and Chronic Kidney Disease. Semin Nephrol 2023; 43:151429. [PMID: 37871362 DOI: 10.1016/j.semnephrol.2023.151429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Heart failure (HF), diabetes, and chronic kidney disease (CKD) frequently coexist, with one comorbidity worsening the prognosis of another. β-blockers, angiotensin-receptor-neprilysin inhibitors, renin-angiotensin-aldosterone system inhibitors, mineralocorticoid-receptor antagonists, and sodium-glucose cotransporter-2 inhibitors all have been shown to reduce mortality in patients with HF with reduced ejection fraction. However, their uptake in real-world clinical practice remains low, especially among patients who have multiple other comorbidities such as CKD and diabetes. The management of HF in patients with diabetes and CKD can be especially challenging because these patients typically are older, frail, and have multiple other comorbidities, and guideline-directed medical therapy used in HF potentially can affect renal function acutely and chronically. In this article, we discuss the available evidence for each of the foundational HF therapies in patients with diabetes and CKD, emphasizing the current challenges and outlining future directions to optimize the management of HF among these high-risk patients.
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Affiliation(s)
| | | | - Tariq Shafi
- Division of Nephrology, University of Mississippi Medical Center, Jackson, MS
| | - Joao Pedro Ferreira
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, Centre Hospitalier Régional Universitaire (CHRU) Nancy, French Clinical Research Infrastructure Network Investigation Network Initiative Cardiovascular and Renal Clinical Trialist (FCRIN INI-CRCT), Nancy, France
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS; Baylor Scott and White Research Institute, Dallas, TX.
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21
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Blanchette V, Armstrong DG, Drudi L, Rizzo M. Upstream comprehensive management of individuals with diabetes with multimorbidity and frailty to act against amputation. J Diabetes Complications 2023; 37:108407. [PMID: 36738597 DOI: 10.1016/j.jdiacomp.2023.108407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 01/21/2023] [Indexed: 01/31/2023]
Abstract
This manuscript constitutes a commentary on: "Retrospective cohort study of long-term outcomes and prognostic factors for survival after lower extremity amputation in patients with diabetes" by Vuorlaakso et al. (2023). We aim to contribute to the reflection of their findings to support the comprehensive management of vulnerable individuals with multimorbidity and/frailty for limb preservation. There is an urgent need to understand the effects of frailty on overall survival after amputation, survival without major amputation, and the effect modification with multimorbidity.
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Affiliation(s)
- Virginie Blanchette
- Department of Human Kinetics and Podiatric Medicine, Université du Québec à Trois-Rivières, Trois-Rivières G8Z 4M3, Canada; VITAM - Sustainable Health Research Centre, Québec, Québec G1J 2G1, Canada; Centre de recherche du CISSS de Chaudière-Appalaches, Lévis G6V 3Z1, Canada.
| | - David G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA 90033, United States
| | - Laura Drudi
- Division of Vascular Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada; Innovation Hub, Centre de Rercherche du CHUM, Montreal, QC, Canada
| | - Manfredi Rizzo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, School of Medicine, University of Palermo, Italy
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22
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Alkabbani W, Gamble JM. Active-comparator restricted disproportionality analysis for pharmacovigilance signal detection studies of chronic disease medications: An example using sodium/glucose cotransporter 2 inhibitors. Br J Clin Pharmacol 2023; 89:431-439. [PMID: 34964156 DOI: 10.1111/bcp.15178] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/25/2021] [Accepted: 12/03/2021] [Indexed: 01/18/2023] Open
Abstract
AIMS Disproportionality analysis is a common pharmacovigilance tool to detect safety signals of type 2 diabetes medications from spontaneous drug reporting databases. The aim was to demonstrate the impact of using active-comparator restricted disproportionality analysis (ACR-DA), wherein the reference group is restricted to reports with a clinically appropriate active comparator. METHODS Using reports from the Food and Drug Administration Adverse Event Reporting System, we assessed if sodium/glucose cotransporter 2 (SGLT2) inhibitors are associated with higher reporting of 5 potential adverse events: acute kidney injury, genitourinary tract infections, diabetic ketoacidosis, fractures, and amputations. For each adverse event, we calculated the proportional reporting ratio (PRR) and adjusted reporting odds ratio (aROR [95% confidence interval, CI]) using 3 types of reference groups: no SGLT2 inhibitor (background risk reference), other diabetes drugs (therapeutic class reference), and dipeptidyl peptidase 4 inhibitors (active comparator reference). RESULTS Based on ACR-DA, we did not detect a safety signal for acute kidney injury (PRR 0.92 [0.81-1.04]; aROR 0.78 [95% CI 0.72-0.85]) or fractures (PRR 0.44[95% CI 0.17-1.15]; aROR 0.74 [95% CI 0.61-0.91]) associated with SGLT2 inhibitors compared to dipeptidyl peptidase 4 inhibitors. However, we detected safety signals for genitourinary tract infections (PRR 2.75[2.02-3.76]; aROR 2.54[2.26-2.86], diabetic ketoacidosis (PRR 63.85[39.37-103.53; aROR 91.49[70.66-118.48]), and amputations (PRR 52.60 [19.66-140.75]; aROR 22.64 [15.32-33.42]. CONCLUSION The use of the proposed ACR-DA to detect safety signals of type 2 diabetes medications may reduce false positive safety signals through careful selection of the comparator which is expected to reduce channelling bias.
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Affiliation(s)
- Wajd Alkabbani
- School of Pharmacy, University of Waterloo, Kitchener, ON, Canada
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23
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Lee HF, Chuang C, Li PR, Yeh YH, Chan YH, See LC. Adverse cardiovascular, limb, and renal outcomes in patients with diabetes after peripheral artery disease revascularization treated with sodium glucose cotransporter 2 inhibitors versus dipeptidyl peptidase-4 inhibitors. Diabetol Metab Syndr 2023; 15:8. [PMID: 36653811 PMCID: PMC9847141 DOI: 10.1186/s13098-023-00982-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 01/07/2023] [Indexed: 01/19/2023] Open
Abstract
AIMS The effectiveness and limb safety of sodium glucose co-transporter 2 inhibitors (SGLT2i) for patients with type-2 diabetes (T2D) who have received peripheral artery disease (PAD) revascularization are unknown. METHODS AND RESULTS In this nationwide retrospective cohort study, we identified a total of 2,455 and 8,695 patients with T2D who had undergone PAD revascularization and received first prescriptions for SGLT2i and dipeptidyl peptidase-4 inhibitors (DPP4i), respectively, between May 1, 2016, and December 31, 2019. We used 1:1 propensity score matching (PSM) to balance covariates between the two study groups. Patients were followed up from the drug index date until the occurrence of specified outcomes, death, discontinuation of the index drug, or the end of the study period, whichever occurred first. After PSM, we observed that compared with DPP4i, SGLT2i were associated with comparable risks of ischemic stroke, acute myocardial infarction, and heart failure hospitalization but were associated with a lower risk of cardiac death (hazard ratio [HR]: 0.60; 95% confidence interval [CI]: 0.40-0.90]; p = 0.0126). Regarding major limb outcomes, SGLT2i were associated with comparable risks of repeated revascularization and lower limb amputation compared with DPP4i. SGLT2i were associated with a lower risk of composite renal outcomes (HR: 0.40; 95% CI: 0.27-0.59; p < 0.0001) compared with DPP4i. CONCLUSION In a real-world study of patients with T2D who had undergone PAD revascularization, SGLT2i were associated with lower risks of cardiac death and composite renal outcomes but not associated with increased risks of adverse limb events compared with DPP4i.
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Affiliation(s)
- Hsin-Fu Lee
- Division of Cardiology, Department of Internal Medicine, New Taipei City Municipal Tucheng Hospital, Taoyuan City, Taiwan
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan City, 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, 33302, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Chi Chuang
- Division of Cardiology, Department of Internal Medicine, New Taipei City Municipal Tucheng Hospital, Taoyuan City, Taiwan
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan City, 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, 33302, Taiwan
| | - Pei-Ru Li
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan City, 33302, Taiwan
| | - Yung-Hsin Yeh
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan City, 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, 33302, Taiwan
| | - Yi-Hsin Chan
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan City, 33305, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan City, 33302, Taiwan.
- Microscopy Core Laboratory, Guishan Dist, Chang Gung Memorial Hospital, No.259, Wenhua 1St Rd, Taoyuan City, 33302, Taiwan.
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan City, 33302, Taiwan.
- Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan City, 33302, Taiwan.
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan City, 33305, Taiwan.
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24
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Lin DSH, Yu AL, Lo HY, Lien CW, Lee JK, Chen WJ. Major adverse cardiovascular and limb events in people with diabetes treated with GLP-1 receptor agonists vs SGLT2 inhibitors. Diabetologia 2022; 65:2032-2043. [PMID: 35945333 DOI: 10.1007/s00125-022-05772-9] [Citation(s) in RCA: 6] [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: 01/04/2022] [Accepted: 05/16/2022] [Indexed: 01/11/2023]
Abstract
AIMS/HYPOTHESIS This study aimed to assess the real-world outcomes of people with diabetes mellitus treated with glucagon-like peptide-1 receptor agonists (GLP1RAs) compared with those treated with sodium-glucose cotransporter 2 inhibitors (SGLT2is) in terms of major adverse cardiovascular and limb events. Peripheral artery disease is a common cause of morbidity in people with diabetes. Previous cardiovascular outcome trials have demonstrated the benefits of GLP1RAs and SGLT2is for reducing various cardiovascular events, but the safety and efficacy of these drugs on limb outcomes remain subject to debate and ambiguity. METHODS A retrospective cohort study was conducted in which data were collected from the Taiwan National Health Insurance Research Database. In total, 379,256 individuals with diabetes receiving either GLP1RA or SGLT2i with treatment initiated between 1 May 2016 and 31 December 2019 were identified. The primary outcome was major adverse limb events (MALE), defined as the composite of newly diagnosed critical limb ischaemia, percutaneous transluminal angioplasty or peripheral bypass for peripheral artery disease, and non-traumatic amputation. The secondary outcome was major adverse cardiac events, which was a composite of cardiovascular death, non-fatal myocardial infarction and non-fatal ischaemic stroke. Other examined outcomes included death from any cause and hospitalisation for heart failure. Propensity score matching was performed at a 1:4 ratio between the GLP1RA and SGLT2i groups to mitigate possible selection bias. RESULTS A total of 287,091 patients were eligible for analysis, with 81,152 patients treated with SGLT2i and 20,288 patients treated with GLP1RA after matching. The incidence of MALE was significantly lower in the GLP1RA group than in the SGLT2i group (3.6 vs 4.5 events per 1000 person-years; subdistribution HR 0.80; 95% CI 0.67, 0.96), primarily due to a lower incidence of critical limb ischaemia. The reduced risks of MALE associated with GLP1RA use were particularly noticeable in people with diabetic peripheral neuropathy (subdistribution HR 0.66 vs 1.11; p for interaction 0.006). CONCLUSIONS/INTERPRETATION In people with diabetes, GLP1RA use was associated with significantly reduced risks of MALE compared with SGLT2i within the first 2 years after initiation, especially among people with diabetic neuropathy.
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Affiliation(s)
- Donna Shu-Han Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu, Taiwan
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - An-Li Yu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hao-Yun Lo
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Cheng-Wei Lien
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jen-Kuang Lee
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
- Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.
- Department of Laboratory Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.
- Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan.
- Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan.
| | - Wen-Jone Chen
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency, National Taiwan University College of Medicine, Taipei, Taiwan
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25
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Huttunen R, Sainio A, Hjelt A, Haapanen-Saaristo AM, Määttä J, Rummukainen P, Paatero I, Järveläinen H. Distinctive effects of SGLT2 inhibitors on angiogenesis in zebrafish embryos. Biomed Pharmacother 2022; 156:113882. [DOI: 10.1016/j.biopha.2022.113882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 10/11/2022] [Accepted: 10/13/2022] [Indexed: 11/29/2022] Open
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26
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Brust-Sisti L, Rudawsky N, Gonzalez J, Brunetti L. The Role of Sodium-Glucose Cotransporter-2 Inhibition in Heart Failure with Preserved Ejection Fraction. PHARMACY 2022; 10:pharmacy10060166. [PMID: 36548322 PMCID: PMC9788031 DOI: 10.3390/pharmacy10060166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 11/19/2022] [Accepted: 11/23/2022] [Indexed: 12/03/2022] Open
Abstract
Sodium-glucose cotransporter-2 (SGLT2) inhibitors are a novel class of antidiabetic mediations found to also reduce cardiovascular morbidity and mortality and hospitalization for heart failure. Positive results from the EMPEROR-Preserved (empagliflozin) and PRESERVED-HF (dapagliflozin) studies led to recommendations for SGLT2 inhibitors in HFpEF within major international heart failure guidelines. However, studies of ipragliflozin and luseogliflozin, agents approved outside the United States (U.S.), reported different outcomes relative to pivotal trials and failed to realize benefits in the HFpEF population. Varying definitions of HFpEF and outcomes studied complicate the interpretation of study results. SGLT2 inhibitors may cause common adverse events (genital mycotic infections, volume depletion) in addition to rare but severe sequela, including euglycemic diabetic ketoacidosis, Fournier's gangrene, and lower limb amputation. While evidence of CV benefits grows, SGLT2 inhibitor prescribing has lagged, particularly among patients without diabetes. In the U.S., high cost and administrative hurdles may contribute to decreased patient and clinician uptake of this drug class. Future trial results and clinical experience with SGLT2 inhibitors may lead to expanded use and greater uptake among patients with heart failure.
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Affiliation(s)
- Lindsay Brust-Sisti
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA
| | - Nicole Rudawsky
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA
| | - Jimmy Gonzalez
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA
| | - Luigi Brunetti
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA
- Correspondence: ; Tel.: +1-848-445-6815
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27
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Neumiller JJ, Lienhard FJ, Alicic RZ, Tuttle KR. Clinical Evidence and Proposed Mechanisms for Cardiovascular and Kidney Benefits from Sodium-Glucose Co-transporter-2 Inhibitors. TOUCHREVIEWS IN ENDOCRINOLOGY 2022; 18:106-115. [PMID: 36694888 PMCID: PMC9835817 DOI: 10.17925/ee.2022.18.2.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 10/24/2022] [Indexed: 12/12/2022]
Abstract
The number of people living with type 2 diabetes (T2D) and its complications worldwide is increasing at an alarming rate. Fortunately, our understanding of the benefits of glucose-lowering agents from the sodium-glucose co-transporter-2 (SGLT2) inhibitor and glucagon-like peptide-1 (GLP-1) receptor agonist classes on cardiovascular and kidney outcomes is advancing; this means we now have new options to mitigate the risks of these complications in patients with T2D. The SGLT2 inhibitors have consistently demonstrated benefits on atherosclerotic cardiovascular disease (ASCVD), chronic kidney disease (CKD) and heart failure (HF) events in dedicated outcome trials. Large guidelines groups now recommend SGLT2 inhibitors as a standard of care in patients with T2D and comorbid ASCVD, CKD and/ or HF. Evolving evidence additionally indicates kidney and HF benefits of SGLT2 inhibitors in populations without diabetes. These agents likely provide heart and kidney benefits through multiple mechanisms, as their impact on heart and kidney outcomes cannot be fully explained by their direct metabolic effects. On-going work to elucidate the beneficial mechanisms at play with SGLT2 inhibitors will help further optimize these life-saving therapies in patients with and without T2D.
