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Korakas E, Thymis J, Oikonomou E, Mourouzis K, Kountouri A, Pliouta L, Pililis S, Pavlidis G, Lampsas S, Katogiannis K, Palaiodimou L, Tsivgoulis G, Siasos G, Ikonomidis I, Raptis A, Lambadiari V. Dulaglutide and Dapagliflozin Combination Concurrently Improves the Endothelial Glycocalyx and Vascular and Myocardial Function in Patients with T2DM and Albuminuria vs. DPP-4i. J Clin Med 2024; 13:7497. [PMID: 39768420 PMCID: PMC11678541 DOI: 10.3390/jcm13247497] [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: 11/10/2024] [Revised: 11/24/2024] [Accepted: 12/06/2024] [Indexed: 01/11/2025] Open
Abstract
Background: The association between diabetic nephropathy and arterial elasticity and endothelial function is well established. In this study, we compared the effect of the combination of dulaglutide and dapagliflozin versus DPP-4 inhibitors on the endothelial glycocalyx, arterial stiffness, myocardial function, and albuminuria. Methods: Overall, 60 patients were randomized to combined dulaglutide and dapagliflozin treatment (n = 30) or DPP-4 inhibitors (DPP-4i, n = 30) (ClinicalTrials.gov: NCT06611904). We measured at baseline and 4 and 12 months post-treatment: (i) the perfused boundary region of the sublingual arterial microvessels, (ii) pulse wave velocity (PWV) and central systolic blood pressure (cSBP), (iii) global left ventricular longitudinal strain (GLS), and (iv) urine albumin-to-creatinine ratio (UACR). Results: After twelve months, dual therapy showed greater improvements vs. DPP-4i in PBR (2.10 ± 0.31 to 1.93 ± 0.23 μm vs. 2.11 ± 0.31 to 2.08 ± 0.28 μm, p < 0.001), UACR (326 ± 61 to 142 ± 47 mg/g vs. 345 ± 48 to 306 ± 60 mg/g, p < 0.01), and PWV (11.77 ± 2.37 to 10.7 ± 2.29 m/s vs. 10.64 ± 2.44 to 10.54 ± 2.84 m/s, p < 0.001), while only dual therapy showed improvement in cSBP (130.21 ± 17.23 to 123.36 ± 18.42 mmHg). These effects were independent of glycemic control. Both treatments improved GLS, but the effect of dual therapy was significantly higher compared to DPP-4i (18.19% vs. 6.01%, respectively). Conclusions: Twelve-month treatment with dulaglutide and dapagliflozin showed a greater improvement in arterial stiffness, endothelial function, myocardial function, and albuminuria than DPP-4is. Early initiation of combined therapy as an add-on to metformin should be considered in these patients.
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Affiliation(s)
- Emmanouil Korakas
- 2nd Department of Internal Medicine Research Unit and Diabetes Centre, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, Rimini 1 Str., Chaidari, 12462 Athens, Greece; (E.K.); (A.K.); (L.P.); (S.P.); (G.P.); (S.L.); (A.R.)
| | - John Thymis
- 2nd Department of Cardiology Laboratory of Preventive Cardiology and Echocardiography Department, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece; (J.T.); (K.K.); (I.I.)
| | - Evangelos Oikonomou
- 3rd Department of Cardiology, Medical School, Sotiria Chest Disease Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (E.O.); (K.M.)
| | - Konstantinos Mourouzis
- 3rd Department of Cardiology, Medical School, Sotiria Chest Disease Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (E.O.); (K.M.)
| | - Aikaterini Kountouri
- 2nd Department of Internal Medicine Research Unit and Diabetes Centre, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, Rimini 1 Str., Chaidari, 12462 Athens, Greece; (E.K.); (A.K.); (L.P.); (S.P.); (G.P.); (S.L.); (A.R.)
| | - Loukia Pliouta
- 2nd Department of Internal Medicine Research Unit and Diabetes Centre, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, Rimini 1 Str., Chaidari, 12462 Athens, Greece; (E.K.); (A.K.); (L.P.); (S.P.); (G.P.); (S.L.); (A.R.)
| | - Sotirios Pililis
- 2nd Department of Internal Medicine Research Unit and Diabetes Centre, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, Rimini 1 Str., Chaidari, 12462 Athens, Greece; (E.K.); (A.K.); (L.P.); (S.P.); (G.P.); (S.L.); (A.R.)
