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Talebi SS, Rezaie S, Hajmiri MS, Zamanirafe M, Ranjbar A, Moridi H, Mirjalili M, Mehrpooya M. Comparison of the effects of empagliflozin and sitagliptin, as add-on to metformin, on serum levels of asprosin and metabolic parameters in patients with type 2 diabetes mellitus. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024:10.1007/s00210-024-03219-z. [PMID: 38900252 DOI: 10.1007/s00210-024-03219-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 06/04/2024] [Indexed: 06/21/2024]
Abstract
The effect of sitagliptin and empagliflozin on serum levels of asprosin and metabolic parameters in patients with type 2 diabetes mellitus (T2DM) was assessed in a non-randomized, prospective observational study. Seventy-nine T2DM patients, without adequate glycemic control with metformin monotherapy, were included in the study. In addition to the ongoing metformin treatment, patients received sitagliptin 100 mg and empagliflozin 10 mg once daily for 12 weeks. Anthropometric parameters, lipid and glycemic profile, insulin resistance (homeostasis model assessment of insulin resistance index [HOMA-IR]), and asprosin serum levels were assessed at baseline and after 12 weeks of therapy. Both empagliflozin and sitagliptin treatments led to similar, significant improvement in fasting blood glucose (FBG) and hemoglobin A1C (HbA1C). Compared to baseline, triglyceride (TG) and high-density lipoprotein cholesterol (HDL-C) were improved with both treatments, but empagliflozin led to the more improvement. No significant change of total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) were observed in either group. Insulin resistance was significantly attenuated in both groups, but to a greater degree with empagliflozin treatment. The reduction in serum asprosin levels from baseline was significantly higher in patients taking empagliflozin compared to those receiving sitagliptin. Additionally, individuals on empagliflozin exhibited a more decrease in body mass index (BMI) and body weight compared to those on sitagliptin. According to our findings, the addition of empagliflozin to metformin appeared to offer greater benefits compared to the addition of sitagliptin in terms of decreasing asprosin levels and improving certain metabolic parameters in T2DM patients.
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Affiliation(s)
- Seyed Saman Talebi
- Department of Internal Medicine, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Shabnam Rezaie
- Department of Clinical Pharmacy, School of Pharmacy, Hamadan University of Medical Sciences, Shahid Fahmideh Ave, Hamadan, 6517838678, Iran
| | - Minoo Sadat Hajmiri
- Department of Internal Medicine, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Maryam Zamanirafe
- Medical Faculty, Hamadan University of Medical Science, Hamadan, Iran
| | - Akram Ranjbar
- Department of Pharmacology Toxicology, School of Pharmacy, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Heresh Moridi
- Department of Medical Laboratory Sciences, Faculty of Paramedical Sciences, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Mahtabalsadat Mirjalili
- Department of Clinical Pharmacy, School of Pharmacy, Yazd University of Medical Sciences, Yazd, Iran
| | - Maryam Mehrpooya
- Department of Clinical Pharmacy, School of Pharmacy, Hamadan University of Medical Sciences, Shahid Fahmideh Ave, Hamadan, 6517838678, Iran.
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Abstract
Objective Young people with type 1 diabetes are likely to gain body weight and not achieve optimal glycemic control with only high doses of insulin. This study examined the efficacy of the sodium-glucose cotransporter 2 (SGLT2) inhibitor dapagliflozin as an adjunct-to-insulin therapy in young Japanese subjects with type 1 diabetes who had been diagnosed before 15 years old, were overweight, and had inadequate control despitereceiving intensive insulin therapy. Methods Twenty-two patients with type 1 diabetes (12 boys and 10 girls 16.0-33.9 years old) were involved in the study. All patients had a body mass index (BMI) >25 kg/m2, glycated hemoglobin (HbA1c) level >7.0%, and daily insulin dose >0.5 units/kg. They were treated with a low dose of dapagliflozin (5.0 mg/day) as an adjunctive therapy to insulin. Fourteen patients were treated with multiple daily injections of insulin, while eight used an insulin pump. Results The body weights and BMIs were significantly reduced during the 12-month study period (change of -4.4 kg and -1.7 kg/m2, p<0.001, respectively). Their insulin dose was significantly decreased (-0.17 units/kg, P <0.001), and glycemic control was significantly improved (fasting plasma glucose: -18.7 mg/dL, HbA1c: -0.62%, p<0.001) during the study period. There was one episode of diabetic ketoacidosis, with no other problematic adverse events, including severe hypoglycemia, observed. Conclusion The use of low-dose dapagliflozin as an adjunct therapy may be beneficial in overweight young people with poorly controlled type 1 diabetes.
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Affiliation(s)
- Tatsuhiko Urakami
- Department of Pediatrics, Nihon University School of Medicine, Japan
| | - Kei Yoshida
- Department of Pediatrics, Nihon University School of Medicine, Japan
| | - Junichi Suzuki
- Department of Pediatrics, Nihon University School of Medicine, Japan
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Mechanism of canagliflozin-induced vasodilation in resistance mesenteric arteries and the regulation of systemic blood pressure. J Pharmacol Sci 2022; 150:211-222. [DOI: 10.1016/j.jphs.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 08/18/2022] [Accepted: 09/21/2022] [Indexed: 11/21/2022] Open
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Impact of NAFLD and its pharmacotherapy on lipid profile and CVD. Atherosclerosis 2022; 355:30-44. [PMID: 35872444 DOI: 10.1016/j.atherosclerosis.2022.07.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 06/16/2022] [Accepted: 07/13/2022] [Indexed: 11/21/2022]
Abstract
Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of death worldwide. Increasing evidence suggests that, in addition to traditional metabolic risk factors such as obesity, hypercholesterolemia, hypertension, diabetes mellitus, and insulin resistance (IR), nonalcoholic fatty liver disease (NAFLD) is an emerging driver of ASCVD via multiple mechanisms, mainly by disrupting lipid metabolism. The lack of pharmaceutical treatment has spurred substantial investment in the research and development of NAFLD drugs. However, many reagents with promising therapeutic potential for NAFLD also have considerable impacts on the circulating lipid profile. In this review, we first summarize the mechanisms linking lipid dysregulation in NAFLD to the progression of ASCVD. Importantly, we highlight the potential risks of/benefits to ASCVD conferred by NAFLD pharmaceutical treatments and discuss potential strategies and next-generation drugs for treating NAFLD without the unwanted side effects.
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Hasan A, Menon SN, Zerin F, Hasan R. Dapagliflozin induces vasodilation in resistance-size mesenteric arteries by stimulating smooth muscle cell K V7 ion channels. Heliyon 2022; 8:e09503. [PMID: 35647331 PMCID: PMC9131249 DOI: 10.1016/j.heliyon.2022.e09503] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 02/17/2022] [Accepted: 05/16/2022] [Indexed: 02/07/2023] Open
Abstract
Dapagliflozin is a sodium-glucose cotransporter 2 (SGLT2) inhibitor that, in addition to glucose reduction, lowers systemic blood pressure. Here, we investigated if dapagliflozin could directly relax small mesenteric arteries that control peripheral vascular resistance and blood pressure, and the underlying molecular mechanism. We used pressurized arterial myography, pharmacological inhibition and Western blotting to investigate the direct effect of dapagliflozin on the contractility of freshly isolated, resistance-size rat mesenteric arteries. Our pressure myography data unveiled that dapagliflozin relaxed small mesenteric arteries in a concentration-dependent manner. Non-selective inhibition of KV channels and selective inhibition of smooth muscle cell voltage-gated K+ channels KV7 attenuated dapagliflozin-induced vasorelaxation. Inhibition of other major KV isoforms such as KV1.3, KV1.5 channels as well as large-conductance Ca2+-activated K+ (BKCa) channels, ATP-sensitive (KATP) channels did not abolish vasodilation. Dapagliflozin-evoked vasodilation remained unaltered by pharmacological inhibition of endothelium-derived nitric oxide (NO) signaling, prostacyclin (PGI2), as well as by endothelium denudation. Our Western blotting data revealed that SGLT2 protein is expressed in rat mesenteric arteries. However, non-selective inhibition of SGLTs did not induce vasodilation, demonstrating that the vasodilatory action is independent of SGLT2 inhibition. Overall, our data suggests that dapagliflozin directly and selectively stimulates arterial smooth muscle cells KV7 channels, leading to vasodilation in resistance-size mesenteric arteries. These findings are significant as it uncovers for the first time a direct vasodilatory action of dapagliflozin in resistance mesenteric arteries, which may lower systemic blood pressure.
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Affiliation(s)
- Ahasanul Hasan
- Department of Pharmaceutical Sciences, College of Pharmacy, Mercer University, Atlanta, GA, United States
| | - Sreelakshmi N Menon
- Department of Pharmaceutical Sciences, College of Pharmacy, Mercer University, Atlanta, GA, United States
| | - Farzana Zerin
- Department of Pharmaceutical Sciences, College of Pharmacy, Mercer University, Atlanta, GA, United States
| | - Raquibul Hasan
- Department of Pharmaceutical Sciences, College of Pharmacy, Mercer University, Atlanta, GA, United States
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Siamashvili M, Davis SN. Sodium-glucose cotransporter 2 inhibitors for the management of type 2 diabetes. Expert Opin Pharmacother 2021; 22:2181-2198. [PMID: 34388350 DOI: 10.1080/14656566.2021.1967320] [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: 10/20/2022]
Abstract
INTRODUCTION Sodium-glucose cotransporter (SGLT) 2 inhibitors reduce glucose reabsorption in the kidney, increase glucosuria, and improve glycemia. Besides glycemic efficacy, the class also lowers risk of cardiovascular and renal disease. AREAS COVERED The authors describe late phase trials of empagliflozin, canagliflozin, dapagliflozin, and ertugliflozin. Safety and efficacy endpoints in monotherapy, combination therapy, cardiovascular, and renal outcomes trials have been identified and presented. EXPERT OPINION SGLT2 inhibitors appear to be safe and effective agents that improve glycemia when used alone or in combination with any other approved antihyperglycemic medications. Other beneficial effects include reductions in body weight and blood pressure, improvements in renal outcomes, all-cause mortality, cardiovascular mortality, and worsening heart failure.
