Meta-Analysis on the Safety and Cardiorenal Efficacy of SGLT2 Inhibitors in Patients Without T2DM

The efficacy and safety of SGLT2 inhibitors in patients with non-diabetic chronic kidney disease: a systematic review and meta-analysis

PURPOSE

In recent years, increasing evidence has shown that sodium-glucose cotransporter 2 inhibitors (SGLT2i) drugs have potential renoprotective effects in patients with diabetes mellitus (DM). However, the renal protective effect of SGLT2i in non-diabetic nephropathy patients has not been extensively demonstrated. In this systematic review and meta-analysis, we aimed to evaluate the renal protective effect and safety of SGLT2i in non-diabetic nephropathy patients.

METHODS

we searched for relevant clinically randomised controlled trials and analyzed the effects of SGLT2i on estimated glomerular filtration rate (eGFR), urinary albumin/creatinine ratio (UACR), and systolic blood pressure (SBP) and the incidence of adverse events in patients with non-diabetic nephropathy.

RESULTS

We collated and analysed clinical data from six groups of patients with nondiabetic nephropathy. It was found that the SGLT2i significantly delayed the decline in eGFR [MD = 1.35 ml/min/1.73 m2, 95% CI 0.84, 1.86), P < 0.0001]. Furthermore, the SGLT2i significantly reduced UACR [MD =  - 24.47% l, 95% CI (- 38.9, -10.04), P = 0.0009], and showed a greater decrease in SBP [MD =  - 4.13 mmHg, 95% CI (- 7.49, - 0.77), P = 0.02]. There was no significant difference in the incidence of adverse reactions between dapagliflozin/empagliflozin and the control group [OR = 1.14, 95% CI (0.88, 1.47), P = 0.33].

CONCLUSION

This study shows that SGLT2i help to delay the progression of non-diabetic kidney disease. Therefore, SGLT2i may contribute to the general treatment of nondiabetic nephropathy.

Efficacy and Safety of Sodium-Glucose Cotransporter-2 Inhibitors in Nondiabetic Patients with Chronic Kidney Disease: A Review of Recent Evidence

Background

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) were initially developed as glucose-lowering agents in patients with type-2 diabetes. However, available data from clinical trials and meta-analyses suggest that SGLT2i have pleiotropic benefits in reducing mortality and delaying the progression of chronic kidney disease (CKD) in both diabetic and nondiabetic patients. Thus, we herein review the current evidence regarding the efficacy and safety of SGLT2i in patients with nondiabetic CKD and appraise the recently reported clinical trials that might facilitate the management of CKD in routine clinical practice.

Summary

The benefits of SGLT2i on nondiabetic CKD are multifactorial and are mediated by a combination of mechanisms. The landmark DAPA-CKD trial revealed that dapagliflozin administered with renin-angiotensin system blockade drugs reduced the risk of a sustained decline (at least 50%) in the estimated glomerular filtration rate, end-stage kidney disease, or death from cardiorenal causes. The recent EMPA-KIDNEY trial showed that empagliflozin therapy led to a lower risk of progression of kidney disease or death from cardiovascular causes. These benefits were consistent in patients with and without diabetes. Moreover, a meta-analysis of DAPA-HF and EMPEROR-Reduced trials confirmed reductions in the combined risk of cardiovascular death or worsening heart failure including composite renal endpoint.

Key Messages

Considering the robust data available from DAPA-CKD, EMPA-KIDNEY, and other trials such as EMPEROR-Preserved, DIAMOND that included nondiabetic patients, it may be necessary to update current guidelines to include SGLT2i as a first-line therapy for CKD and reevaluate current CKD therapeutic approaches.

Effect of Dapagliflozin on Clinical Outcome after Drug-Eluting Stent Implantation in Elderly T2DM Patients: A Real-World Study

Objective

To investigate the effect of dapagliflozin therapy on the clinical outcome of drug-eluting stent (DES) implantation in elderly patients with type 2 diabetes mellitus (T2DM).