| | - George Pavlidis
- 2nd Department of Internal Medicine Research Unit and Diabetes Centre, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, Rimini 1 Str., Chaidari, 12462 Athens, Greece; (E.K.); (A.K.); (L.P.); (S.P.); (G.P.); (S.L.); (A.R.)
| | - Stamatios Lampsas
- 2nd Department of Internal Medicine Research Unit and Diabetes Centre, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, Rimini 1 Str., Chaidari, 12462 Athens, Greece; (E.K.); (A.K.); (L.P.); (S.P.); (G.P.); (S.L.); (A.R.)
| | - Konstantinos Katogiannis
- 2nd Department of Cardiology Laboratory of Preventive Cardiology and Echocardiography Department, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece; (J.T.); (K.K.); (I.I.)
| | - Lina Palaiodimou
- 2nd Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 12462 Athens, Greece (G.T.)
| | - Georgios Tsivgoulis
- 2nd Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 12462 Athens, Greece (G.T.)
| | - Gerasimos Siasos
- Cardiovascular Division, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA 02115, USA;
| | - Ignatios Ikonomidis
- 2nd Department of Cardiology Laboratory of Preventive Cardiology and Echocardiography Department, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece; (J.T.); (K.K.); (I.I.)
| | - Athanasios Raptis
- 2nd Department of Internal Medicine Research Unit and Diabetes Centre, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, Rimini 1 Str., Chaidari, 12462 Athens, Greece; (E.K.); (A.K.); (L.P.); (S.P.); (G.P.); (S.L.); (A.R.)
| | - Vaia Lambadiari
- 2nd Department of Internal Medicine Research Unit and Diabetes Centre, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, Rimini 1 Str., Chaidari, 12462 Athens, Greece; (E.K.); (A.K.); (L.P.); (S.P.); (G.P.); (S.L.); (A.R.)
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Katogiannis K, Thymis J, Kousathana F, Pavlidis G, Korakas E, Kountouri A, Balampanis K, Prentza V, Kostelli G, Michalopoulou H, Tsilivarakis D, Lambadiari V, Ikonomidis I. Effects of Liraglutide, Empagliflozin and Their Combination on Left Atrial Strain and Arterial Function. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:395. [PMID: 38541121 PMCID: PMC10971983 DOI: 10.3390/medicina60030395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 02/18/2024] [Accepted: 02/22/2024] [Indexed: 04/09/2024]
Abstract
Background and Objectives: Glucagon-like peptide-1 receptor agonists (GLP-1RA) and sodium-glucose cotransporter-2 inhibitors (SGLT-2i) are cardioprotective drugs. We investigated their effects on left atrial function, a major determinant of cardiac diastolic dysfunction in type 2 diabetes mellitus. We also explored the association of changes in arterial stiffness with those of the LA strain after treatment. Materials and Methods: A total of 200 patients (59.5 ± 9.1 year old, 151 male) with type 2 diabetes mellitus treated with metformin were randomized to insulin (n = 50 served as controls), liraglutide (n = 50), empagliflozin (n = 50) or their combination (liraglutide + empagliflozin) (n = 50). We measured at baseline and 6 months post-treatment: (a) left atrial and global left ventricular longitudinal strain by speckle tracking echocardiography; (b) pulse wave velocity (PWV) and central systolic blood pressure. Results: At baseline, there was a correlation of the LA reservoir strain with PWV (r = -0.209, p = 0.008), central SBP (r = -0.151, p = 0.030), EF (r = 0.214, p = 0.004) and GLS (r = -0.279, p = 0.009). The LA reservoir change 6 months post-treatment was correlated with the PWV change in all groups (r = -0.242, p = 0.028). The LA reservoir change 6 months post-treatment was correlated with the GLS change in all groups (r = -0.322, p = 0.004). Six months after intervention, patients treated with liraglutide, empagliflozin and their combination improved the left atrial reservoir strain (GLP1RA 30.7 ± 9.3 vs. 33.9 ± 9.7%, p = 0.011, SGLT2i 30 ± 8.3 vs. 32.3 ± 7.3%, p = 0.04, GLP1&SGLT2i 29.1 ± 8.7 vs. 31.3 ± 8.2, p = 0.007) compared to those treated with insulin (33 ± 8.3% vs. 32.8 ± 7.4, p = 0.829). Also, patients treated with liraglutide and the combination liraglutide and empagliflozin had improved left atrial conduction strain (p < 0.05). Empagliflozin or the combination liraglutide and empagliflozin showed a greater decrease of PWV and central and brachial systolic blood pressure than insulin or GLP-1RA. (p < 0.05). Conclusions: Impaired aortic elastic properties are associated with a decreased LA strain in type 2 diabetics. Treatment with liraglutide, empagliflozin and their combination for 6 months showed a greater improvement of left atrial function compared to insulin treatment in parallel with the improvement of arterial and myocardial functions.