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Affiliation(s)
- Maka Siamashvili
- School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Stephen N Davis
- School of Medicine, University of Maryland, Baltimore, Maryland, USA
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Grubić Rotkvić P, Cigrovski Berković M, Bulj N, Rotkvić L. Minireview: are SGLT2 inhibitors heart savers in diabetes? Heart Fail Rev 2021; 25:899-905. [PMID: 31410757 DOI: 10.1007/s10741-019-09849-3] [Citation(s) in RCA: 9] [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] [Indexed: 12/28/2022]
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors, a class of drugs that promote urinary glucose excretion in the treatment of diabetes, have provoked large interest of scientific and professional community due to their positive and, somehow, unexpected results in the three major cardiovascular outcome trials (EMPA-REG OUTCOME trial with empagliflozin, CANVAS Program with canagliflozin, and DECLARE-TIMI 58 with dapagliflozin). In fact, along with the reduction of major adverse cardiovascular events, SGLT2 inhibitors reduced significantly hospitalization for heart failure regardless of existing atherosclerotic cardiovascular disease or a history of heart failure. The latter have reminded us of the frequent but neglected entity of diabetic cardiomyopathy which is currently poorly understood despite its great clinical importance. Physiological mechanisms responsible for the benefits of SGLT2 inhibitors are complex and multifactorial and still not well defined. Interestingly, the time frame of their effect excludes a glucose- and antiatherosclerotic-mediated effect. It would be of great importance to better understand SGLT2 inhibitor mechanisms of action since they could have a potential to be used in early stages of diabetes as cardioprotective agents. There are widely available biomarkers as well as echocardiography that are used in everyday clinical practice and could elucidate physiological mechanisms in the heart protection with SGLT2 inhibitors treatment but studies are still lacking. The purpose of this minireview is to summarize the latest concepts about SGLT2 inhibitors and its benefits regarding diabetic cardiomyopathy especially on its early stage development and to discuss controversies and potential future developments in the field.
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Affiliation(s)
| | - Maja Cigrovski Berković
- Department of Endocrinology, Diabetes, and Metabolism, University Hospital Centre "Sestre milosrdnice", Zagreb, Croatia
- Department for Medicine of Sports and Exercise, Faculty of Kinesiology, University of Zagreb, Zagreb, Croatia
| | - Nikola Bulj
- Department of Cardiology, University Hospital Centre "Sestre milosrdnice", Zagreb, Croatia
| | - Luka Rotkvić
- Department of Cardiology, Magdalena Clinic for Cardiovascular Disease, Krapinske Toplice, Croatia
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The Mystery of Diabetic Cardiomyopathy: From Early Concepts and Underlying Mechanisms to Novel Therapeutic Possibilities. Int J Mol Sci 2021; 22:ijms22115973. [PMID: 34205870 PMCID: PMC8198766 DOI: 10.3390/ijms22115973] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 05/26/2021] [Accepted: 05/30/2021] [Indexed: 02/07/2023] Open
Abstract
Diabetic patients are predisposed to diabetic cardiomyopathy, a specific form of cardiomyopathy which is characterized by the development of myocardial fibrosis, cardiomyocyte hypertrophy, and apoptosis that develops independently of concomitant macrovascular and microvascular diabetic complications. Its pathophysiology is multifactorial and poorly understood and no specific therapeutic guideline has yet been established. Diabetic cardiomyopathy is a challenging diagnosis, made after excluding other potential entities, treated with different pharmacotherapeutic agents targeting various pathophysiological pathways that need yet to be unraveled. It has great clinical importance as diabetes is a disease with pandemic proportions. This review focuses on the potential mechanisms contributing to this entity, diagnostic options, as well as on potential therapeutic interventions taking in consideration their clinical feasibility and limitations in everyday practice. Besides conventional therapies, we discuss novel therapeutic possibilities that have not yet been translated into clinical practice.
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Kralova E, Marusakova M, Hadova K, Krenek P, Klimas J. Dapagliflozin elevates plasma high-density lipoprotein levels and influences visceral fat gene expression in streptozotocin-induced diabetes mellitus. J Pharm Pharmacol 2021; 73:778-784. [PMID: 33749792 DOI: 10.1093/jpp/rgab005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/13/2021] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Dapagliflozin (Dapa) could potentially be used to treat type 1 diabetes mellitus. We tested the hypothesis that it would influence blood lipid levels and visceral fat accumulation in a rodent diabetic model. METHODS We used three groups of male Wistar rats: Controls, streptozotocin (STZ)-treated rats and STZ-treated orally with Dapa (STZ+Dapa), 10 mg/kg/day for six weeks. Blood glucose and serum lipids levels were determined. Plasma levels of lipases (hormone-sensitive lipase, HSL and lipoprotein lipase, LPL), adipokines (leptin and adiponectin) and proinflammatory cytokines [tumour necrosis factor-alpha (TNFα) and interleukin-6 (IL-6)] were determined by ELISA assays. mRNA levels in the perirenal fat were determined by real-time PCR. KEY FINDINGS Dapa suppressed STZ-related hyperglycemia by 20% (P < 0.05) and increased serum HDL when compared to the controls and the STZ-only treated rats (both P < 0.05). STZ treatment caused elevations of other serum lipids that were resistant to Dapa treatment. Dapa treatment also increased both plasma and visceral fat mRNA levels of leptin, LPL and IL-6, while decreasing plasma and fat expressions of HSL and TNFα compared to the STZ-only treated rats (all P < 0.05). CONCLUSIONS Our results suggest that Dapa, in addition to its antidiabetic effect, also influences the function of adipose tissue which could be beneficial in the treatment of diabetes.
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Affiliation(s)
- Eva Kralova
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Comenius University in Bratislava, Bratislava, Slovakia
| | - Margareta Marusakova
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Comenius University in Bratislava, Bratislava, Slovakia
| | - Katarina Hadova
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Comenius University in Bratislava, Bratislava, Slovakia
| | - Peter Krenek
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Comenius University in Bratislava, Bratislava, Slovakia
| | - Jan Klimas
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Comenius University in Bratislava, Bratislava, Slovakia
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Szekeres Z, Toth K, Szabados E. The Effects of SGLT2 Inhibitors on Lipid Metabolism. Metabolites 2021; 11:87. [PMID: 33535652 PMCID: PMC7912792 DOI: 10.3390/metabo11020087] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/22/2021] [Accepted: 01/28/2021] [Indexed: 02/08/2023] Open
Abstract
Sodium glucose co-transporter 2 (SGLT2) inhibitors are effective antihyperglycemic agents by inhibiting glucose reabsorption in the proximal tubule of the kidney. Besides improving glycemic control in patients with type 2 diabetes, they also have additional favorable effects, such as lowering body weight and body fat. Several clinical studies have demonstrated their positive effect in reducing cardiovascular morbidity and mortality. Furthermore, the use of SGLT2 inhibitors were associated with fewer adverse renal outcomes comparing to other diabetic agents, substantiating their renoprotective effect in diabetic patients. SGLT2 inhibitors have also remarkable effect on lipid metabolism acting at different cellular levels. By decreasing the lipid accumulation, visceral and subcutaneous fat, they do not only decrease the body weight but also change body composition. They also regulate key molecules in lipid synthesis and transportation, and they affect the oxidation of fatty acids. Notably, they shift substrate utilization from carbohydrates to lipids and ketone bodies. In this review we intended to summarize the role of SGLT2 inhibitors in lipid metabolism especially on lipoprotein levels, lipid regulation, fat storage and substrate utilization.
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Affiliation(s)
- Zsolt Szekeres
- 1st Department of Medicine, Division of Preventive Cardiology and Rehabilitation, University of Pecs, Medical School, H-7624 Pecs, Hungary;
| | - Kalman Toth
- 1st Department of Medicine, Division of Cardiology, University of Pecs, Medical School, H-7624 Pecs, Hungary;
| | - Eszter Szabados
- 1st Department of Medicine, Division of Preventive Cardiology and Rehabilitation, University of Pecs, Medical School, H-7624 Pecs, Hungary;
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Nada AM, Younan MA. Dapagliflozin improves cardiovascular risk factors in Emirati patients with T2DM. Ther Adv Endocrinol Metab 2021; 12:2042018821995364. [PMID: 33796252 PMCID: PMC7970182 DOI: 10.1177/2042018821995364] [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: 07/28/2020] [Accepted: 01/21/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Dapagliflozin is a sodium-glucose co transporter-2 inhibitor that proved efficacy in reduction of blood glucose level through extrusion of glucose in urine. It is used in treatment of type 2 diabetes mellitus (T2DM). It also has reported cardiovascular and renal benefits in patients with T2DM. Data are very limited about its effects in Emirati patients with diabetes. Our aim was to evaluate dapagliflozin treatment in Emirati patients with T2DM. PATIENTS AND METHODS This is a retrospective study involving 89 diabetes patients who were using dapagliflozin 10 mg once daily as add-on therapy for 12 months. All patients had T2DM, aged over 18 years and had an estimated glomerular filtration rate (eGFR) over 60 ml/min/1.73 m². Body weight, height, body mass index, sitting blood pressure and heart rate were collected. Fasting plasma glucose, glycosylated hemoglobin (HbA1c), lipid profile and other available biochemical parameters, for example, creatinine, blood urea nitrogen, and urine albumin/creatinine ratio were traced from medical records and eGFR was calculated. RESULTS Patients were aged 62.3 ± 9.4 years with a median duration of diabetes of 15 (10-20) years. Data were analyzed before, at 6 months and 12 months of treatment. Fasting plasma glucose, HbA1c, body mass index, systolic and diastolic blood pressure significantly decreased (p = 0.002, p < 0.0005, p < 0.002, p < 0.0005, p < 0.0005, respectively). The median reduction of HbA1c was 0.7% (0.2-1.2) and 0.9% (0.5-1.8) at 6 and 12 months, respectively. Systolic blood pressure decreased by a median of 7 mmHg (4-20 mmHg) and 9 mmHg (1-10 mmHg) on the 6th and 12th month of treatment, respectively, while the diastolic decreased by a median of 3 mmHg (4 to 10 mmHg) and 6 mmHg (1-10 mmHg); without increase in heart rate (p = 0.188). A significant reduction of body mass index, C-reactive protein and rate pressure product was noticed (p = 0.002, p = 0.001, p < 0.0005, respectively). No decline in eGFR or microalbuminuria was noticed. Stage I chronic kidney disease with eGFR < 90 ml/min/1.73 m² showed continuous progressive reduction of HbA1c without a significant change in other variables. CONCLUSION Our data indicate improved cardiovascular risk profile in dapagliflozin-treated Emirati patients with T2DM.
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Affiliation(s)
| | - Mariam Adel Younan
- Assistant Professor of Clinical Pathology, Cairo
Medical School, Kasr Al-Ainy, Egypt; Specialist Clinical Pathologist,
Zulekha Hospital, Sharjah, UAE
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Newman CB, Blaha MJ, Boord JB, Cariou B, Chait A, Fein HG, Ginsberg HN, Goldberg IJ, Murad MH, Subramanian S, Tannock LR. Lipid Management in Patients with Endocrine Disorders: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2020; 105:5909161. [PMID: 32951056 DOI: 10.1210/clinem/dgaa674] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 09/17/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE This guideline will provide the practicing endocrinologist with an approach to the assessment and treatment of dyslipidemia in patients with endocrine diseases, with the objective of preventing cardiovascular (CV) events and triglyceride-induced pancreatitis. The guideline reviews data on dyslipidemia and atherosclerotic cardiovascular disease (ASCVD) risk in patients with endocrine disorders and discusses the evidence for the correction of dyslipidemia by treatment of the endocrine disease. The guideline also addresses whether treatment of the endocrine disease reduces ASCVD risk. CONCLUSION This guideline focuses on lipid and lipoprotein abnormalities associated with endocrine diseases, including diabetes mellitus, and whether treatment of the endocrine disorder improves not only the lipid abnormalities, but also CV outcomes. Based on the available evidence, recommendations are made for the assessment and management of dyslipidemia in patients with endocrine diseases.