Methods

We retrospectively studied the real-world data of patients with coronary heart disease who received DES implantation in our hospital from May 2019 to May 2021. Baseline general data and laboratory results of patients were collected. All patients were followed up for two years after PCI, and the follow-up endpoints included in-stent restenosis, major adverse cardiovascular events (MACE), revascularization, rehospitalization, and all-cause mortality.

Results

Compared with those before treatment, body mass index, systolic blood pressure, diastolic blood pressure, TG, TC, LDL-C, FBG, and HbA1c were decreased in both groups after treatment, while HDL-C was increased after treatment (P < 0.05). There were significant differences in BMI, systolic blood pressure, diastolic blood pressure, FBG, and HbA1c between the two groups before and after treatment. At the end of follow-up, the incidence of in-stent restenosis and MACE in the dapagliflozin group was lower than that in the nondapagliflozin group. K-M curve analysis showed a significant difference in in-stent restenosis and MACE after DES implantation between the dapagliflozin group and the nondapagliflozin group (logrankχ2 = 5.093, 4.524; P = 0.024, 0.033).

Conclusion

In accurate clinical data, dapagliflozin could significantly improve the postoperative BMI, blood pressure, and blood glucose outcome of patients with T2DM complicated with coronary heart disease and positively impact in-stent restenosis and MACE.

The Anti-Inflammatory Effect of Novel Antidiabetic Agents

The incidence of type 2 diabetes (T2DM) has been increasing worldwide and remains one of the leading causes of atherosclerotic disease. Several antidiabetic agents have been introduced in trying to regulate glucose control levels with different mechanisms of action. These agents, and sodium-glucose cotransporter-2 inhibitors in particular, have been endorsed by contemporary guidelines in patients with or without T2DM. Their widespread usage during the last three decades has raised awareness in the scientific community concerning their pleiotropic mechanisms of action, including their putative anti-inflammatory effect. In this review, we delve into the anti-inflammatory role and mechanism of the existing antidiabetic agents in the cardiovascular system and their potential use in other chronic sterile inflammatory conditions.

Preoperative Management of Cardiovascular Medications: A Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement

Cardiovascular conditions such as hypertension, arrhythmias, and heart failure are common in patients undergoing anesthesia for surgical or other procedures. Numerous guidelines from various specialty societies offer variable recommendations for the perioperative management of these medications. The Society for Perioperative Assessment and Quality Improvement identified a need to provide multidisciplinary evidence-based recommendations for preoperative medication management. The society convened a group of 13 members with expertise in perioperative medicine and training in anesthesiology or internal medicine. The aim of this consensus effort is to provide perioperative clinicians with guidance on the management of cardiovascular medications commonly encountered during the preoperative evaluation. We used a modified Delphi process to establish consensus. Twenty-one classes of medications were identified: α-adrenergic receptor antagonists, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, angiotensin receptor-neprilysin inhibitors, β-adrenoceptor blockers, calcium-channel blockers, centrally acting sympatholytic medications, direct-acting vasodilators, loop diuretics, thiazide diuretics, potassium-sparing diuretics, endothelin receptor antagonists, cardiac glycosides, nitrodilators, phosphodiesterase-5 inhibitors, class III antiarrhythmic agents, potassium-channel openers, renin inhibitors, class I antiarrhythmic agents, sodium-channel blockers, and sodium glucose cotransportor-2 inhibitors. We provide recommendations for the management of these medications preoperatively.

Meta-analysis of the association between new hypoglycemic agents and digestive diseases

BACKGROUND

New hypoglycemic agents include sodium-glucose cotransporter-2 inhibitors (SGLT2is), glucagon-like peptide 1 receptor agonists (GLP1RAs), and dipeptidyl peptidase-4 inhibitors (DPP4is). The association between each class of these new hypoglycemic drugs and the risks of various digestive system diseases is unknown. We aimed to explore this relationship by performing a meta-analysis.

METHODS

We included large randomized trials of SGLT2is, GLP1RAs, and DPP4is. Outcomes of interest were 91 kinds of digestive diseases including 75 kinds of gastrointestinal disorders and 16 kinds of hepatobiliary disorders. Meta-analysis was done to generate pooled risk ratio (RR) and 95% confidence interval (CI). Subgroup analysis was conducted according to 3 different drug classes.