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Affiliation(s)
- Joshua J Neumiller
- College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA, USA,Providence Medical Research Center, Providence Health and Services, Spokane, WA, USA
| | - Fredrick J Lienhard
- College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA, USA
| | - Radica Z Alicic
- Providence Medical Research Center, Providence Health and Services, Spokane, WA, USA,University of Washington School of Medicine, University of Washington, Spokane and Seattle, WA, USA
| | - Katherine R Tuttle
- Providence Medical Research Center, Providence Health and Services, Spokane, WA, USA,University of Washington School of Medicine, University of Washington, Spokane and Seattle, WA, USA,Nephrology Division, Kidney Research Institute, and Institute of Translational Health Sciences, University of Washington, Spokane and Seattle, WA, USA
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Luo LL, Han JX, Wu SR, Kasim V. Intramuscular injection of sotagliflozin promotes neovascularization in diabetic mice through enhancing skeletal muscle cells paracrine function. Acta Pharmacol Sin 2022; 43:2636-2650. [PMID: 35292769 PMCID: PMC9525294 DOI: 10.1038/s41401-022-00889-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 02/13/2022] [Indexed: 12/28/2022] Open
Abstract
Diabetes mellitus is associated with series of macrovascular and microvascular pathological changes that cause a wide range of complications. Diabetic patients are highly susceptible to hindlimb ischemia (HLI), which remains incurable. Evidence shows that skeletal muscle cells secrete a number of angiogenic factors to promote neovascularization and restore blood perfusion, this paracrine function is crucial for therapeutic angiogenesis in diabetic HLI. In this study we investigated whether sotagliflozin, an anti-hyperglycemia SGLT2 inhibitor, exerted therapeutic angiogenesis effects in diabetic HLI in vitro and in vivo. In C2C12 skeletal muscle cells, we showed that high glucose (HG, 25 mM) under hypoxia markedly inhibited cell viability, proliferation and migration potentials, which were dose-dependently reversed by pretreatment with sotagliflozin (5-20 μM). Sotagliflozin pretreatment enhanced expression levels of angiogenic factors HIF-1α, VEGF-A and PDGF-BB in HG-treated C2C12 cells under hypoxia as well as secreted amounts of VEGF-A and PDGF-BB in the medium; pretreatment with the HIF-1α inhibitor 2-methoxyestradiol (2-ME2, 10 μM) or HIF-1α knockdown abrogated sotagliflozin-induced increases in VEGF-A and PDGF-BB expression, as well as sotagliflozin-stimulated cell proliferation and migration potentials. Furthermore, the conditioned media from sotagliflozin-treated C2C12 cells in HG medium enhanced the migration and proliferation capabilities of vascular endothelial and smooth muscle cells, two types of cells necessary for forming functional blood vessels. In vivo study was conducted in diabetic mice subjected to excising the femoral artery of the left limb. After the surgery, sotagliflozin (10 mg/kg) was directly injected into gastrocnemius muscle of the left hindlimb once every 3 days for 3 weeks. We showed that intramuscular injection of sotagliflozin effectively promoted the formation of functional blood vessels, leading to significant recovery of blood perfusion in diabetic HLI mice. Together, our results highlight a new indication of SGLT2 inhibitor sotagliflozin as a potential therapeutic angiogenesis agent for diabetic HLI.
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Affiliation(s)
- Lai-Liu Luo
- Key Laboratory for Biorheological Science and Technology of Ministry of Education, College of Bioengineering, Chongqing University, Chongqing, 400044, China
- The 111 Project Laboratory of Biomechanics and Tissue Repair, College of Bioengineering, Chongqing University, Chongqing, 400044, China
| | - Jing-Xuan Han
- Key Laboratory for Biorheological Science and Technology of Ministry of Education, College of Bioengineering, Chongqing University, Chongqing, 400044, China
- The 111 Project Laboratory of Biomechanics and Tissue Repair, College of Bioengineering, Chongqing University, Chongqing, 400044, China
| | - Shou-Rong Wu
- Key Laboratory for Biorheological Science and Technology of Ministry of Education, College of Bioengineering, Chongqing University, Chongqing, 400044, China.
- The 111 Project Laboratory of Biomechanics and Tissue Repair, College of Bioengineering, Chongqing University, Chongqing, 400044, China.
- State and Local Joint Engineering Laboratory for Vascular Implants, College of Bioengineering, Chongqing University, Chongqing, 400044, China.
| | - Vivi Kasim
- Key Laboratory for Biorheological Science and Technology of Ministry of Education, College of Bioengineering, Chongqing University, Chongqing, 400044, China.
- The 111 Project Laboratory of Biomechanics and Tissue Repair, College of Bioengineering, Chongqing University, Chongqing, 400044, China.
- State and Local Joint Engineering Laboratory for Vascular Implants, College of Bioengineering, Chongqing University, Chongqing, 400044, China.
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Mizutani G, Horii T, Oikawa Y, Atsuda K, Shimada A. Real-world risk of lower-limb amputation associated with sodium-glucose cotransporter 2 inhibitors versus metformin: A propensity score-matched model analysis in Japan. J Diabetes Investig 2022; 13:2000-2009. [PMID: 36124433 DOI: 10.1111/jdi.13906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 08/11/2022] [Accepted: 09/01/2022] [Indexed: 11/29/2022] Open
Abstract
AIMS/INTRODUCTION We aimed to clarify the real-world risk of lower-limb amputation and identify factors related to increased risk in Japanese patients with type 2 diabetes using sodium-glucose cotransporter 2 inhibitors (SGLT2is). MATERIALS AND METHODS We carried out a retrospective observational cohort study utilizing the Japanese Medical Data Vision, a diagnosis procedure combination database. We identified 107,296 patients with type 2 diabetes who were initiated on SGLT2is or metformin (control; n = 53,648 per group) using 1:1 propensity score matching from April 2014 to October 2019. The hazard ratio (HR) for the risk of lower-limb amputation was analyzed using a Cox proportional hazards model adjusted for patients' baseline characteristics and use of concomitant medical agents. RESULTS Of the 107,296 patients, 66 (0.06%); that is, 41 (0.08%) in the SGLT2is group and 25 (0.05%) in the metformin group, underwent amputation, with no significant difference in the proportions between the groups. There was no significant difference in the risk of amputation between the SGLT2is and metformin groups (HR 1.34, 95% confidence interval [CI] 0.80-2.24). However, female sex (HR 2.78, 95% CI 1.12-6.94) and use of strong statins (HR 2.68; 95% CI 1.18-8.20) were significantly associated with a higher risk of amputation in the SGLT2is group than in the metformin group. CONCLUSIONS SGLT2is might not be related to an increased risk of lower-limb amputation in patients with type 2 diabetes in real-world clinical practice. The possible increased risk of SGLT2is-associated amputation in female patients with type 2 diabetes and patients with type 2 diabetes requiring strong statins is notable.
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Affiliation(s)
- Gen Mizutani
- Department of Endocrinology and Diabetes, School of Medicine, Saitama Medical University, Saitama, Japan
| | - Takeshi Horii
- Research and Education Center for Clinical Pharmacy, Division of Clinical Pharmacy, Laboratory of Pharmacy Practice and Science 1, Kitasato University School of Pharmacy, Kanagawa, Japan.,Department of Pharmacy, Faculty of Pharmacy, Musashino University, Tokyo, Japan
| | - Yoichi Oikawa
- Department of Endocrinology and Diabetes, School of Medicine, Saitama Medical University, Saitama, Japan
| | - Koichiro Atsuda
- Research and Education Center for Clinical Pharmacy, Division of Clinical Pharmacy, Laboratory of Pharmacy Practice and Science 1, Kitasato University School of Pharmacy, Kanagawa, Japan
| | - Akira Shimada
- Department of Endocrinology and Diabetes, School of Medicine, Saitama Medical University, Saitama, Japan
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Pan Y, Luo Y, Hong J, He H, Dai L, Zhu H, Wu J. Advances for the treatment of lower extremity arterial disease associated with diabetes mellitus. Front Mol Biosci 2022; 9:929718. [PMID: 36060247 PMCID: PMC9429832 DOI: 10.3389/fmolb.2022.929718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/19/2022] [Indexed: 11/13/2022] Open
Abstract
Lower extremity arterial disease (LEAD) is a major vascular complication of diabetes. Vascular endothelial cells dysfunction can exacerbate local ischemia, leading to a significant increase in amputation, disability, and even mortality in patients with diabetes combined with LEAD. Therefore, it is of great clinical importance to explore proper and effective treatments. Conventional treatments of diabetic LEAD include lifestyle management, medication, open surgery, endovascular treatment, and amputation. As interdisciplinary research emerges, regenerative medicine strategies have provided new insights to treat chronic limb threatening ischemia (CLTI). Therapeutic angiogenesis strategies, such as delivering growth factors, stem cells, drugs to ischemic tissues, have also been proposed to treat LEAD by fundamentally stimulating multidimensional vascular regeneration. Recent years have seen the rapid growth of tissue engineering technology; tissue-engineered biomaterials have been used to study the treatment of LEAD, such as encapsulation of growth factors and drugs in hydrogel to facilitate the restoration of blood perfusion in ischemic tissues of animals. The primary purpose of this review is to introduce treatments and novel biomaterials development in LEAD. Firstly, the pathogenesis of LEAD is briefly described. Secondly, conventional therapies and therapeutic angiogenesis strategies of LEAD are discussed. Finally, recent research advances and future perspectives on biomaterials in LEAD are proposed.