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Affiliation(s)
- Connie B Newman
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, New York University Grossman School of Medicine, New York, New York
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland
| | - Jeffrey B Boord
- Department of Administration and Parkview Physicians Group Endocrinology Section, Parkview Health System, Fort Wayne, Indiana
| | - Bertrand Cariou
- Department of Endocrinology, L'institut du thorax, INSERM, CNRS, UNIV Nantes, CHU Nantes, Nantes, France
| | - Alan Chait
- Department of Medicine, University of Washington, Seattle, Washington
| | - Henry G Fein
- Department of Medicine, Division of Endocrinology, Sinai Hospital, Baltimore, Maryland
| | - Henry N Ginsberg
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Ira J Goldberg
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, New York University Grossman School of Medicine, New York, New York
| | - M Hassan Murad
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
| | | | - Lisa R Tannock
- Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
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Grubić Rotkvić P, Cigrovski Berković M, Bulj N, Rotkvić L, Ćelap I. Sodium-glucose cotransporter 2 inhibitors’ mechanisms of action in heart failure. World J Diabetes 2020; 11:269-279. [PMID: 32843930 PMCID: PMC7415232 DOI: 10.4239/wjd.v11.i7.269] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/11/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023] Open
Abstract
Three major cardiovascular outcome trials (CVOTs) with a new class of antidiabetic drugs - sodium-glucose cotransporter 2 (SGLT2) inhibitors (EMPA-REG OUTCOME trial with empagliflozin, CANVAS Program with canagliflozin, DECLARE-TIMI 58 with dapagliflozin) unexpectedly showed that cardiovascular outcomes could be improved possibly due to a reduction in heart failure risk, which seems to be the most sensitive outcome of SGLT2 inhibition. No other CVOT to date has shown any significant benefit on heart failure events. Even more impressive findings came recently from the DAPA-HF trial in patients with confirmed and well-treated heart failure: Dapagliflozin was shown to reduce heart failure risk for patients with heart failure with reduced ejection fraction regardless of diabetes status. Nevertheless, despite their possible wide clinical implications, there is much doubt about the mechanisms of action and a lot of questions to unravel, especially now when their benefits translated to non-diabetic patients, rising doubts about the validity of some current mechanistic assumptions.The time frame of their cardiovascular benefits excludes glucose-lowering and antiatherosclerotic-mediated effects and multiple other mechanisms, direct cardiac as well as systemic, are suggested to explain their early cardiorenal benefits. These are: Anti-inflammatory, antifibrotic, antioxidative, antiapoptotic properties, then renoprotective and hemodynamic effects, attenuation of glucotoxicity, reduction of uric acid levels and epicardial adipose tissue, modification of neurohumoral system and cardiac fuel energetics, sodium-hydrogen exchange inhibition. The most logic explanation seems that SGLT2 inhibitors timely target various mechanisms underpinning heart failure pathogenesis. All the proposed mechanisms of their action could interfere with evolution of heart failure and are discussed separately within the main text.
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Affiliation(s)
| | - Maja Cigrovski Berković
- Department of Endocrinology, Diabetes, Metabolism and Clinical Pharmacology, University Hospital, Zagreb 10000, Croatia
- Department for Medicine of Sports and Exercise, Faculty of Kinesiology University of Zagreb, Zagreb 10000, Croatia
| | - Nikola Bulj
- Department of Cardiology, University Hospital Centre, Zagreb 10000, Croatia
| | - Luka Rotkvić
- Department of Cardiology, Magdalena Clinic for Cardiovascular Disease, Krapinske Toplice 49217, Croatia
| | - Ivana Ćelap
- Department of Clinical Chemistry, University Hospital Centre, Zagreb 10000, Croatia
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Patti AM, Rizvi AA, Giglio RV, Stoian AP, Ligi D, Mannello F. Impact of Glucose-Lowering Medications on Cardiovascular and Metabolic Risk in Type 2 Diabetes. J Clin Med 2020; 9:jcm9040912. [PMID: 32225082 PMCID: PMC7230245 DOI: 10.3390/jcm9040912] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/20/2020] [Accepted: 03/24/2020] [Indexed: 02/07/2023] Open
Abstract
Type 2 Diabetes Mellitus (T2DM) is associated with a high risk of atherosclerotic cardiovascular (CV) disease. Among the well-known pathophysiologic factors, crucial roles are played by endothelial dysfunction (caused by oxidative stress and inflammation hyperglycemia-linked), increased activity of nuclear factor kB, altered macrophage polarization, and reduced synthesis of resident endothelial progenitor cells. As consequence, a potentially rapid progression of the atherosclerotic disease with a higher propensity to unstable plaque is arguable, finally leading to significantly increased cardiovascular mortality. Main managements are focused on both prevention and early diagnosis, by targeted treatment of hyperglycemia and vascular complications. Innovative therapeutic approaches for T2DM seek to customize the antidiabetic treatment to each patient in order to optimize glucose-lowering effects, minimize hypoglycemia and adverse effects, and prevent cardiovascular events. The newer drugs (e.g., Glucagon Like Peptide-1 Receptor Agonists, GLP-1 RAs; Sodium GLucose coTransporter-2 inhibitors, SGLT2is; DiPeptidyl Peptidase-4 inhibitors, and DPP4is) impact body weight, lipid parameters, and blood pressure, as well as endothelial (dys)functions, inflammatory markers, biomarkers of both oxidative stress, and subclinical atherosclerosis. The present review summarizes the results of the main trials focused on the cardiovascular safety of these drugs from the CV standpoint.
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Affiliation(s)
- Angelo Maria Patti
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), School of Medicine, University of Palermo, 90121 Palermo, Italy;
- Correspondence: (A.M.P.); (F.M.)
| | - Ali A Rizvi
- Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA;
| | - Rosaria Vincenza Giglio
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), School of Medicine, University of Palermo, 90121 Palermo, Italy;
| | - Anca Pantea Stoian
- Faculty of General Medicine, Diabetes, Nutrition and Metabolic Diseases Department, Carol Davila University, 050474 Bucharest, Romania;
| | - Daniela Ligi
- Department of Biomolecular Sciences, Section of Biochemistry and Biotechnology, University Carlo Bo of Urbino, 61029 Urbino, Italy;
| | - Ferdinando Mannello
- Department of Biomolecular Sciences, Section of Biochemistry and Biotechnology, University Carlo Bo of Urbino, 61029 Urbino, Italy;
- Correspondence: (A.M.P.); (F.M.)
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15
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Yehya A, Sadhu A. Sodium-Glucose Cotransporter 2 Inhibitor-Associated Prolonged Euglycemic Diabetic Ketoacidosis in Type 2 Diabetes: A Case Report and Literature Review. Clin Diabetes 2020; 38:112-116. [PMID: 31975762 PMCID: PMC6969664 DOI: 10.2337/cd19-0035] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Ahmad Yehya
- Division of Endocrinology, Diabetes & Metabolism, Houston Methodist Hospital, Houston, TX
| | - Archana Sadhu
- Division of Endocrinology, Diabetes & Metabolism, Houston Methodist Hospital, Houston, TX
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Basu D, Huggins LA, Scerbo D, Obunike J, Mullick AE, Rothenberg PL, Di Prospero NA, Eckel RH, Goldberg IJ. Mechanism of Increased LDL (Low-Density Lipoprotein) and Decreased Triglycerides With SGLT2 (Sodium-Glucose Cotransporter 2) Inhibition. Arterioscler Thromb Vasc Biol 2019; 38:2207-2216. [PMID: 30354257 DOI: 10.1161/atvbaha.118.311339] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Objective- SGLT2 (sodium-glucose cotransporter 2) inhibition in humans leads to increased levels of LDL (low-density lipoprotein) cholesterol and decreased levels of plasma triglyceride. Recent studies, however, have shown this therapy to lower cardiovascular mortality. In this study, we aimed to determine how SGLT2 inhibition alters circulating lipoproteins. Approach and Results- We used a mouse model expressing human CETP (cholesteryl ester transfer protein) and human ApoB100 (apolipoprotein B100) to determine how SGLT2 inhibition alters plasma lipoprotein metabolism. The mice were fed a high-fat diet and then were made partially insulin deficient using streptozotocin. SGLT2 was inhibited using a specific antisense oligonucleotide or canagliflozin, a clinically available oral SGLT2 inhibitor. Inhibition of SGLT2 increased circulating levels of LDL cholesterol and reduced plasma triglyceride levels. SGLT2 inhibition was associated with increased LpL (lipoprotein lipase) activity in the postheparin plasma, decreased postprandial lipemia, and faster clearance of radiolabeled VLDL (very-LDL) from circulation. Additionally, SGLT2 inhibition delayed turnover of labeled LDL from circulation. Conclusions- Our studies in diabetic CETP-ApoB100 transgenic mice recapitulate many of the changes in circulating lipids found with SGLT2 inhibition therapy in humans and suggest that the increased LDL cholesterol found with this therapy is because of reduced clearance of LDL from the circulation and greater lipolysis of triglyceride-rich lipoproteins. Most prominent effects of SGLT2 inhibition in the current mouse model were seen with antisense oligonucleotides-mediated knockdown of SGLT2.
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Affiliation(s)
- Debapriya Basu
- From the Division of Endocrinology, Diabetes and Metabolism, New York University School of Medicine (D.B., L.-A.H., D.S., J.O., I.J.G.)
| | - Lesley-Ann Huggins
- From the Division of Endocrinology, Diabetes and Metabolism, New York University School of Medicine (D.B., L.-A.H., D.S., J.O., I.J.G.)
| | - Diego Scerbo
- From the Division of Endocrinology, Diabetes and Metabolism, New York University School of Medicine (D.B., L.-A.H., D.S., J.O., I.J.G.)
| | - Joseph Obunike
- From the Division of Endocrinology, Diabetes and Metabolism, New York University School of Medicine (D.B., L.-A.H., D.S., J.O., I.J.G.)
| | - Adam E Mullick
- Cardiovascular Antisense Drug Discovery, Ionis Pharmaceuticals, Carlsbad, CA (A.E.M.)
| | - Paul L Rothenberg
- Cardiovascular and Metabolism Clinical Development, Janssen Research & Development, LLC, Raritan, NJ (P.L.R., N.A.D.P.)
| | - Nicholas A Di Prospero
- Cardiovascular and Metabolism Clinical Development, Janssen Research & Development, LLC, Raritan, NJ (P.L.R., N.A.D.P.)
| | - Robert H Eckel
- Division of Endocrinology, University of Colorado, Anschutz Campus, Denver (R.H.E.)
| | - Ira J Goldberg
- From the Division of Endocrinology, Diabetes and Metabolism, New York University School of Medicine (D.B., L.-A.H., D.S., J.O., I.J.G.)