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Affiliation(s)
- Konstantinos Katogiannis
- Second Cardiology Department, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 15772 Athens, Greece; (J.T.); (G.K.); (H.M.); (D.T.); (I.I.)
| | - John Thymis
- Second Cardiology Department, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 15772 Athens, Greece; (J.T.); (G.K.); (H.M.); (D.T.); (I.I.)
| | - Foteini Kousathana
- Second Department of Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 15772 Athens, Greece; (F.K.); (G.P.); (E.K.); (A.K.); (K.B.); (V.P.); (V.L.)
| | - George Pavlidis
- Second Department of Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 15772 Athens, Greece; (F.K.); (G.P.); (E.K.); (A.K.); (K.B.); (V.P.); (V.L.)
| | - Emmanouil Korakas
- Second Department of Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 15772 Athens, Greece; (F.K.); (G.P.); (E.K.); (A.K.); (K.B.); (V.P.); (V.L.)
| | - Aikaterini Kountouri
- Second Department of Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 15772 Athens, Greece; (F.K.); (G.P.); (E.K.); (A.K.); (K.B.); (V.P.); (V.L.)
| | - Konstantinos Balampanis
- Second Department of Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 15772 Athens, Greece; (F.K.); (G.P.); (E.K.); (A.K.); (K.B.); (V.P.); (V.L.)
| | - Vasiliki Prentza
- Second Department of Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 15772 Athens, Greece; (F.K.); (G.P.); (E.K.); (A.K.); (K.B.); (V.P.); (V.L.)
| | - Gavriella Kostelli
- Second Cardiology Department, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 15772 Athens, Greece; (J.T.); (G.K.); (H.M.); (D.T.); (I.I.)
| | - Helen Michalopoulou
- Second Cardiology Department, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 15772 Athens, Greece; (J.T.); (G.K.); (H.M.); (D.T.); (I.I.)
| | - Damianos Tsilivarakis
- Second Cardiology Department, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 15772 Athens, Greece; (J.T.); (G.K.); (H.M.); (D.T.); (I.I.)
| | - Vaia Lambadiari
- Second Department of Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 15772 Athens, Greece; (F.K.); (G.P.); (E.K.); (A.K.); (K.B.); (V.P.); (V.L.)
| | - Ignatios Ikonomidis
- Second Cardiology Department, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 15772 Athens, Greece; (J.T.); (G.K.); (H.M.); (D.T.); (I.I.)
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Stachteas P, Karakasis P, Patoulias D, Clemenza F, Fragakis N, Rizzo M. The effect of sodium-glucose co-transporter-2 inhibitors on markers of subclinical atherosclerosis. Ann Med 2024; 55:2304667. [PMID: 38233735 PMCID: PMC10798275 DOI: 10.1080/07853890.2024.2304667] [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: 08/22/2023] [Accepted: 12/19/2023] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Despite the widespread use of classical cholesterol-lowering drugs to mitigate the adverse impacts of dyslipidaemia on atherosclerosis, many patients still face a substantial residual risk of developing atherosclerotic cardiovascular disease (CVD). This risk is partially attributed to non-traditional pathophysiological pathways. Latest evidence suggests that sodium glucose co-transporter-2 (SGLT2) inhibitors are beneficial for patients suffering from type 2 diabetes mellitus (T2DM) or established CVD by reducing morbidity and mortality. However, the underlying mechanisms of this benefit have not been clearly elucidated. It has been hypothesized that one possible mechanism could be the attenuation of subclinical atherosclerosis (SA) progression. AIM The objective of this narrative review is to examine the present evidence concerning the impact of SGLT2 inhibitors on markers of SA. RESULTS The current evidence on the efficacy of SGLT2 on SA, endothelial function and arterial stiffness remains controversial. Findings from observational and randomized studies are quite heterogeneous; however, they converge that the antiatherosclerotic activity of SGLT2 inhibitors is not strong enough to be widely used for prevention of atherosclerosis progression in patients with or without T2DM. CONCLUSIONS Further research is needed to investigate the underlying mechanisms and the possible beneficial impact of SGLT2i on primary and secondary CVD prevention through attenuation of premature atherosclerosis progression.