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Affiliation(s)
- Yang Pan
- Department of Endocrinology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yuting Luo
- Key Laboratory of Biotechnology and Pharmaceutical Engineering, School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Jing Hong
- Department of Endocrinology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Huacheng He
- College of Chemistry and Materials Engineering, Wenzhou University, Wenzhou, Zhejiang, China
- *Correspondence: Huacheng He, ; Hong Zhu,
| | - Lu Dai
- The Fourth Outpatient Department, The Affiliated Stomatological Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Hong Zhu
- Department of Endocrinology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
- *Correspondence: Huacheng He, ; Hong Zhu,
| | - Jiang Wu
- Key Laboratory of Biotechnology and Pharmaceutical Engineering, School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, Zhejiang, China
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31
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Marchiori E, Rodionov RN, Peters F, Magnussen C, Nordanstig J, Gombert A, Spanos K, Jarzebska N, Behrendt CA. SGLT2 Inhibitors and Peripheral Vascular Events. Heart Fail Clin 2022; 18:609-623. [DOI: 10.1016/j.hfc.2022.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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32
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González-Clemente JM, García-Castillo M, Gorgojo-Martínez JJ, Jiménez A, Llorente I, Matute E, Tejera C, Izarra A, Lecube A. Beyond the Glycaemic Control of Dapagliflozin: Impact on Arterial Stiffness and Macroangiopathy. Diabetes Ther 2022; 13:1281-1298. [PMID: 35687260 PMCID: PMC9240142 DOI: 10.1007/s13300-022-01280-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/13/2022] [Indexed: 11/20/2022] Open
Abstract
Dapagliflozin is a selective sodium-glucose cotransporter 2 inhibitor (SGLT2i) indicated for the treatment of type 2 diabetes mellitus (T2DM), heart failure with reduced ejection fraction and chronic kidney disease. In all indications, treatment can be initiated in adults with estimated glomerular filtration rate of at least 25 mL/min/1.73 m2. As monotherapy or as an additive therapy, dapagliflozin has been shown to promote better glycaemic control, associated with a reduction in body weight and blood pressure in a wide range of patients. In addition, dapagliflozin has a positive impact on arterial stiffness, helps to control the lipid profile and contributes to a reduced risk of cardiovascular complications. This article reviews the current scientific evidence on the role of dapagliflozin in cardiovascular risk factors including arterial stiffness, cardiovascular disease and heart failure in patients with T2DM, with the aim of helping to translate this evidence into clinical practice. The underuse of SGLT2i in actual clinical practice is also discussed.
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Affiliation(s)
- José M. González-Clemente
- Endocrinology and Nutrition Service, Parc Taulí University Hospital, Institute for Research and Innovation Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Barcelona Spain
- Biomedical Research Networking Center in Diabetes and Associated Metabolic Disorders (CIBERDEM), Carlos III Health Institute, Madrid, Spain
| | | | - Juan J. Gorgojo-Martínez
- Endocrinology and Nutrition Unit, Alcorcón Foundation University Hospital, Alcorcón, Madrid Spain
| | | | - Ignacio Llorente
- Endocrinology and Nutrition Service, Nuestra Señora de la Candelaria University Hospital, Canarias, Spain
| | | | - Cristina Tejera
- Endocrinology and Nutrition Service, Ferrol University Hospital Complex, Ferrol, Spain
| | | | - Albert Lecube
- Biomedical Research Networking Center in Diabetes and Associated Metabolic Disorders (CIBERDEM), Carlos III Health Institute, Madrid, Spain
- Endocrinology and Nutrition Service, Arnau de Vilanova University Hospital of Lleida, Avda. Rovira Roure 80, 25198 Lleida, Spain
- Research Group on Obesity, Diabetes and Metabolism (ODIM), Institute of Biomedical Research of Lleida (IRBLleida), University of Lleida, Lleida, Spain
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Han J, Luo L, Marcelina O, Kasim V, Wu S. Therapeutic angiogenesis-based strategy for peripheral artery disease. Theranostics 2022; 12:5015-5033. [PMID: 35836800 PMCID: PMC9274744 DOI: 10.7150/thno.74785] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 06/14/2022] [Indexed: 01/12/2023] Open
Abstract
Peripheral artery disease (PAD) poses a great challenge to society, with a growing prevalence in the upcoming years. Patients in the severe stages of PAD are prone to amputation and death, leading to poor quality of life and a great socioeconomic burden. Furthermore, PAD is one of the major complications of diabetic patients, who have higher risk to develop critical limb ischemia, the most severe manifestation of PAD, and thus have a poor prognosis. Hence, there is an urgent need to develop an effective therapeutic strategy to treat this disease. Therapeutic angiogenesis has raised concerns for more than two decades as a potential strategy for treating PAD, especially in patients without option for surgery-based therapies. Since the discovery of gene-based therapy for therapeutic angiogenesis, several approaches have been developed, including cell-, protein-, and small molecule drug-based therapeutic strategies, some of which have progressed into the clinical trial phase. Despite its promising potential, efforts are still needed to improve the efficacy of this strategy, reduce its cost, and promote its worldwide application. In this review, we highlight the current progress of therapeutic angiogenesis and the issues that need to be overcome prior to its clinical application.
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Affiliation(s)
- Jingxuan Han
- The Key Laboratory of Biorheological Science and Technology, Ministry of Education, College of Bioengineering, Chongqing University, Chongqing 400044, China.,State and Local Joint Engineering Laboratory for Vascular Implants, Chongqing 400044, China
| | - Lailiu Luo
- The Key Laboratory of Biorheological Science and Technology, Ministry of Education, College of Bioengineering, Chongqing University, Chongqing 400044, China.,State and Local Joint Engineering Laboratory for Vascular Implants, Chongqing 400044, China
| | - Olivia Marcelina
- The Key Laboratory of Biorheological Science and Technology, Ministry of Education, College of Bioengineering, Chongqing University, Chongqing 400044, China.,State and Local Joint Engineering Laboratory for Vascular Implants, Chongqing 400044, China
| | - Vivi Kasim
- The Key Laboratory of Biorheological Science and Technology, Ministry of Education, College of Bioengineering, Chongqing University, Chongqing 400044, China.,State and Local Joint Engineering Laboratory for Vascular Implants, Chongqing 400044, China.,The 111 Project Laboratory of Biomechanics and Tissue Repair, College of Bioengineering, Chongqing University, Chongqing 400044, China.,✉ Corresponding authors: Vivi Kasim, College of Bioengineering, Chongqing University, Chongqing, China; Phone: +86-23-65112672, Fax: +86-23-65111802, ; Shourong Wu, College of Bioengineering, Chongqing University, Chongqing, China; Phone: +86-23-65111632, Fax: +86-23-65111802,
| | - Shourong Wu
- The Key Laboratory of Biorheological Science and Technology, Ministry of Education, College of Bioengineering, Chongqing University, Chongqing 400044, China.,State and Local Joint Engineering Laboratory for Vascular Implants, Chongqing 400044, China.,The 111 Project Laboratory of Biomechanics and Tissue Repair, College of Bioengineering, Chongqing University, Chongqing 400044, China.,✉ Corresponding authors: Vivi Kasim, College of Bioengineering, Chongqing University, Chongqing, China; Phone: +86-23-65112672, Fax: +86-23-65111802, ; Shourong Wu, College of Bioengineering, Chongqing University, Chongqing, China; Phone: +86-23-65111632, Fax: +86-23-65111802,
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Yu WH, Zhang T, Xu H. Role of Dipeptidyl Dipeptidase 4 Inhibitors in the Management of Diabetic Foot. INT J LOW EXTR WOUND 2022:15347346221082776. [PMID: 35225718 DOI: 10.1177/15347346221082776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Patients with diabetes mellitus face difficulties in wound healing. It is important to explore therapeutic options for diabetic complications such as ulcers. This study evaluates the role of dipeptidyl dipeptidase 4 inhibitors (DPP4i) in the management of diabetic foot. Methods: Literature search was conducted in electronic databases (Google Scholar, Ovid, PubMed, Science Direct, and Springer) and studies were selected for inclusion if they reported the incidence rate of diabetic foot ulcer during DPP4i treatment or evaluated the effect of DPP4i on wound healing. Incidence rates of foot ulcer, amputation and peripheral vascular disease were pooled to achieve overall estimates. Meta-analyses of odds ratios were performed to evaluate the risk of foot ulcer, amputation, and peripheral vascular disease with DPP4i, and to examine the effect of DPP4i treatment on ulcer healing. Results: Ten studies (532354 DPP4i and 2092010 non-DPP4i treated diabetes patients) were included. Incidence rates of foot ulcer, amputation, and peripheral vascular disease were 3.80 [95% confidence interval (CI): 0.22, 7.39], 0.82 [95%CI: 0.60, 1.05], and 22.33 [95%CI: 9.14, 35.53] per 1000 person-years respectively in patients treated with DPP4i and 3.60 [95%CI: 1.77, 5.39], 0.76 [95%CI: 0.58, 0.94], and 20.9 [95%CI: 16.04, 25.81] per 1000 person-years respectively in patients treated with non-DPP4i drugs. Risk of ulcer or amputation with DPP4i was not consistent across studies. Odds of non-healing of ulcer were significantly lower with DPP4i in comparison with controls (odds ratio: 0.27 [95%CI: 0.10, 0.71]; p = 0.008). Conclusion: Incidence rates of diabetic foot and amputation are found to be similar with DPP4i and non-DPP4i drugs. DPP4i improved wound healing of diabetic foot in 3-month randomized trials.