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17
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Sakai T, Miura S. Effects of Sodium-Glucose Cotransporter 2 Inhibitor on Vascular Endothelial and Diastolic Function in Heart Failure With Preserved Ejection Fraction - Novel Prospective Cohort Study. Circ Rep 2019; 1:286-295. [PMID: 33693152 PMCID: PMC7892484 DOI: 10.1253/circrep.cr-19-0018] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background: Pathogenesis of heart failure with preserved ejection fraction (HFpEF) may involve endothelial dysfunction and abnormal vascular structure. Sodium-glucose cotransporter 2 (SGLT2) inhibitors have beneficial cardiovascular effects and may improve vascular function in patients with HFpEF. Methods and Results: We recruited 184 patients with type 2 diabetes and HFpEF (mean age, 66.0±14.4 years) who were scheduled for treatment with SGLT2 inhibitors, had transthoracic echocardiogram to identify diastolic function, and flow-mediated dilation (FMD) to evaluate endothelial function, and assessed cardio-ankle vascular index (CAVI) and carotid intima-media thickness as indices of vascular function and vascular structure, respectively. Body weight, systolic blood pressure, diastolic blood pressure, triglycerides, remnant lipoprotein cholesterol, fasting plasma glucose, hemoglobin A1c, urinary albumin/creatinine ratio, and insulin resistance (IR) decreased, hematocrit and FMD increased significantly, and CAVI decreased significantly, after 12-week treatment (P<0.05). Short-term SGLT2 inhibitors improved diastolic function, significantly reducing the mitral ratios of septal E/early septal annular tissue Doppler velocity (P=0.003) and lateral E/early lateral e' (P=0.044). On multiple regression statistically significant associations were seen between ∆mean E/e' and ∆FMD, ∆CAVI, and ∆IR. Conclusions: SGLT2 inhibitors can improve diastolic function in patients with type 2 diabetes, suggesting that current treatment policies for diabetes should be re-examined. Further prospective studies with larger sample sizes could provide mechanistic insights into the benefits of SGLT2 inhibitors.
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Affiliation(s)
- Takaaki Sakai
- Department of Cardiology, Ichijyukai NISHIO Hospital Fukuoka Japan.,Department of Cardiology, Fukuoka University School of Medicine Fukuoka Japan
| | - Shinichiro Miura
- Department of Cardiology, Fukuoka University School of Medicine Fukuoka Japan
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Park SH, Choi YJ, Rhee EJ, Huh KB. Retrospective Analysis of the Efficacy of Dapagliflozin in Patients with Type 2 Diabetes in a Primary Clinic in Korea. Endocrinol Metab (Seoul) 2019; 34:70-79. [PMID: 30912340 PMCID: PMC6435850 DOI: 10.3803/enm.2019.34.1.70] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 01/20/2019] [Accepted: 01/28/2019] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND We aimed to retrospectively analyze the efficacy of 10 mg dapagliflozin (DAPA), which is a sodium-glucose cotransporter-2 inhibitor, in Korean patients with type 2 diabetes who visited a primary diabetes clinic. METHODS In total, 83 patients with type 2 diabetes, who received treatment with DAPA for the first time in a primary diabetes clinic between January 2015 and October 2015, were included in the study. The effect of DAPA in lowering glycosylated hemoglobin (HbA1c) levels was evaluated via chart review at 6 months follow-up. The patients were categorized into five groups according to add-on to or switched from other glucose-lowering agents: add-on to metformin (MET, n=10), add-on to MET+dipeptidyl peptidase 4 inhibitor (DPP4i, n=12), switched from sulfonylurea (SU, n=13), switched from DPP4i (n=11), and switched from thiazolidinedione (TZD, n=37). All the participants had already used MET for their regimen. RESULTS Treatment with DAPA reduced HbA1c level by 1.2%±0.8%. Moreover, a significant decrease was observed in all subgroups: add-on to MET, -1.2%±0.7%; add-on to MET+DPP4i, -1.4%±0.8%; switched from SU, -1.4%±0.7%; switched from DPP4i, -0.5%±0.7%; and switched from TZD, -1.2%±0.9% (P<0.01). A significant decrease in body weight (-3.1±2.6 kg, P<0.001) was observed after DAPA administration. Estimated glomerular filtration rate and urine microalbumin were significantly decreased after 6 months of treatment with DAPA (-4.0±13.5 mL/min/1.73 m², P=0.03; -23.6±45.9 mg/L, P<0.001). CONCLUSION Treatment with DAPA, whether added to or switched from other glucose-lowering agents, significantly decreased HbA1c levels in Korean patients with type 2 diabetes who visited a single primary diabetes clinic. DAPA can be considered as an optimal second-line treatment for patients with type 2 diabetes, as supported by real-world evidence studies.
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Affiliation(s)
- Sang Hyun Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Ju Choi
- Huh's Diabetes Center and 21st Century Diabetes and Vascular Research Institute, Seoul, Korea
| | - Eun Jung Rhee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Kab Bum Huh
- Huh's Diabetes Center and 21st Century Diabetes and Vascular Research Institute, Seoul, Korea.
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19
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Sertbas M, Sertbas Y, Okuroglu N, Akyildiz AB, Sancak S, Ozdemir A. Effıcacy and safety of dapagliflozin on diabetic patients receiving high-doses of insulin. Pak J Med Sci 2019; 35:399-403. [PMID: 31086522 PMCID: PMC6500813 DOI: 10.12669/pjms.35.2.21] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Revised: 12/12/2018] [Accepted: 01/28/2019] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE In this study we aimed to investigate the efficacy and safety of dapagliflozin addition to diabetic patients using high dose insulin. METHODS The current study was carried out in the outpatient diabetic clinics of Fatih Sultan Mehmet Education and Research Hospital. Thirty diabetic patients who were receiving high dose (>0,5U/kg) insulin and oral antidiabetic treatment (other than SGLT 2 inhibitors) were included in this study. Primary end point was the change in HbA1c, insulin doses and serum electrolyte from the addition of dapagliflozin 10 mg to the week 12. RESULTS At the end of three month BMI were obviously decreased from 33.31 ±4.51 to 32.14 ±4.66 (p: 0.001). There was also an evident decrease of insulin requirement from 76 ±23.15 U/kg to 57.60 ±17.61 U/day (p<0.001). As well as the decrease in insulin doses, there was also a significant decline in HbA1c (Δ 1.6 %) and fasting blood glucose levels (Δ68.6 mg/dl) (p<0.001). Among serum electrolyte levels slight but meaningful increase of blood urea nitrogen (BUN) and sodium (Na) levels were seen (p: 0.044 and p: 0.026). There were no significant changes in serum cholesterol levels with electrolytes such as potassium, calcium, phosphorus magnesium and vitamin D (p> 0.05). CONCLUSION In diabetic patients with inadequately controlled glucose regulation despite high-dose insulin therapy, dapagliflozin may be an alternative combination choice to decrease the need of insulin dose and obtain an optimal HbA1c, fasting plasma glucose levels and weight without major side effects.
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Affiliation(s)
- Meltem Sertbas
- Meltem Sertbas, Department of Internal Medicine, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey
| | - Yasar Sertbas
- Yasar Sertbas Department of Internal Medicine, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey
| | - Nalan Okuroglu
- Nalan Okurglu, Department of Internal Medicine, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey
| | - Ali Burkan Akyildiz
- Ali Burkan Akyildiz, Department of Internal Medicine, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey
| | - Seda Sancak
- Seda Sancak, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey
| | - Ali Ozdemir
- Ali Ozdemir, Department of Internal Medicine, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey
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Adingupu DD, Göpel SO, Grönros J, Behrendt M, Sotak M, Miliotis T, Dahlqvist U, Gan LM, Jönsson-Rylander AC. SGLT2 inhibition with empagliflozin improves coronary microvascular function and cardiac contractility in prediabetic ob/ob -/- mice. Cardiovasc Diabetol 2019; 18:16. [PMID: 30732594 PMCID: PMC6366096 DOI: 10.1186/s12933-019-0820-6] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 01/28/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Sodium-glucose cotransporter 2 inhibitors (SGLT2i) is the first class of anti-diabetes treatment that reduces mortality and risk for hospitalization due to heart failure. In clinical studies it has been shown that SGLT2i's promote a general shift to fasting state metabolism characterized by reduced body weight and blood glucose, increase in glucagon/insulin ratio and modest increase in blood ketone levels. Therefore, we investigated the connection between metabolic changes and cardiovascular function in the ob/ob-/- mice; a rodent model of early diabetes with specific focus on coronary microvascular function. Due to leptin deficiency these mice develop metabolic syndrome/diabetes and hepatic steatosis. They also develop cardiac contractile and microvascular dysfunction and are thus a promising model for translational studies of cardiometabolic diseases. We investigated whether this mouse model responded in a human-like manner to empagliflozin treatment in terms of metabolic parameters and tested the hypothesis that it could exert direct effects on coronary microvascular function and contractile performance. METHODS Lean, ob/ob-/- untreated and ob/ob-/- treated with SGLT2i were followed for 10 weeks. Coronary flow velocity reserve (CFVR) and fractional area change (FAC) were monitored with non-invasive Doppler ultrasound imaging. Food intake, urinary glucose excursion and glucose control via HbA1c measurements were followed throughout the study. Liver steatosis was assessed by histology and metabolic parameters determined at the end of the study. RESULTS Sodium-glucose cotransporter 2 inhibitors treatment of ob/ob-/- animals resulted in a switch to a more catabolic state as observed in clinical studies: blood cholesterol and HbA1c were decreased whereas glucagon/insulin ratio and ketone levels were increased. SGLT2i treatment reduced liver triglyceride, steatosis and alanine aminotransferase, an indicator for liver dysfunction. L-Arginine/ADMA ratio, a marker for endothelial function was increased. SGLT2i treatment improved both cardiac contractile function and coronary microvascular function as indicated by improvement of FAC and CFVR, respectively. CONCLUSIONS Sodium-glucose cotransporter 2 inhibitors treatment of ob/ob-/- mice mimics major clinical findings regarding metabolism and cardiovascular improvements and is thus a useful translational model. We demonstrate that SGLT2 inhibition improves coronary microvascular function and contractile performance, two measures with strong predictive values in humans for CV outcome, alongside with the known metabolic changes in a preclinical model for prediabetes and heart failure.