RESULTS

We included 21 large trials in this meta-analysis. Compared with placebo, GLP1RAs were associated with the higher risks of gastric ulcer hemorrhage (RR 2.68, 95% CI 1.07-6.68; Pdrug = .035; I2 = 0), pancreatitis (RR 1.48, 95% CI 1.02-2.15; Pdrug = .041; I2 = 0), cholangitis acute (RR 5.96, 95% CI 1.04-34.08; Pdrug = .045; I2 = 0), and cholecystitis acute (RR 1.52, 95% CI 1.08-2.15; Pdrug = .017; I2 = 1.5%), but were not significantly associated with the occurrences of the other 87 kinds of digestive diseases (Pdrug ranged from .064 to .999). SGLT2is versus placebo were not significantly associated with the occurrences of 91 kinds of digestive diseases (Pdrug ranged from .077 to .995). DPP4is versus placebo were not significantly associated with the occurrences of 91 kinds of digestive diseases (Pdrug ranged from .085 to .999).

CONCLUSIONS

Neither SGLT2is nor DPP4is are associated with the occurrences of various kinds of digestive diseases, whereas GLP1RAs are associated with the higher risks of 4 kinds of digestive diseases, namely, gastric ulcer hemorrhage, pancreatitis, cholangitis acute, and cholecystitis acute. These findings seem to suggest that GLP1RAs are not applicable for patients at high risk of 4 specific digestive diseases, whereas SGLT2is and DPP4is are safe for patients susceptible to digestive diseases. However, our findings require to be further verified by future studies with sufficient statistical power.

Expression of TNF-α and IL-1β in Peripheral Blood of Patients with T2DM Retinopathy

Aims

The expression and clinical significance of tumor necrosis factor-α (INF-α) and interleukin 1-β (IL-1β) in retinal cells of patients with type 2 diabetes (T2DM) retinopathy were detected by flow cytometry.

Materials and Methods

Fifty patients with T2DM who attended our ophthalmology clinic between May 2021 and May 2022 were selected as the observation group. Another 50 healthy individuals who were examined at our hospital during the same period were selected as the comparison group. Tear film rupture time (BUT), fluorescein staining (FL), basal tear secretion (Schirmer I) test, and conjunctival impression cytology (CIC) were detected in both groups, and the expression of TNF-α and IL-1β in retinal cells was observed by immunohistochemical staining.

Results

The levels of IL13 and TNF-α in the two groups were not exactly the same. The serum levels of IL13 and TNF-α in the observation group were significantly higher than those in the control group, and there was a statistically significant difference (P < 0.05). TNF-α and IL-1B expressions in the observation group were positively correlated with the fluorescence staining, and the expression of TNF-α and IL-1β in the observation group was significantly negatively correlated with the BUT test and Schirmer I test.

Conclusion

Serums TNF-α and IL-1β are significantly elevated in patients with T2DM retinopathy and gradually increase with disease progression. Combined detection of serums TNF-α and IL-1β can help determine the severity of the disease and assess the prognosis.

Sodium Glucose Cotransporter-2 Inhibitors: Spotlight on Favorable Effects on Clinical Outcomes beyond Diabetes

Sodium glucose transporter type 2 (SGLT2) molecules are found in proximal tubules of the kidney, and perhaps in the brain or intestine, but rarely in any other tissue. However, their inhibitors, intended to improve diabetes compensation, have many more beneficial effects. They improve kidney and cardiovascular outcomes and decrease mortality. These benefits are not limited to diabetics but were also found in non-diabetic individuals. The pathophysiological pathways underlying the treatment success have been investigated in both clinical and experimental studies. There have been numerous excellent reviews, but these were mostly restricted to limited aspects of the knowledge. The aim of this review is to summarize the known experimental and clinical evidence of SGLT2 inhibitors' effects on individual organs (kidney, heart, liver, etc.), as well as the systemic changes that lead to an improvement in clinical outcomes.