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Affiliation(s)
- Wen-Hui Yu
- Department of Vascular Surgery, the First Affiliated Hospital of Heilongjiang University of Traditional Chinese Medicine, Harbin Heilongjiang 150040, China
| | - Tong Zhang
- Department of Vascular Surgery, the First Affiliated Hospital of Heilongjiang University of Traditional Chinese Medicine, Harbin Heilongjiang 150040, China
| | - Heng Xu
- Department of Vascular Surgery, 159365Heilongjiang Provincial Hospital, Harbin, Heilongjiang 150001, China
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Doğruel H, Aydemir M, Balci MK. Management of diabetic foot ulcers and the challenging points: An endocrine view. World J Diabetes 2022; 13:27-36. [PMID: 35070057 PMCID: PMC8771264 DOI: 10.4239/wjd.v13.i1.27] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/18/2021] [Accepted: 12/11/2021] [Indexed: 02/06/2023] Open
Abstract
Diabetic foot ulcers (DFU) are one of the most challenging complications of diabetes. Up to one-third of patients with diabetes mellitus (DM) may suffer from DFUs during their life. DFU is one of the leading causes of morbidity in patients with DM. The treatment period is challenging, and the recurrence rate of DFUs is high. Hence, establishing prevention strategies is the most important point to be emphasized. A multidisciplinary approach is necessary in the prevention and treatment of DFUs. Patients at risk should be identified, and prevention measures should be taken based on the risk category. Once a DFU is formed, the appropriate classification and evidence-based treatment interventions should be executed. Glycemic control, diagnosis and treatment of vascular disease, local wound care, diagnosis, and treatment of infection should be addressed along with the proper evaluation and management of general health status.
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Affiliation(s)
- Hakan Doğruel
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Akdeniz University Hospital, Konyaaltı 07059, Antalya, Turkey
| | - Mustafa Aydemir
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Akdeniz University Hospital, Konyaaltı 07059, Antalya, Turkey
| | - Mustafa Kemal Balci
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Akdeniz University Faculty of Medicine, Konyaaltı 07059, Antalya, Turkey
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36
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Salazar IMC, Tibuakuu M, Blumenthal RS, Sarkar S. Cardiovascular Disease in Patients with Diabetes: A Comparison of Professional Society Guidelines. Curr Diabetes Rev 2022; 18:e200821195733. [PMID: 34420507 DOI: 10.2174/1573399817666210820105514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 06/15/2021] [Accepted: 06/24/2021] [Indexed: 11/22/2022]
Abstract
In this review, we compare major points given in the 2021 American Diabetes Association and the 2020 American Association of Clinical Endocrinologists/American College of Endocrinology guidelines, in particular, the assessment and management of cardiovascular risk in patients with diabetes with a focus on dyslipidemia, blood pressure, and pharmacotherapy in diabetes.
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Affiliation(s)
- Ilton M Cubero Salazar
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins Hospital, Baltimore, MD, USA
- Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Martin Tibuakuu
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins Hospital, Baltimore, MD, USA
- Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Roger S Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins Hospital, Baltimore, MD, USA
- Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Sudipa Sarkar
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins Hospital, Baltimore, MD, USA
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
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Pahud de Mortanges A, Salvador D, Laimer M, Muka T, Wilhelm M, Bano A. The Role of SGLT2 Inhibitors in Atherosclerosis: A Narrative Mini-Review. Front Pharmacol 2021; 12:751214. [PMID: 34803693 PMCID: PMC8602558 DOI: 10.3389/fphar.2021.751214] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 10/01/2021] [Indexed: 01/10/2023] Open
Abstract
Objective: Sodium glucose cotransporter 2 inhibitors (SGLT2-is) are antidiabetic drugs that improve glycemic control by limiting urinary glucose reuptake in the proximal tubule. SGLT2-is might suppress atherosclerotic processes and ameliorate the prognosis of patients with diabetes mellitus diagnosed with or at high risk of atherosclerotic cardiovascular disease (ASCVD). In this mini review, we examine the role of SGLT2-is in the development and progression of atherosclerosis throughout its spectrum, from subclinical atherosclerosis to ASCVD. Data Sources—PubMed and Google Scholar were searched for publications related to SGLT2-is and atherosclerosis. All types of articles were considered, including clinical trials, animal studies, in vitro observations, and reviews and meta-analyses. Data were examined according to their impact and clinical relevance. Synopsis of Content—We first review the underlying mechanisms of SGLT2-is on the development and progression of atherosclerosis, including favorable effects on lipid metabolism, reduction of systemic inflammation, and improvement of endothelial function. We then discuss the putative impact of SGLT2-is on the formation, composition, and stability of atherosclerotic plaque. Furthermore, we evaluate the effects of SGLT2-is in subclinical atherosclerosis assessed by carotid intima media thickness and pulse wave velocity. Subsequently, we summarize the effects of SGLT2-is in ASCVD events, including ischemic stroke, angina pectoris, myocardial infarction, revascularization, and peripheral artery disease, as well as major adverse cardiovascular events, cardiovascular mortality, heart failure, and chronic kidney disease. Moreover, we examine factors that could modify the role of SGLT2-is in atherosclerosis, including sex, age, diabetes, glycemic control, ASCVD, and SGLT2-i compounds. Additionally, we propose future directions that can improve our understanding of SGLT2-is and atherosclerosis.
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Affiliation(s)
| | - Dante Salvador
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus Laimer
- Department of Diabetes, Endocrinology, Nutritional Medicine, and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Taulant Muka
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Matthias Wilhelm
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Arjola Bano
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Rodionov RN, Peters F, Marschall U, L'Hoest H, Jarzebska N, Behrendt CA. Initiation of SGLT2 Inhibitors and the Risk of Lower Extremity Minor and Major Amputation in Patients with Type 2 Diabetes and Peripheral Arterial Disease: A Health Claims Data Analysis. Eur J Vasc Endovasc Surg 2021; 62:981-990. [PMID: 34782230 DOI: 10.1016/j.ejvs.2021.09.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 09/01/2021] [Accepted: 09/18/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To assess the association between long term risk of hospitalisation for heart failure (HHF) and lower extremity minor and major amputation (LEA) in patients initiating sodium glucose cotransporter 2 inhibitors (SGLT2i) suffering from type 2 diabetes and peripheral arterial disease (PAD). Outcomes were compared with patients without PAD and evaluated separately for the time periods before and after the official warning of the European Medicines Agency (EMA) in early 2017. METHODS This study used BARMER German health claims data including all patients suffering from type 2 diabetes initiating SGLT2i therapy between 1 January 2013 and 31 December 2019 with follow up until the end of 2020. New users of glucagon like peptide 1 receptor agonists (GLP1-RAs) were used as active comparators. Inverse probability weighting with truncated stabilised weights was used to adjust for confounding, and five year risks of HHF and LEA were estimated using Cox regression. Periods before and after the EMA warning were analysed separately and stratified by presence of concomitant PAD. RESULTS In total, 44 284 (13.6% PAD) and 56 878 (16.3% PAD) patients initiated SGLT2i or GLP1-RA, respectively. Before the EMA warning, initiation of SGLT2i was associated with a lower risk of HHF in patients with PAD (hazard ratio, HR, 0.85, 95% confidence interval, CI, 0.73 - 0.99) and a higher risk of LEA in patients without PAD (HR 1.79, 95% CI 1.04 - 2.92). After the EMA warning, the efficacy and safety endpoints were no longer statistically different between groups. CONCLUSION The results from this large nationwide real world study highlight that PAD patients exhibit generally high amputation risks. This study refutes the idea that the presence of PAD explains the excess LEA risk associated with initiation of SGLT2i. The fact that differentials among study groups diminished after the EMA warning in early 2017 emphasises that regulatory surveillance measures worked in everyday clinical practice.