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Affiliation(s)
- Damilola D. Adingupu
- Bioscience, Cardiovascular, Renal and Metabolic Diseases, IMED Biotech Unit, AstraZeneca Gothenburg, Pepparedsleden 1, Mölndal, 431 83 Gothenburg, Sweden
| | - Sven O. Göpel
- Bioscience, Cardiovascular, Renal and Metabolic Diseases, IMED Biotech Unit, AstraZeneca Gothenburg, Pepparedsleden 1, Mölndal, 431 83 Gothenburg, Sweden
| | - Julia Grönros
- Bioscience, Cardiovascular, Renal and Metabolic Diseases, IMED Biotech Unit, AstraZeneca Gothenburg, Pepparedsleden 1, Mölndal, 431 83 Gothenburg, Sweden
| | - Margareta Behrendt
- Bioscience, Cardiovascular, Renal and Metabolic Diseases, IMED Biotech Unit, AstraZeneca Gothenburg, Pepparedsleden 1, Mölndal, 431 83 Gothenburg, Sweden
| | - Matus Sotak
- Bioscience, Cardiovascular, Renal and Metabolic Diseases, IMED Biotech Unit, AstraZeneca Gothenburg, Pepparedsleden 1, Mölndal, 431 83 Gothenburg, Sweden
| | - Tasso Miliotis
- Translational Science, Cardiovascular, Renal and Metabolic Diseases, IMED Biotech Unit, AstraZeneca Gothenburg, Gothenburg, Sweden
| | - Ulrika Dahlqvist
- Bioscience, Cardiovascular, Renal and Metabolic Diseases, IMED Biotech Unit, AstraZeneca Gothenburg, Pepparedsleden 1, Mölndal, 431 83 Gothenburg, Sweden
| | - Li-Ming Gan
- Early Clinical Development, Cardiovascular, Renal and Metabolic Diseases, IMED Biotech Unit, AstraZeneca Gothenburg, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ann-Cathrine Jönsson-Rylander
- Bioscience, Cardiovascular, Renal and Metabolic Diseases, IMED Biotech Unit, AstraZeneca Gothenburg, Pepparedsleden 1, Mölndal, 431 83 Gothenburg, Sweden
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Patti AM, Giglio RV, Papanas N, Rizzo M, Rizvi AA. Future perspectives of the pharmacological management of diabetic dyslipidemia. Expert Rev Clin Pharmacol 2019; 12:129-143. [PMID: 30644763 DOI: 10.1080/17512433.2019.1567328] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Diabetic dyslipidemia is frequent among patients with type 2 diabetes mellitus (T2DM) and is characterized by an increase in triglycerides (TGs), low-density lipoprotein cholesterol (LDL-C), and small-dense (atherogenic) particles, and by a decrease in low high-density lipoprotein cholesterol (HDL-C) and apolipoprotein (Apo) A1 that are strongly related to insulin resistance. The increased flux of free fatty acids from adipose tissue to the liver aggravates hepatic insulin resistance and promotes all of aspects of the dyslipidemic state. Areas covered: Statins are the first-line agents for treatment while other lipid-lowering drugs (ezetimibe, fibrate and proprotein convertase subtilisin/kexin type 9) or novel anti-diabetic agents (dipeptidyl peptidase-4 inhibitors (DPP-4is), glucagon like peptide-1 receptor agonist (GLP-1RA), sodium/glucose cotransporter 2 inhibitors (SGLT2is)) or nutraceuticals (berberine, omega 3 fatty acid, red yeast rice) can be used alone or in combination. Expert commentary: In patients with T2DM, lipid abnormalities should be identified and treated as part of the overall diabetic treatment, in order to prevent cardiovascular disease. The choice of drugs to be used is mainly based on the lipid profile and on the characteristic lipoprotein abnormalities; the use of new drugs for the treatment of hyperglycemia and lipids alteration in these patients can improve diabetic dyslipidemia.
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Affiliation(s)
- Angelo Maria Patti
- a Biomedical Department of Internal Medicine and Medical Specialties , University of Palermo , Palermo , Italy
| | - Rosaria Vincenza Giglio
- a Biomedical Department of Internal Medicine and Medical Specialties , University of Palermo , Palermo , Italy
| | - Nikolaos Papanas
- b Diabetes Centre, Second Department of Internal Medicine , Democritus University of Thrace, University Hospital of Alexandroupolis , Alexandroupolis , Greece
| | - Manfredi Rizzo
- a Biomedical Department of Internal Medicine and Medical Specialties , University of Palermo , Palermo , Italy.,c Division of Endocrinology , Diabetes and Metabolism University of South Carolina School of Medicine Columbia , South Carolina , SC , USA
| | - Ali A Rizvi
- c Division of Endocrinology , Diabetes and Metabolism University of South Carolina School of Medicine Columbia , South Carolina , SC , USA
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Yeo SM, Park H, Paek JH, Park WY, Han S, Park SB, Jin K. Ketoacidosis with euglycemia in a patient with type 2 diabetes mellitus taking dapagliflozin: A case report. Medicine (Baltimore) 2019; 98:e14150. [PMID: 30653152 PMCID: PMC6370067 DOI: 10.1097/md.0000000000014150] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Dapagliflozin (a sodium-glucose cotransporter-2 [SGLT2] inhibitor) represents the most recently approved class of oral medications for the treatment of type 2 diabetes. Dapagliflozin lowers plasma glucose concentration by inhibiting the renal reuptake of glucose in the proximal renal tubules. In 2015, the US Food and Drug Administration released a warning concerning a potential increased risk of ketoacidosis in patients taking this medication. PATIENT CONCERNS We present the case of a 23-year-old woman with type 2 diabetes treated with dapagliflozin (10 mg, once a day) for 2 years who presented to the emergency department with abdominal pain. DIAGNOSES We diagnosed her with severe ketoacidosis with a normal glucose level (177 mg/dL) due to dapagliflozin, accompanying acute pancreatitis due to hypertriglyceridemia. We concluded that the precipitating factor for euglycemic ketoacidosis was pseudomembranous colitis. INTERVENTIONS She was treated with intravenous infusions of insulin, isotonic saline, and sodium bicarbonate as diabetic ketoacidosis treatment. OUTCOMES She was in shock with severe metabolic acidosis. After continuous renal replacement therapy, the uncontrolled metabolic ketoacidosis was treated, and she is currently under follow-up while receiving metformin (500 mg, once a day) and short- and long-acting insulins (8 units 3 times and 20 units once a day). LESSONS We report an unusual case of SGLT2 inhibitor-induced euglycemic ketoacidosis recovered by continuous renal replacement therapy in a patient with type 2 diabetes and recurrent acute pancreatitis due to hypertriglyceridemia. We diagnosed a rare complication of the SGLT2 inhibitor in a patient with type 2 diabetes in whom uncontrolled metabolic ketoacidosis could be effectively managed via continuous renal replacement therapy.
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Affiliation(s)
- Sang Mok Yeo
- Department of Internal Medicine, Keimyung University School of Medicine
| | - Hayeon Park
- Department of Internal Medicine, Keimyung University School of Medicine
| | - Jin Hyuk Paek
- Department of Internal Medicine, Keimyung University School of Medicine
- Keimyung University Kidney Institute, Daegu, Korea
| | - Woo Yeong Park
- Department of Internal Medicine, Keimyung University School of Medicine
- Keimyung University Kidney Institute, Daegu, Korea
| | - Seungyeup Han
- Department of Internal Medicine, Keimyung University School of Medicine
- Keimyung University Kidney Institute, Daegu, Korea
| | - Sung Bae Park
- Department of Internal Medicine, Keimyung University School of Medicine
- Keimyung University Kidney Institute, Daegu, Korea
| | - Kyubok Jin
- Department of Internal Medicine, Keimyung University School of Medicine
- Keimyung University Kidney Institute, Daegu, Korea
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Kuriyama S. Protection of the kidney with sodium–glucose cotransporter 2 inhibitors: potential mechanisms raised by the large-scaled randomized control trials. Clin Exp Nephrol 2018; 23:304-312. [DOI: 10.1007/s10157-018-1673-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 11/14/2018] [Indexed: 12/15/2022]
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Fioretto P, Del Prato S, Buse JB, Goldenberg R, Giorgino F, Reyner D, Langkilde AM, Sjöström CD, Sartipy P. Efficacy and safety of dapagliflozin in patients with type 2 diabetes and moderate renal impairment (chronic kidney disease stage 3A): The DERIVE Study. Diabetes Obes Metab 2018; 20:2532-2540. [PMID: 29888547 PMCID: PMC6175614 DOI: 10.1111/dom.13413] [Citation(s) in RCA: 112] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 05/31/2018] [Accepted: 06/08/2018] [Indexed: 01/10/2023]
Abstract
AIMS Dapagliflozin is a selective inhibitor of sodium glucose co-transporter 2 (SGLT2). This study assessed the efficacy and safety of dapagliflozin 10 mg vs placebo in patients with type 2 diabetes (T2D) and moderate renal impairment (estimated glomerular filtration rate [eGFR], 45-59 mL/min/1.73 m2 ; chronic kidney disease [CKD] stage 3A). MATERIALS AND METHODS In this double-blind, parallel group, Phase 3 study (NCT02413398, clinicaltrials.gov) patients with inadequately controlled T2D (HbA1c 7.0%-11.0%) were randomized (1:1) to dapagliflozin 10 mg once daily (N = 160) or matching placebo (N = 161) for 24 weeks. Randomization was stratified by pre-enrolment glucose-lowering therapy. The primary endpoint was change from baseline in HbA1c at Week 24. RESULTS At Week 24, compared with placebo, dapagliflozin significantly decreased HbA1c (difference [95% CI], -0.34% [-0.53, -0.15]; P < 0.001), body weight (difference [95% CI], -1.25 kg [-1.90, -0.59]; P < 0.001), fasting plasma glucose (difference [95% CI], -0.9 mmol/L [-1.5, -0.4]; P = 0.001) and systolic blood pressure (difference [95% CI], -3.1 mm Hg [-6.3, 0.0]; P < 0.05). Decreases from baseline in eGFR were greater with dapagliflozin than placebo at Week 24 (-2.49 mL/min/1.73 m2 [-4.96, -0.02]), however, eGFR returned to baseline levels at Week 27 (3 weeks post-treatment) (0.61 mL/min/1.73 m2 [-1.59, 2.81]). No increase in adverse events (AEs; 41.9% vs 47.8%) or serious AEs (5.6% vs 8.7%) were reported with dapagliflozin versus placebo. No AEs of bone fractures, amputations or DKA were reported. CONCLUSIONS The findings of this study (NCT02413398, clinicaltrials.gov) support the positive benefit/risk profile of dapagliflozin for the treatment of patients with T2D and CKD 3A.