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Affiliation(s)
- Panagiotis Stachteas
- Second Department of Cardiology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Paschalis Karakasis
- 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
| | - Francesco Clemenza
- Department for the Study and Treatment of Cardiothoracic Diseases and for Cardiothoracic Transplants, Cardiology Unit, IRCCS – ISMETT, Palermo, Italy
| | - 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
| | - Manfredi Rizzo
- Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (Promise), School of Medicine, University of Palermo, Palermo, Italy
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Bechlioulis A, Markozannes G, Chionidi I, Liberopoulos E, Naka KK, Ntzani EE, Liatis S, Rizzo M, Rizos EC. The effect of SGLT2 inhibitors, GLP1 agonists, and their sequential combination on cardiometabolic parameters: A randomized, prospective, intervention study. J Diabetes Complications 2023; 37:108436. [PMID: 36842186 DOI: 10.1016/j.jdiacomp.2023.108436] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 02/02/2023] [Accepted: 02/19/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND Pulse wave velocity (PWV) and augmentation index (AIx) are indices used to assess arterial stiffness. We aim to compare the effect of empagliflozin, liraglutide and their sequential combination on arterial stiffness indices in patients with type 2 diabetes (T2D). METHODS This was a randomized single blind study evaluating the effect of empagliflozin vs liraglutide in adult patients with T2D. Patients were randomized to liraglutide titrated gradually to 1.8 mg or empagliflozin 25 mg in 1:1 ratio. Three months later empagliflozin was added to the liraglutide group, and liraglutide was added to the empagliflozin group. Patients were assessed with non-invasive tests for arterial stiffness (i.e., carotid-femoral PWV and AIx of aortic pressure) at baseline, 3-month and 9-month visits (final visit was extended for 3 months from the initial design due to Covid 19 pandemic). The primary outcome was the between-group difference of PWV change (ΔPWV) and ΔAIx at 3 months. Secondary outcomes included the between-group difference of ΔPWV and ΔAIx at 9 months, as well as the ΔPWV and ΔAIx between baseline and 9-month visit when total study population was assessed. RESULTS A total of 62 patients with T2D (30 started liraglutide; 32 empagliflozin, mean age 63 years, 25 % with established cardiovascular disease) participated in the study. We failed to show any significant between-group differences of ΔPWV and ΔΑΙx at 3 and 9 months, as well as between-group difference of ΔPWV and ΔAIx for the total study population between baseline and 9-month visit. In contrast, systemic vascular resistance and lipoprotein(a) levels improved, showing better results with liraglutide than empagliflozin. Favorable effects were also observed on body weight, body mass index, body and visceral fat, blood pressure, HbA1c, and uric acid levels. CONCLUSION No evidence of a favorable change in arterial stiffness indices was seen with empagliflozin or liraglutide or their combination in this study. Well-designed powerful studies are needed to address any potential effects on arterial stiffness in selected populations.
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Affiliation(s)
- Aris Bechlioulis
- 2nd Department of Cardiology, Faculty of Medicine, School of Health Sciences, University of Ioannina and University Hospital of Ioannina, Ioannina, Greece
| | - Georgios Markozannes
- Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Ifigeneia Chionidi
- Diabetes Outpatient Clinic, University Hospital of Ioannina, Ioannina, Greece
| | - Evangelos Liberopoulos
- First Department of Propaedeutic Internal Medicine, Medical School, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Katerina K Naka
- 2nd Department of Cardiology, Faculty of Medicine, School of Health Sciences, University of Ioannina and University Hospital of Ioannina, Ioannina, Greece
| | - Evangelia E Ntzani
- Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece; Center for Evidence-Based Medicine, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI, USA
| | - Stavros Liatis
- First Department of Propaedeutic Internal Medicine, Medical School, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Manfredi Rizzo
- Department of Internal Medicine and Medical Specialties, School of Medicine, University of Palermo, Palermo, Italy
| | - Evangelos C Rizos
- Department of Internal Medicine, University Hospital of Ioannina, Ioannina, Greece; School of Medicine, European University Cyprus, Nicosia, Cyprus.
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