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Affiliation(s)
- Roman N Rodionov
- University Centre for Vascular Medicine, University Clinic Carl Gustav Carus, Technische Universität Dresden, Germany; College of Medicine and Public Health, Flinders University and Flinders Medical Centre, Adelaide, Australia
| | - Frederik Peters
- Research Group GermanVasc, Department of Vascular Medicine, University Heart and Vascular Centre UKE Hamburg, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Natalia Jarzebska
- University Centre for Vascular Medicine, University Clinic Carl Gustav Carus, Technische Universität Dresden, Germany; Clinical Sensoring and Monitoring, Department of Anaesthetics and Intensive Care Medicine, University Clinic Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Christian-Alexander Behrendt
- Research Group GermanVasc, Department of Vascular Medicine, University Heart and Vascular Centre UKE Hamburg, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.
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Biscetti F, Cecchini AL, Rando MM, Nardella E, Gasbarrini A, Massetti M, Flex A. Principal predictors of major adverse limb events in diabetic peripheral artery disease: A narrative review. ATHEROSCLEROSIS PLUS 2021; 46:1-14. [PMID: 36643723 PMCID: PMC9833249 DOI: 10.1016/j.athplu.2021.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 10/10/2021] [Accepted: 10/28/2021] [Indexed: 01/18/2023]
Abstract
Background and aims The increasing prevalence of diabetes mellitus is causing a massive growth of peripheral artery disease incidences, a disabling complication of diabetic atherosclerosis, which leads often to the amputation of the affected limb. Critical limb ischemia is the terminal disease stage, which requires a prompt intervention to relieve pain and save limbs. However, patients undergoing revascularization often suffer from cardiovascular, cerebrovascular and major adverse limb events with poor outcomes. Furthermore, the same procedure performed in apparently similar patients has various outcomes and lack of an outcome predictive support causes a high lower limb arterial revascularization rate with disastrous effects for patients. We collected the main risk factors of major adverse limb events in a more readable and immediate format of the topic, to propose an overview of parameters to manage effectively peripheral artery disease patients and to propose basics of a new predictive tool to prevent from disabling vascular complications of the disease. Methods Most recent and updated literature about the prevalence of major adverse limb events in peripheral artery disease was reviewed to identify possible main predictors. Results In this article, we summarized major risk factors of limb revascularization failure and disabling vascular complications collecting those parameters principally responsible for major adverse limb events, which provides physio-pathological explanation of their role in peripheral artery disease. Conclusion We evaluated and listed a panel of possible predictors of MALE (Major Adverse Limb Event) in order to contribute to the development of a predictive score, based on a summary of the main risk factors reported in scientific articles, which could improve the management of peripheral artery disease by preventing vascular accidents.
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Affiliation(s)
- Federico Biscetti
- Internal and Cardiovascular Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy,Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, Roma, Italy,Corresponding author. Internal and Cardiovascular Medicine Unit. Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli, 8, Rome, 00168, Italy.
| | | | - Maria Margherita Rando
- Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Elisabetta Nardella
- Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Antonio Gasbarrini
- Department of Medical and Surgical Sciences, Universitá Cattolica del Sacro Cuore, Roma, Italy
| | - Massimo Massetti
- Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Andrea Flex
- Internal and Cardiovascular Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy,Department of Medical and Surgical Sciences, Universitá Cattolica del Sacro Cuore, Roma, Italy
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Sundström J, Kristófi R, Östlund O, Bennet L, Eliasson B, Jansson S, Leksell J, Almby K, Lundqvist M, Eriksson JW. A registry-based randomised trial comparing an SGLT2 inhibitor and metformin as standard treatment of early stage type 2 diabetes (SMARTEST): Rationale, design and protocol. J Diabetes Complications 2021; 35:107996. [PMID: 34389234 DOI: 10.1016/j.jdiacomp.2021.107996] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/08/2021] [Accepted: 07/19/2021] [Indexed: 11/30/2022]
Abstract
AIM SGLT2 inhibitors have been shown to reduce cardiovascular and renal complications in type 2 diabetes (T2D) patients at high cardiovascular risk. Metformin is currently widely used as initial monotherapy in T2D but lacks convincing data to show that it reduces risk of complications. We aim to compare the SGLT2 inhibitor dapagliflozin and metformin as first-line T2D medication with regard to development of complications in a registry-based randomised controlled trial. METHODS The SGLT2 inhibitor or metformin as standard treatment of early stage type 2 diabetes (SMARTEST) trial will enrol 4300 subjects at 30-40 study sites in Sweden who will be randomised 1:1 to either metformin or dapagliflozin. Participants must have T2D duration <4 years, no prior cardiovascular disease, and be either drug-naïve or on monotherapy for T2D. RESULTS The primary endpoint is a composite of all-cause death, major adverse cardiovascular events and occurrence or progression of microvascular complications (retinopathy, nephropathy, diabetic foot lesions). Secondary endpoints include individual components of the primary endpoint, start of insulin therapy, risk factor biomarkers, patient-reported outcome measures, and cost-effectiveness analysis. Outcomes will primarily be assessed using nationwide healthcare registries. CONCLUSIONS The SMARTEST trial will investigate whether dapagliflozin is superior to metformin in preventing complications in early stage T2D. (Clinicaltrials.gov identifier NCT03982381, EudraCT 2019-001046-17).
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Affiliation(s)
- Johan Sundström
- Department of Medical Sciences, Clinical Epidemiology, Uppsala University, Uppsala, Sweden; The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Robin Kristófi
- Department of Medical Sciences, Clinical Diabetes and Metabolism, Uppsala University, Uppsala, Sweden
| | | | - Louise Bennet
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Björn Eliasson
- Institute of Medicine, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Stefan Jansson
- Institution of Medical Sciences, University Health Care Research Center, Örebro University, Örebro, Sweden; Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Janeth Leksell
- Department of Medical Sciences, Clinical Diabetes and Metabolism, Uppsala University, Uppsala, Sweden
| | - Kristina Almby
- Department of Medical Sciences, Clinical Diabetes and Metabolism, Uppsala University, Uppsala, Sweden
| | - Martin Lundqvist
- Department of Medical Sciences, Clinical Diabetes and Metabolism, Uppsala University, Uppsala, Sweden
| | - Jan W Eriksson
- Department of Medical Sciences, Clinical Diabetes and Metabolism, Uppsala University, Uppsala, Sweden.
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Xu D, Chandler O, Wee C, Ho C, Affandi JS, Yang D, Liao X, Chen W, Li Y, Reid C, Xiao H. Sodium-Glucose Cotransporter-2 Inhibitor (SGLT2i) as a Primary Preventative Agent in the Healthy Individual: A Need of a Future Randomised Clinical Trial? Front Med (Lausanne) 2021; 8:712671. [PMID: 34497814 PMCID: PMC8419219 DOI: 10.3389/fmed.2021.712671] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 07/23/2021] [Indexed: 01/10/2023] Open
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are a relatively novel class of drug for treating type 2 diabetes mellitus (T2DM) that inhibits glucose reabsorption in the renal proximal tubule to promote glycosuria and reduce blood glucose levels. SGLT2i has been clinically indicated for treating T2DM, with numerous recent publications focussing on both primary and secondary prevention of cardiovascular and renal events in Type 2 diabetic patients. The most recent clinical trials showed that SGLT2i have moderately significant beneficial effects on atherosclerotic major adverse cardiovascular events (MACE) in patients with histories of atherosclerotic cardiovascular disease. In this review and analysis, SGLT2i have however demonstrated clinically significant benefits in reducing hospitalisation for heart failure and worsening of chronic kidney disease (CKD) irrespective of pre-existing atherosclerotic cardiovascular disease or previous heart failure history. A meta-analysis suggests that all SGLT2 inhibitors demonstrated the therapeutic benefit on all-cause and cardiovascular mortality, as shown in EMPAREG OUTCOME study with a significant decrease in myocardial infarction, without increased stroke risk. All the above clinical trial recruited type 2 diabetic patients. This article aims to postulate and review the possible primary prevention role of SGLT2i in healthy individuals by reviewing the current literature and provide a prospective overview. The emphasis will include primary prevention of Type 2 Diabetes, Heart Failure, CKD, Hypertension, Obesity and Dyslipidaemia in healthy individuals, whom are defined as healthy, low or intermediate risks patients.