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Affiliation(s)
| | - Stefano Del Prato
- Department of Clinical & Experimental MedicineUniversity of PisaPisaItaly
| | - John B. Buse
- Department of MedicineUniversity of North Carolina School of MedicineChapel HillNorth Carolina
| | | | - Francesco Giorgino
- Department of Emergency and Organ TransplantationUniversity of Bari Aldo MoroBariItaly
| | | | | | | | - Peter Sartipy
- AstraZenecaGothenburgSweden
- School of Bioscience, Systems Biology Research CenterUniversity of SkövdeSkövdeSweden
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Pancholia AK. Sodium-glucose cotransporter-2 inhibition for the reduction of cardiovascular events in high-risk patients with diabetes mellitus. Indian Heart J 2018; 70:915-921. [PMID: 30580866 PMCID: PMC6306386 DOI: 10.1016/j.ihj.2018.08.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 08/21/2018] [Accepted: 08/28/2018] [Indexed: 12/11/2022] Open
Abstract
Patients with type 2 diabetes mellitus (T2DM) exhibit an increased risk for cardiovascular (CV) events. Hyperglycemia itself contributes to the pathogenesis of atherosclerosis and heart failure (HF) in these patients, but glucose-lowering strategies studied to date have had little or no impact on reducing CV risk, especially in patients with a long duration of T2DM and prevalent CV disease (CVD). Sodium-glucose cotransporter-2 (SGLT2) inhibitors are the new class of glucose-lowering medications that increase urinary glucose excretion, thus improving glycemic control, independent of insulin. The recently published CV outcome trial, Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients-Removing Excess Glucose (EMPA-REG OUTCOME), demonstrated that the SGLT2 inhibitor empagliflozin significantly reduced the combined CV end point of CV death, nonfatal myocardial infarction, and nonfatal stroke vs. placebo in a population of patients with T2DM and prevalent atherosclerotic CVD. In addition, and quite unexpectedly, empagliflozin significantly and robustly reduced the individual end points of CV death, overall mortality, and hospitalization for HF in this high-risk population. Several beneficial factors beyond glucose control, such as weight loss, lowering blood pressure, sodium depletion, renal hemodynamic effects, effects on myocardial energetics, and/or neurohormonal effects, have been seen with SGLT2 inhibition.
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Affiliation(s)
- A K Pancholia
- Medicine and Preventive Cardiology, Arihant Hospital and Research Centre, Gumashta Nagar, Indore.
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Cai X, Gao X, Yang W, Chen Y, Zhang S, Zhou L, Han X, Ji L. No disparity of the efficacy and all-cause mortality between Asian and non-Asian type 2 diabetes patients with sodium-glucose cotransporter 2 inhibitors treatment: A meta-analysis. J Diabetes Investig 2018; 9:850-861. [PMID: 29029369 PMCID: PMC6031489 DOI: 10.1111/jdi.12760] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 09/23/2017] [Accepted: 10/04/2017] [Indexed: 12/25/2022] Open
Abstract
AIMS/INTRODUCTION To evaluate whether there is disparity of the efficacy and all-cause mortality and other adverse effects between Asian and non-Asian patients with sodium-glucose cotransporter 2 (SGLT2) inhibitors treatment. MATERIALS AND METHODS Randomized clinical trials publicly available before January 2017, comparing SGLT2 inhibitors treatment with a placebo in type 2 diabetes patients were identified. The association between treatment and outcomes was estimated by computing the weighted mean difference for glycated hemoglobin level, blood pressure level, lipid profile levels and bodyweight, and the odds ratios for adverse events. RESULTS A total of 17 trials with Asian patients were included and 39 trials with non-Asian patients were included. Comparison of the glycated hemoglobin decreases corrected by a placebo between Asian and non-Asian patients showed that there was a non-significant difference of 0.05% between groups (P > 0.05). Comparisons of the bodyweight changes and blood pressure changes corrected by a placebo between Asian and non-Asian patients did not show a significant difference between groups (P > 0.05). The risk of all-cause mortality was not increased when compared with a placebo both in Asian and non-Asian populations, and the risk of genital infection in Asian and non-Asian populations were both significant increased. CONCLUSIONS Overall, according to the present meta-analysis, comparison of the efficacy in SGLT2 inhibitors treatment between Asian and non-Asian type 2 diabetes patients showed no significant difference in glycated hemoglobin reduction and bodyweight reduction. Furthermore, no disparity was found in the risk of all-cause mortality or hypoglycemia in SGLT2 inhibitors treatment between Asian and non-Asian patients.
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Affiliation(s)
- Xiaoling Cai
- Endocrine & Metabolism DepartmentPeking University People's HospitalBeijingChina
| | - Xueying Gao
- Endocrine & Metabolism DepartmentPeking University People's HospitalBeijingChina
| | - Wenjia Yang
- Endocrine & Metabolism DepartmentPeking University People's HospitalBeijingChina
| | - Yifei Chen
- Endocrine & Metabolism DepartmentPeking University People's HospitalBeijingChina
| | - Simin Zhang
- Endocrine & Metabolism DepartmentPeking University People's HospitalBeijingChina
| | - Lingli Zhou
- Endocrine & Metabolism DepartmentPeking University People's HospitalBeijingChina
| | - Xueyao Han
- Endocrine & Metabolism DepartmentPeking University People's HospitalBeijingChina
| | - Linong Ji
- Endocrine & Metabolism DepartmentPeking University People's HospitalBeijingChina
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Abdelgadir E, Rashid F, Bashier A, Ali R. SGLT-2 Inhibitors and Cardiovascular Protection: Lessons and Gaps in Understanding the Current Outcome Trials and Possible Benefits of Combining SGLT-2 Inhibitors With GLP-1 Agonists. J Clin Med Res 2018; 10:615-625. [PMID: 29977418 PMCID: PMC6031247 DOI: 10.14740/jocmr3467w] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 06/04/2018] [Indexed: 12/21/2022] Open
Abstract
Landmark trials on diabetes control have shown variable results in terms of cardiovascular benefits, with the majority showing a favorable effect of glycemic control on microvascular and, more recently, macrovascular complications. However, some trials pointed out a CV hazard with tight diabetes mellitus (DM) control. Most of those trials were assessing the impact of glycemic control, more than evaluating the effect of a certain medication. In the last decade, food and drugs administration (FDA) has mandated that all new hypoglycemic agents run a CV outcome trial (CVOT) for safety in order to grant and sustain approval. The most stunning results came from relatively new agents in the field of diabetes management, sodium-glucose cotransporter-2 inhibitors (SGLT2i) and the glucagon-like peptide-1 agonists (GLP-1 agonists), details of these CVOTs will be addressed later in this document. SGLT2i effect on the cardiovascular system remains an area of extensive research. We aimed in this review to summarize what is the current evidence of cardiovascular protection upon using SGLT2i. Moreover, we wanted to raise a point that may be strongly adopted in the future, combining SGLT2i plus GLP-1 agonists, having a cardiovascular privilege in both molecules.
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Wilcox CS, Shen W, Boulton DW, Leslie BR, Griffen SC. Interaction Between the Sodium-Glucose-Linked Transporter 2 Inhibitor Dapagliflozin and the Loop Diuretic Bumetanide in Normal Human Subjects. J Am Heart Assoc 2018; 7:JAHA.117.007046. [PMID: 29440005 PMCID: PMC5850181 DOI: 10.1161/jaha.117.007046] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background Dapagliflozin inhibits the sodium‐glucose–linked transporter 2 in the renal proximal tubule, thereby promoting glycosuria to reduce hyperglycemia in type 2 diabetes mellitus. Because these patients may require loop diuretics, and sodium‐glucose–linked transporter 2 inhibition causes an osmotic diuresis, we evaluated the diuretic interaction between dapagliflozin and bumetanide. Methods and Results Healthy subjects (n=42) receiving a fixed diet with ≈110 mmol·d−1 of Na+ were randomized to bumetanide (1 mg·d−1), dapagliflozin (10 mg·d−1), or both for 7 days, followed by 7 days of both. There were no meaningful pharmacokinetic interactions. Na+ excretion increased modestly with the first dose of dapagliflozin (22±6 mmol·d−1; P<0.005) but by more (P<0.005) with the first dose of bumetanide (74±7 mmol·d−1; P<0.005), which was not significantly different from both diuretics together (80±5 mmol·d−1; P<0.005). However, Na+ excretion with dapagliflozin was 190% greater (P<0.005) when added after 1 week of bumetanide (64±6 mmol·d−1), and Na+ excretion with bumetanide was 36% greater (P<0.005) when added after 1 week of dapagliflozin (101±8 mmol·d−1). Serum urate was increased 4% by bumetanide but reduced 40% by dapagliflozin or 20% by combined therapy (P<0.05). Conclusions First‐dose Na+ excretion with bumetanide and dapagliflozin is not additive, but the weekly administration of one diuretic enhances the initial Na+ excretion with the other, thereby demonstrating mutual adaptive natriuretic synergy. Combined therapy reverses bumetanide‐induced hyperuricemia. This requires further study in diabetic patients with hyperglycemia who have enhanced glycosuria and natriuresis with dapagliflozin. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00930865.
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Affiliation(s)
- Christopher S Wilcox
- Division of Nephrology and Hypertension, and Hypertension Research Center, Georgetown University, Washington, DC
| | - Wen Shen
- Division of Nephrology and Hypertension, and Hypertension Research Center, Georgetown University, Washington, DC
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Li H, Shin SE, Seo MS, An JR, Choi IW, Jung WK, Firth AL, Lee DS, Yim MJ, Choi G, Lee JM, Na SH, Park WS. The anti-diabetic drug dapagliflozin induces vasodilation via activation of PKG and Kv channels. Life Sci 2018; 197:46-55. [PMID: 29409796 DOI: 10.1016/j.lfs.2018.01.032] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 01/22/2018] [Accepted: 01/31/2018] [Indexed: 12/20/2022]
Abstract
AIM Considering the clinical efficacy of dapagliflozin in patients with type 2 DM and the pathophysiological relevance of Kv channels for vascular reactivity. We investigate the vasodilatory effect of dapagliflozin and related mechanisms using phenylephrine (Phe)-induced contracted aortic rings. MATERIAL AND METHODS Arterial tone measurement was performed in aortic smooth muscle. KEY FINDINGS Application of dapagliflozin induced vasodilation in a concentration-dependent manner. Pre-treatment with the BKCa channel inhibitor paxilline, the KATP channel inhibitor glibenclamide, and the Kir channel inhibitor Ba2+ did not change dapagliflozin-induced vasodilation. However, application of the Kv channels inhibitor 4-AP effectively inhibited dapagliflozin-induced vasodilation. Application of the Ca2+ channel inhibitor nifedipine and the sarcoplasmic/endoplasmic reticulum Ca2+-ATPase (SERCA) pump inhibitor thapsigargin did not alter the vasodilatory effect of dapagliflozin. Moreover, the adenylyl cyclase inhibitor SQ 22536 and the protein kinase A (PKA) inhibitor KT 5720 had no effect on dapagliflozin-induced vasodilation. Although guanylyl cyclase inhibitors, NS 2028 and ODQ, did not reduce the vasodilatory effect of dapagliflozin, the protein kinase G (PKG) inhibitor KT 5823 effectively inhibited dapagliflozin-induced vasodilation. The vasodilatory effect of dapagliflozin was not affected by elimination of the endothelium. Furthermore, pretreatment with the nitric oxide synthase inhibitor L-NAME or the small-conductance Ca2+-activated K (SKCa) channel inhibitor apamin did not change the vasodilatory effect of dapagliflozin. SIGNIFICANCE We concluded that dapagliflozin induced vasodilation via the activation of Kv channels and PKG, and was independent of other K+ channels, Ca2+ channels, intracellular Ca2+, and the endothelium.
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Affiliation(s)
- Hongliang Li
- Institute of Medical Sciences, Department of Physiology, Kangwon National University School of Medicine, Chuncheon 24341, South Korea
| | - Sung Eun Shin
- Institute of Medical Sciences, Department of Physiology, Kangwon National University School of Medicine, Chuncheon 24341, South Korea
| | - Mi Seon Seo
- Institute of Medical Sciences, Department of Physiology, Kangwon National University School of Medicine, Chuncheon 24341, South Korea
| | - Jin Ryeol An
- Institute of Medical Sciences, Department of Physiology, Kangwon National University School of Medicine, Chuncheon 24341, South Korea
| | - Il-Whan Choi
- Department of Microbiology, Inje University College of Medicine, Busan 48516, South Korea
| | - Won-Kyo Jung
- Department of Biomedical Engineering, and Center for Marine-Integrated Biomedical Technology (BK21 Plus) Pukyong National University, Busan 608-737, South Korea
| | - Amy L Firth
- Department of Pulmonary, Critical Care and Sleep Medicine, University of Southern California, Keck School of Medicine, Los Angeles CA90033, USA
| | - Dae-Sung Lee
- Department of Applied Research, National Marine Biodiversity Institute of Korea, Seocheon 33662, South Korea
| | - Mi-Jin Yim
- Department of Applied Research, National Marine Biodiversity Institute of Korea, Seocheon 33662, South Korea
| | - Grace Choi
- Department of Applied Research, National Marine Biodiversity Institute of Korea, Seocheon 33662, South Korea
| | - Jeong Min Lee
- Department of Applied Research, National Marine Biodiversity Institute of Korea, Seocheon 33662, South Korea
| | - Sung Hun Na
- Institute of Medical Sciences, Department of Obstetrics and Gynecology, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon 24341, South Korea.
| | - Won Sun Park
- Institute of Medical Sciences, Department of Physiology, Kangwon National University School of Medicine, Chuncheon 24341, South Korea.
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Abstract
PURPOSE OF REVIEW This article reviews current knowledge concerning diabetic dyslipidemia and cardiovascular disease (CVD). It reviews strategies to reduce diabetes-associated CVD, including reducing low-density lipoprotein levels, lowering triglycerides, and increasing high-density lipoproteins (HDL). Special considerations, such as the multifactorial chylomicronemia syndrome and partial lipodystrophy, and the role of glucose-lowering strategies in the management of diabetic dyslipidemia are discussed. RECENT FINDINGS The strongest evidence to date for reducing CVD in diabetes comes from the use of statins. While triglyceride lowering remains inconclusive, an ongoing trial might provide some finality to this question. The role of increasing HDL remains elusive, and HDL cholesterol appears to be an unsatisfactory metric for monitoring therapy. The use of statins offers the best current way to reduce diabetes-associated CVD. However, several novel and promising approaches for the management of diabetic dyslipidemia aimed at reducing CVD are in the pipeline.
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Affiliation(s)
- Alan Chait
- Division of Metabolism, Endocrinology and Nutrition, University of Washington, Seattle, WA, USA.
| | - Ira Goldberg
- Division of Endocrinology, New York University, New York, NY, USA
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Fioretto P, Mansfield TA, Ptaszynska A, Yavin Y, Johnsson E, Parikh S. Long-Term Safety of Dapagliflozin in Older Patients with Type 2 Diabetes Mellitus: A Pooled Analysis of Phase IIb/III Studies. Drugs Aging 2017; 33:511-22. [PMID: 27357173 PMCID: PMC4937081 DOI: 10.1007/s40266-016-0382-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Objective To evaluate the 104-week safety of dapagliflozin in older patients with type 2 diabetes mellitus. Methods Pooled analysis assessing general safety (nine phase III studies ≤104 weeks) and cardiovascular safety (21 phase IIb/III studies ≤208 weeks) by age (<65; ≥65; ≥75 years). Patients with type 2 diabetes mellitus (±background glucose-lowering therapy) received: dapagliflozin 10 mg (n = 2026) vs. placebo (n = 1956) (nine-study pool); or dapagliflozin (2.5–50 mg; n = 5936) vs. control (placebo/comparator) (n = 3403) (21-study pool). Results Adverse events (AEs) and discontinuations owing to AEs were more common in older vs. younger patients, and were more frequent with dapagliflozin than placebo (AEs: <65 years: 73.1 vs. 70.7 %; ≥65 years: 77.4 vs. 73.1 %; ≥75 years: 80.4 vs. 75.3 %, respectively; discontinuations: <65 years: 5.9 vs. 5.0 %; ≥65 years: 14.4 vs. 12.2 %; ≥75 years: 26.8 vs. 22.1 %, respectively); serious AE (SAE) frequency was similar (<65 years: 11.0 vs. 11.8 %; ≥65 years: 20.0 vs. 20.2 %; ≥75 years: 19.6 vs. 18.2 %, respectively). Hypoglycaemia frequency was similar across age groups and was higher with dapagliflozin than placebo (<65 years: 18.0 vs. 13.4 %; ≥65 years: 20.2 vs. 17.7 %; ≥75 years: 17.5 vs. 16.9 %, respectively); major episodes were rare. Urinary tract infection frequency was similar between treatment groups in older patients, with no increase vs. younger patients (<65 years: 8.8 vs. 5.5 %; ≥65 years: 8.1 vs. 7.6 %; ≥75 years: 8.2 vs. 9.1 %, respectively); urinary tract infection SAEs were rare. Genital infection AEs were more common with dapagliflozin, with no increase in older patients (<65 years: 8.2 vs. 1.0 %; ≥65 years: 6.6 vs. 0.9 %; ≥75 years: 7.2 vs. 0.0 %, respectively) and no SAEs. Volume reduction AEs were uncommon, with a higher frequency with dapagliflozin vs. placebo and in patients ≥75 years (<65 years: 1.7 vs. 1.2 %; ≥65 years: 2.3 vs. 1.7 %; ≥75 years: 3.1 vs. 2.6 %, respectively). Dapagliflozin did not increase the risk of fractures (<65 years: 1.1 vs. 1.1 %; ≥65 years: 1.1 vs. 2.7 %; ≥75 years: 1.0 vs. 2.6 %, respectively) or falls (<65 years: 0.7 vs. 0.7 %; ≥65 years: 0.6 vs. 2.1 %; ≥75 years: 0.0 vs. 1.3 %, respectively), regardless of age. AEs of renal function were more common with dapagliflozin than placebo and increased with age (<65 years: 3.5 vs. 2.3 %; ≥65 years: 14.0 vs. 7.9 %; ≥75 years: 29.9 vs. 20.8 %, respectively). Most were non-serious small transient increases in serum creatinine. Dapagliflozin did not increase cardiovascular risk regardless of age [hazard ratio (95 % confidence interval) vs. control: <65 years: 0.726 (0.473, 1.114); ≥65 years: 0.879 (0.565, 1.366); ≥75 years: 0.950 (0.345, 2.617), respectively]. Conclusion Dapagliflozin treatment up to 104 weeks was well tolerated in older patients. Older dapagliflozin-treated patients had more renal AEs than placebo-treated patients; the majority of which were non-serious small transient changes in serum creatinine. Electronic supplementary material The online version of this article (doi:10.1007/s40266-016-0382-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Paola Fioretto
- Department of Medicine, University of Padova, Via Giustiniani 2, Padua, 35128, Italy.
| | | | | | - Yshai Yavin
- Bristol-Myers Squibb, Princeton, NJ, USA.,Johnson & Johnson, Raritan, NJ, USA
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Lioudaki E, Whyte M, Androulakis ES, Stylianou KG, Daphnis EK, Ganotakis ES. Renal Effects of SGLT-2 Inhibitors and Other Anti-diabetic Drugs: Clinical Relevance and Potential Risks. Clin Pharmacol Ther 2017; 102:470-480. [DOI: 10.1002/cpt.731] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 04/28/2017] [Accepted: 05/02/2017] [Indexed: 12/11/2022]
Affiliation(s)
- E Lioudaki
- Renal Unit; Epsom and St Helier University Hospitals NHS Trust; London UK
- Department of Nephrology; University Hospital of Heraklion; Greece
| | - M Whyte
- Department of Clinical & Experimental Medicine; University of Surrey; Department of Medicine King's College Hospital
| | - ES Androulakis
- Cardiology Department; St George's University Hospital NHS; London UK
| | - KG Stylianou
- Department of Nephrology; University Hospital of Heraklion; Greece
| | - EK Daphnis
- Department of Nephrology; University Hospital of Heraklion; Greece
| | - ES Ganotakis
- Department of Internal Medicine; University Hospital of Heraklion; Greece
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Abstract
The mechanism of action of empagliflozin in reducing the risk of adverse cardiovascular outcomes vs placebo in patients with type 2 diabetes mellitus and a high risk of cardiovascular disease in the Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients-Removing Excess Glucose (EMPA-REG OUTCOME) trial is currently unknown. An antiatherosclerotic effect is considered unlikely given the speed of the observed decrease in cardiovascular mortality. Hemodynamic effects, such as reductions in blood pressure and intravascular volume, and involving osmotic diuresis, may provide a more plausible explanation. Metabolic effects, such as cardiac fuel energetics, and hormonal effects, such as increased glucagon release, may also contribute to the results observed during EMPA-REG OUTCOME. This review discusses the main hypotheses suggested to date.
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Abstract
The mechanism of action of empagliflozin in reducing the risk of adverse cardiovascular outcomes vs placebo in patients with type 2 diabetes mellitus and a high risk of cardiovascular disease in the Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients-Removing Excess Glucose (EMPA-REG OUTCOME) trial is currently unknown. An antiatherosclerotic effect is considered unlikely given the speed of the observed decrease in cardiovascular mortality. Hemodynamic effects, such as reductions in blood pressure and intravascular volume, and involving osmotic diuresis, may provide a more plausible explanation. Metabolic effects, such as cardiac fuel energetics, and hormonal effects, such as increased glucagon release, may also contribute to the results observed during EMPA-REG OUTCOME. This review discusses the main hypotheses suggested to date.
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Affiliation(s)
- Bart Staels
- Université Lille, INSERM, CHU Lille, Institut Pasteur de Lille, U1011-EGID, Lille, France.