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Affiliation(s)
- Dan Xu
- Faculty of Health Sciences, CCRE, Curtin School of Population Health, Curtin University, Perth, WA, Australia.,Faculty of Health Sciences, Curtin Medical School, Curtin University, Perth, WA, Australia.,Department of Medical Education, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Owain Chandler
- Faculty of Health Sciences, Curtin Medical School, Curtin University, Perth, WA, Australia
| | - Cleo Wee
- Faculty of Health Sciences, Curtin Medical School, Curtin University, Perth, WA, Australia
| | - Chau Ho
- Faculty of Health Sciences, CCRE, Curtin School of Population Health, Curtin University, Perth, WA, Australia
| | - Jacquita S Affandi
- Faculty of Health Sciences, CCRE, Curtin School of Population Health, Curtin University, Perth, WA, Australia
| | - Daya Yang
- Department of Medical Education, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Department of Cardiology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xinxue Liao
- Department of Medical Education, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Department of Cardiology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wei Chen
- Department of Medical Education, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Department of Renal Medicine, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yanbing Li
- Department of Medical Education, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Department of Endocrinology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Christopher Reid
- Faculty of Health Sciences, CCRE, Curtin School of Population Health, Curtin University, Perth, WA, Australia
| | - Haipeng Xiao
- Department of Medical Education, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Department of Endocrinology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Permission to prescribe: do cardiologists need permission to prescribe diabetes medications that afford cardiovascular benefit? Curr Opin Cardiol 2021; 36:672-681. [PMID: 34173772 DOI: 10.1097/hco.0000000000000892] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Antihyperglycemic therapies including sodium glucose contransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1 RA) have been demonstrated to confer significant cardiovascular benefit and reduce future events in patients with type 2 diabetes mellitus (T2DM). However, despite positive data from cardiovascular outcome trials, these therapies remain underutilized in a large proportion of patients who have clinical indications and meet coverage guidelines for their initiation. One of the causes of the observed gap between scientific evidence and clinical cardiology practice is therapeutic hesitancy (otherwise known as therapeutic inertia). The purpose of this review is to discuss the contributors to therapeutic hesitancy in the implementation of these evidence-based therapies and, more importantly, provide pragmatic solutions to address these barriers. RECENT FINDINGS Recent studies have demonstrated that clinicians may not initiate cardiovascular protective therapies due to a reluctance to overstep perceived interdisciplinary boundaries, concerns about causing harm due to medication side effects, and a sense of unfamiliarity with the optimal choice of therapy amidst a rapidly evolving landscape of T2DM therapies. SUMMARY Herein, we describe a multifaceted approach aimed at creating a 'permission to prescribe' culture, developing integrated multidisciplinary models of care, enhancing trainees' experiences in cardiovascular disease prevention, and utilizing technology to motivate change. Taken together, these interventions should increase the implementation of evidence-based therapies and improve the quality of life and cardiovascular outcomes of individuals with T2DM.
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Heyward J, Christopher J, Sarkar S, Shin JI, Kalyani RR, Alexander GC. Ambulatory noninsulin treatment of type 2 diabetes mellitus in the United States, 2015 to 2019. Diabetes Obes Metab 2021; 23:1843-1850. [PMID: 33881795 DOI: 10.1111/dom.14408] [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: 07/16/2020] [Revised: 04/01/2021] [Accepted: 04/02/2021] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To examine trends in the noninsulin drug treatment of type 2 diabetes, including first- and second-line therapies on top of metformin, from 2015 to 2019. PARTICIPANTS AND METHODS We conducted a descriptive analysis of cross-sectional data using the IQVIA National Disease and Therapeutic Index, a nationally representative audit of ambulatory physician practices in the United States. We focused on the use of noninsulin pharmacological treatments for type 2 diabetes among individuals aged 35 years and older between January 1, 2015 and December 31, 2019. The main outcome was type 2 diabetes visits where a prescription drug was used ("treatment visit"). RESULTS Ambulatory diabetes visits decreased from 30.1 million treatment visits in 2015 to 29.5 million treatment visits in 2019. Among treatment visits where a single drug was prescribed, the use of metformin declined from 57.0% of monotherapy in 2015 to 46.0% of monotherapy in 2019, while during the same period the share of monotherapy accounted for by glucagon-like peptide-1 (GLP-1) receptor agonists increased from 4.3% to 8.5% and the share accounted for by sodium-glucose cotransporter-2 (SGLT2) inhibitors increased from 7.3% to 19.5%. Among treatment visits where metformin plus another drug was prescribed, the share of second-line therapy accounted for by dipeptidyl peptidase-4 (DPP-4) inhibitors decreased from 21.9% of treatment visits in 2015 to 20.8% of treatment visits in 2019; sulphonylurea use declined from 45.2% to 32.7%, use of SGLT2 inhibitors increased from 14.5% to 21.2% and use of GLP-1 receptor agonists increased from 9.8% to 18.2%. CONCLUSIONS Significant changes in the landscape of ambulatory care for diabetes have taken place during the past 6 years, including moderate declines in metformin monotherapy, moderate declines in second-line sulphonylurea use, and large increases in SGLT2 use. These changes underscore the dynamic nature of drug utilization for diabetes in the United States, and reflect the effects of emerging evidence, evolving clinical guidelines and evolving regulatory and payment policies.
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Affiliation(s)
- James Heyward
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jacob Christopher
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sudipa Sarkar
- Division of Endocrinology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Jung-Im Shin
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Rita R Kalyani
- Division of Endocrinology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - G Caleb Alexander
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
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Sunner SS, Welsh RC, Bainey KR. Medical Management of Peripheral Arterial Disease: Deciphering the Intricacies of Therapeutic Options. CJC Open 2021; 3:936-949. [PMID: 34401701 PMCID: PMC8348339 DOI: 10.1016/j.cjco.2021.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 03/08/2021] [Indexed: 01/01/2023] Open
Abstract
Due to the pathophysiology of atherosclerosis, the management for coronary artery disease and peripheral arterial disease (PAD) were considered homogenous, with therapies focused on the use of lipid-lowering medications, antiplatelet therapy, glucose control, and blood pressure management. However, more recently, studies have supported the use of tailored therapeutics and medical targets for patients with PAD that sometimes differ from those for coronary artery disease. Moreover, we are now witnessing large randomized PAD-specific trials that have altered therapeutic regimens and targets. Given these updates, dissemination of knowledge is lacking, as evidenced by discordant guideline recommendations. This comprehensive review provides an overview of contemporary therapeutic options for secondary prevention for patients with PAD.
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Affiliation(s)
- Sanjot S. Sunner
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Robert C. Welsh
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Kevin R. Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
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45
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Lin DSH, Lee JK, Chen WJ. Clinical Adverse Events Associated with Sodium-Glucose Cotransporter 2 Inhibitors: A Meta-Analysis Involving 10 Randomized Clinical Trials and 71 553 Individuals. J Clin Endocrinol Metab 2021; 106:2133-2145. [PMID: 33895840 DOI: 10.1210/clinem/dgab274] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Indexed: 12/23/2022]
Abstract
CONTEXT SGLT2is are first-line antidiabetic agents with demonstrated cardiovascular benefits. Prior meta-analyses have examined adverse events (AEs) associated with these drugs in general, but such knowledge needs to be updated with the results of more recent trials. In addition, the occurrence of various AEs with different underlying diseases is unknown. OBJECTIVE This meta-analysis aimed to investigate the occurrence of various AEs associated with sodium-glucose cotransporter 2 inhibitors (SGLT2is) and to examine the level of risk of AEs in patients with different underlying diseases. METHODS We conducted a quantitative meta-analysis of randomized controlled trials (RCTs) retrieved from the MEDLINE and EMBASE databases and the Cochrane library on January 31, 2021. Outcomes of interest included 4 overall safety outcomes (AEs) and 12 specified safety outcomes. Further analyses were performed on various subgroups, which were defined based on the status of diabetes mellitus (DM), atherosclerotic cardiovascular disease (ASCVD), chronic kidney disease, and congestive heart failure, and by the dosage of SGLT2i (high dose vs low dose). RESULTS Our analysis included 10 eligible studies with a total of 71 553 participants. The meta-analysis showed that SGLT2i led to increased risks of genital infection (risk ratio [RR] 3.56, 95% CI 2.84-4.46), urinary tract infection (RR 1.06, 95% CI 1.00-1.12), diabetic ketoacidosis (RR 2.23, 95% CI 1.36-3.63), and volume depletion (RR 1.14, 95% CI 1.06-1.23). However, the use of SGLT2i was associated with reduced risks of any serious AE (RR 0.92, 95% CI 0.90-0.94), acute kidney injury (AKI) (RR 0.84, 95% CI 0.77-0.91), and hyperkalemia (RR 0.84, 95% CI 0.72-0.99). Within the different subgroups, the risk of amputation was higher in patients with ASCVD than in those without (RR 1.44 vs 0.96, P = .066). CONCLUSION The use of SGLT2is is generally safe. SGLT2is may be associated with increased risks of genital infection but are protective against AKI. Of note, the risk of amputation was higher in patients with ASCVD. The key to the safe use of SGLT2is lies in the identification of high-risk populations and close surveillance of patients after treatment.
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Affiliation(s)
- Donna Shu-Han Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jen-Kuang Lee
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Laboratory Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
- Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
- Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Jone Chen
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency, National Taiwan University College of Medicine, Taipei, Taiwan
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46
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Gill GS, Latif A, Hilleman D, Lavie CJ, Alla VM. Challenges in Implementing Evidence Based Cross-Disciplinary Therapies: Are Cardiovascular Specialists Ready to Claim SGLT-2 Inhibitors and GLP-1 Analogs? Curr Probl Cardiol 2021; 47:100878. [PMID: 34078543 DOI: 10.1016/j.cpcardiol.2021.100878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 04/23/2021] [Indexed: 11/17/2022]
Abstract
Cardiovascular disease is a leading cause of morbidity, mortality and financial burden to the United States health system. A change in focus towards preventive medicine along with advances in pharmacologic and invasive therapies, has led to improved cardiac death rates. These benefits however, come with increased prevalence of heart failure and soaring readmission rates. Reducing burden of hospitalizations has therefore, been a focus of clinicians and researchers over the years. An improvement in clinical outcomes has been demonstrated in multiple trials investigating HF therapies, however, execution of guideline recommendations has been trailing. Over the past decade, 2 classes of hypoglycemic agents, the glucagon-like peptide-1 (GLP-1) receptor agonists and the sodium-glucose cotransporter 2 (SGLT-2) inhibitors have been recognized for their cardiovascular morbidity and mortality benefits. Studies have shown that there has been a steady increase in prescription rates of these medications, however, overall usage remains quite low. Various patient, physician and system-based factors have been identified that cause barriers to translation of trial data to real-world clinical outcomes. A strategy focused on physician and patient education, quality improvement, multi-disciplinary team approach, and patient centered care is essential to meet treatment goals.
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Affiliation(s)
- Gauravpal S Gill
- Division of Cardiology, Creighton University School of Medicine, Omaha, NE.
| | - Azka Latif
- Department of Medicine, Creighton University School of Medicine, Omaha, NE
| | - Daniel Hilleman
- Creighton University School of Pharmacy and Health Professions, Omaha, NE
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA
| | - Venkata M Alla
- Division of Cardiology, Creighton University School of Medicine, Omaha, NE
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Lin C, Zhu X, Cai X, Yang W, Lv F, Nie L, Ji L. SGLT2 inhibitors and lower limb complications: an updated meta-analysis. Cardiovasc Diabetol 2021; 20:91. [PMID: 33910574 PMCID: PMC8082772 DOI: 10.1186/s12933-021-01276-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 04/15/2021] [Indexed: 02/08/2023] Open
Abstract
Background To exam the associations between the use of sodium glucose co-transporter 2 inhibitor (SGLT2i) and the risk of lower limb complications, and to analyze the associated factors. Methods Pubmed, Medline, Embase, the Cochrane Center Register of Controlled Trials for Studies and Clinicaltrial.gov were searched from the inception to November 2020. Randomized controlled trials of SGLT2i conducted in population containing diabetic patients with reports of amputation, peripheral arterial disease (PAD) and diabetic foot (DF) events were included. Random-effect model, fixed-effect model and meta-regression analysis were accordingly used. Result The numbers of SGLT2i users versus non-SGLT2i users in the analyses of amputation, PAD and DF were 40,925/33,414, 36,446/28,685 and 31,907/25,570 respectively. Compared with non-SGLT2i users, the risks of amputation and PAD were slightly increased in patients with canagliflozin treatment (amputation: OR = 1.60, 95% CI 1.04 to 2.46; PAD: OR = 1.53, 95 % CI 1.14 to 2.05). Meta-regression analyses indicated that greater weight reduction in SGLT2i users was significantly associated with the increased risks of amputation (β = − 0.461, 95% CI − 0.726 to − 0.197), PAD (β = − 0.359, 95% CI − 0.545 to − 0.172) and DF (β = − 0.476, 95% CI − 0.836 to − 0.116). Lower baseline diastolic blood pressure (β = − 0.528, 95% CI − 0.852 to − 0.205), more systolic blood pressure reduction (β = − 0.207, 95% CI − 0.390 to − 0.023) and more diastolic blood pressure reduction (β = − 0.312, 95% CI − 0.610 to − 0.015) were significantly associated with the increased risks of amputation, PAD and DF respectively in patients with SGLT2i treatment. Conclusions The risks of amputation and PAD were slightly increased in patients with canagliflozin treatment. Reductions in body weight and blood pressure were associated with lower limb complications in patients with SGLT2i treatment.
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Affiliation(s)
- Chu Lin
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Xingyun Zhu
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Xiaoling Cai
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China.
| | - Wenjia Yang
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Fang Lv
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Lin Nie
- Department of Endocrinology and Metabolism, Beijing Airport Hospital, Beijing, China
| | - Linong Ji
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China.
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Patoulias D, Papadopoulos C, Doumas M. Updated meta-analysis assessing the risk of amputation with sodium-glucose co-transporter-2 inhibitors in the hallmark cardiovascular and renal outcome trials. Diabetes Obes Metab 2021; 23:1063-1065. [PMID: 33319468 DOI: 10.1111/dom.14297] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/07/2020] [Accepted: 12/09/2020] [Indexed: 01/15/2023]
Affiliation(s)
- Dimitrios Patoulias
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, General Hospital "Hippokration", Thessaloniki, Greece
| | - Christodoulos Papadopoulos
- Third Department of Cardiology, Aristotle University of Thessaloniki, General Hospital "Hippokration", Thessaloniki, Greece
| | - Michael Doumas
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, General Hospital "Hippokration", Thessaloniki, Greece
- Veterans Affairs Medical Center, George Washington University, Washington, District of Columbia, USA
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Qiu M, Ding LL, Zhang M, Zhou HR. Safety of four SGLT2 inhibitors in three chronic diseases: A meta-analysis of large randomized trials of SGLT2 inhibitors. Diab Vasc Dis Res 2021; 18:14791641211011016. [PMID: 33887983 PMCID: PMC8481734 DOI: 10.1177/14791641211011016] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
There are no relevant meta-analyses that have assessed the safety of the sodium-glucose transporter 2 (SGLT2) inhibitors in different chronic diseases. We aimed at evaluating the safety of four SGLT2 inhibitors in three chronic diseases by meta-analysis of the large randomized trials of SGLT2 inhibitors. We performed random-effects meta-analysis and carried out subgroup analysis according to type of underlying diseases and type of SGLT2 inhibitors. SGLT2 inhibitors versus placebo significantly reduced the risk of acute kidney injury (RR 0.75, 95% CI 0.66-0.85), and showed the reduced trend in the risk of severe hypoglycemia (RR 0.86, 95% CI 0.71-1.03). SGLT2 inhibitors significantly increased the risks of diabetic ketoacidosis (RR 2.57), genital infection (RR 3.75), and volume depletion (RR 1.14); and showed the increased trends in the risks of fracture (RR 1.07), amputation (RR 1.21), and urinary tract infection (RR 1.07). These effects exhibited by SGLT2 inhibitors were consistent across three chronic diseases (i.e. type 2 diabetes, chronic heart failure, and chronic kidney disease) and four SGLT2 inhibitors (i.e. dapagliflozin, empagliflozin, ertugliflozin, and canagliflozin) (all Psubgroup > 0.05). These findings will guide that specific adverse events are monitored when SGLT2 inhibitors are used in clinical practice.
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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
| | - Hai-Rong Zhou
- Department of General Medicine, Shenzhen Longhua District Central Hospital, Shenzhen, China
- Hai-Rong Zhou, Department of General Medicine, Shenzhen Longhua District Central Hospital, Shenzhen 518110, 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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