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Avogaro A, Giaccari A, Fioretto P, Genovese S, Purrello F, Giorgino F, Del Prato S. A consensus statement for the clinical use of the renal sodium-glucose co-transporter-2 inhibitor dapagliflozin in patients with type 2 diabetes mellitus. Expert Rev Clin Pharmacol 2017; 10:763-772. [PMID: 28431476 DOI: 10.1080/17512433.2017.1322507] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION The present review developed a clinical consensus based on a Delphi method on Dapagliflozin, a selective inhibitor of the renal sodium-glucose co-transporter-2 (SGLT2-I) in the treatment of patients with Type 2 diabetes mellitus. Areas covered: Panel members, using a 5-point scale, were asked to rate 9 statements on pharmakodinamic, mode of action on glycaemic and extra-glycaemic effects, and safety of dapaglifozin, Members also aimed to identify the patient most susceptible to the treatment with dapagliflozin . Expert commentary: Dapagliflozin is effective in lowering the plasma glucose concentration with a good safety profile. Dapagliflozin can be utilized in combination with all other antihyperglycaemic agents at all stages of the disease: however, a reduced GFR limits its efficacy. As for the other drugs of the class, Dapagliflozin positively modifies other risk factors for CV disease: these effects will be tested in the so far largest cardiovascular outcome trial for the SGLT2 inhibitors so far, the DECLARE trial, which will communicate whether this class of drugs will be disease-modifier in patients with type 2 diabetes also in primary prevention.
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Affiliation(s)
- A Avogaro
- a Department of Internal Medicine , University of Padova , Padova , Italy
| | - A Giaccari
- b Università Cattolica del Sacro Cuore, Section of Endocrinology and Metabolic Diseases, Policlinico Gemelli , Rome , Italy
| | - P Fioretto
- a Department of Internal Medicine , University of Padova , Padova , Italy
| | - S Genovese
- c Department of Cardiovascular and Metabolic Diseases , IRCCS Multimedica , Sesto San Giovanni , Milan , Italy
| | - F Purrello
- d Department of Biomedical Sciences and Biotechnology, Section of Biology and Genetics Giovanni Sichel , Unit of Biomolecular, Genome and Complex Systems Biomedicine , Catania , Italy
| | - F Giorgino
- e Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, Department of Emergency and Organ Transplantation , University of Bari Aldo Moro , Bari , Italy
| | - S Del Prato
- f Department of Clinical and Experimental Medicine , University of Pisa , Pisa , Italy
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Budoff MJ, Wilding JPH. Effects of canagliflozin on cardiovascular risk factors in patients with type 2 diabetes mellitus. Int J Clin Pract 2017; 71:e12948. [PMID: 28508457 PMCID: PMC5488174 DOI: 10.1111/ijcp.12948] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 03/12/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND AIMS Cardiovascular disease is the most common cause of morbidity and mortality among people with type 2 diabetes mellitus (T2DM). The main contributors to cardiovascular risk in T2DM are chronic hyperglycaemia, reduced insulin sensitivity, hypertension and dyslipidaemia. Other cardiovascular risk factors include obesity and visceral adiposity, increased arterial stiffness and renal dysfunction. Results from clinical trials, including a long-term cardiovascular outcome study, have shown that sodium glucose co-transporter 2 (SGLT2) inhibitors can provide multiple cardiometabolic benefits beyond glycaemic control including inducing mild osmotic diuresis, natriuresis and weight loss. This review article describes the effects of canagliflozin on cardiovascular risk factors based on results from its clinical development programme. METHODS This review is based on structured searches to identify literature related to the effects of canagliflozin on cardiovascular risk factors in patients with T2DM. DISCUSSION AND CONCLUSIONS Canagliflozin treatment has been shown to provide glycaemic improvements as well as reductions in blood pressure and body weight across a broad range of patients with T2DM, including those with elevated cardiovascular risk. Other observed effects of canagliflozin that may contribute to improved cardiometabolic outcomes include reduction in uric acid levels, decreased albuminuria and increases in serum magnesium. Results of ongoing long-term cardiovascular outcomes studies of canagliflozin are expected to provide additional evidence on the cardiometabolic effects of canagliflozin treatment.
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Affiliation(s)
- Matthew J. Budoff
- Division of CardiologyLos Angeles Biomedical Research InstituteTorranceCAUSA
| | - John P. H. Wilding
- Obesity and Endocrinology Clinical ResearchInstitute of Ageing and Chronic DiseaseUniversity of LiverpoolLiverpoolUK
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Dandona P, Chaudhuri A. Sodium-glucose co-transporter 2 inhibitors for type 2 diabetes mellitus: An overview for the primary care physician. Int J Clin Pract 2017; 71:e12937. [PMID: 28440009 PMCID: PMC5518299 DOI: 10.1111/ijcp.12937] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 02/13/2017] [Indexed: 12/23/2022] Open
Abstract
AIMS Sodium-glucose co-transporter type 2 (SGLT2) inhibitors are a new class of anti-hyperglycaemic agents in type 2 diabetes mellitus (T2DM). This review examines their mechanism of action and provides an overview of safety and efficacy from the main studies of SGLT2 inhibitors marketed in the United States and Europe, namely, canagliflozin, dapagliflozin and empagliflozin. METHODS We searched the PubMed database to identify relevant publications on the mechanism of action of SGLT2 inhibitors and clinical trial reports. RESULTS Clinical trials in patients with T2DM have shown significant improvements in glycaemic control vs placebo with canagliflozin, dapagliflozin and empagliflozin: patients were more likely to reach target glycated haemoglobin levels compared with patients receiving placebo. All SGLT2 inhibitors also led to modest reductions in body weight and blood pressure vs placebo. Generally, all agents were well tolerated, with the most common adverse events with this class being genital mycotic infections and urinary tract infections. Hypoglycaemia was reported at rates similar to those seen with placebo, except when SGLT2 inhibitors were given in combination with insulin or an insulin secretagogue. Long-term outcome data are available only for empagliflozin: in the EMPA-REG OUTCOME study, empagliflozin demonstrated reduced risk of the composite end-point of 3-point major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction or non-fatal stroke), primarily because of a significant reduction in cardiovascular mortality. CONCLUSIONS SGLT2 inhibitors are an exciting addition to the list of available agents for T2DM, and may be suitable for various types of patients who need additional glycaemic control.
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Affiliation(s)
- Paresh Dandona
- Department of MedicineState University of New York at BuffaloBuffaloNYUSA
| | - Ajay Chaudhuri
- Department of MedicineState University of New York at BuffaloBuffaloNYUSA
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Zurek AM, Yendapally R, Urteaga EM. A Review of the Efficacy and Safety of Sodium-Glucose Cotransporter 2 Inhibitors: A Focus on Diabetic Ketoacidosis. Diabetes Spectr 2017; 30:137-142. [PMID: 28588380 PMCID: PMC5439357 DOI: 10.2337/ds16-0030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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The Effect of Sodium-Glucose Co-transporter-2 (SGLT-2) Inhibitors on Cardiometabolic Profile; Beyond the Hypoglycaemic Action. Cardiovasc Drugs Ther 2017; 31:215-225. [DOI: 10.1007/s10557-017-6724-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Cha SA, Park YM, Yun JS, Lim TS, Song KH, Yoo KD, Ahn YB, Ko SH. A comparison of effects of DPP-4 inhibitor and SGLT2 inhibitor on lipid profile in patients with type 2 diabetes. Lipids Health Dis 2017; 16:58. [PMID: 28403877 PMCID: PMC5390350 DOI: 10.1186/s12944-017-0443-4] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 03/07/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Previous studies suggest that dipeptidyl peptidase-4 (DPP-4) inhibitors and sodium glucose cotransporter 2 (SGLT2) inhibitors have different effects on the lipid profile in patients with type 2 diabetes. We investigated the effects of DPP-4 inhibitors and SGLT2 inhibitors on the lipid profile in patients with type 2 diabetes. METHODS From January 2013 to December 2015, a total of 228 patients with type 2 diabetes who were receiving a DPP-4 inhibitor or SGLT2 inhibitor as add-on therapy to metformin and/or a sulfonylurea were consecutively enrolled. We compared the effects of DPP-4 inhibitors and SGLT2 inhibitors on the lipid profile at baseline and after 24 weeks of treatment. To compare lipid parameters between the two groups, we used the analysis of covariance (ANCOVA). RESULTS A total of 184 patients completed follow-up (mean age: 53.1 ± 6.9 years, mean duration of diabetes: 7.1 ± 5.7 years). From baseline to 24 weeks, HDL-cholesterol (HDL-C) levels were increased by 0.5 (95% CI, -0.9 to 2.0) mg/dl with a DPP-4 inhibitor and by 5.1 (95% CI, 3.0 to 7.1) mg/dl with an SGLT2 inhibitor (p = 0.001). LDL-cholesterol (LDL-C) levels were reduced by 8.4 (95% CI, -14.0 to -2.8) mg/dl with a DPP-4 inhibitor, but increased by 1.3 (95% CI, -5.1 to 7.6) mg/dl with an SGLT2 inhibitor (p = 0.046). There was no significant difference in the mean hemoglobin A1c (8.3 ± 1.1 vs. 8.0 ± 0.9%, p = 0.110) and in the change of total cholesterol (TC) (p = 0.836), triglyceride (TG) (p = 0.867), apolipoprotein A (p = 0.726), apolipoprotein B (p = 0.660), and lipoprotein (a) (p = 0.991) between the DPP-4 inhibitor and the SGLT2 inhibitor. CONCLUSIONS The SGLT2 inhibitor was associated with a significant increase in HDL-C and LDL-C after 24 weeks of SGLT2 inhibitor treatment in patients with type 2 diabetes compared with those with DPP-4 inhibitor treatment in this study. TRIAL REGISTRATION This study was conducted by retrospective medical record review.
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Affiliation(s)
- Seon-Ah Cha
- Department of Internal Medicine, Division of Endocrinology and Metabolism, College of Medicine, The Catholic University of Korea, St. Vincent’s Hospital, 93 Jungbu − daero, Paldal − gu, Suwon, Gyeonggi − do, Seoul, 442-723 Republic of Korea
| | - Yong-Moon Park
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, Durham, NC USA
| | - Jae-Seung Yun
- Department of Internal Medicine, Division of Endocrinology and Metabolism, College of Medicine, The Catholic University of Korea, St. Vincent’s Hospital, 93 Jungbu − daero, Paldal − gu, Suwon, Gyeonggi − do, Seoul, 442-723 Republic of Korea
| | - Tae-Seok Lim
- Department of Internal Medicine, Division of Endocrinology and Metabolism, College of Medicine, The Catholic University of Korea, St. Vincent’s Hospital, 93 Jungbu − daero, Paldal − gu, Suwon, Gyeonggi − do, Seoul, 442-723 Republic of Korea
| | - Ki-Ho Song
- Department of Internal Medicine, Division of Endocrinology and Metabolism, College of Medicine, The Catholic University of Korea, St. Vincent’s Hospital, 93 Jungbu − daero, Paldal − gu, Suwon, Gyeonggi − do, Seoul, 442-723 Republic of Korea
| | - Ki-Dong Yoo
- Department of Internal Medicine, Division of Cardiology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yu-Bae Ahn
- Department of Internal Medicine, Division of Endocrinology and Metabolism, College of Medicine, The Catholic University of Korea, St. Vincent’s Hospital, 93 Jungbu − daero, Paldal − gu, Suwon, Gyeonggi − do, Seoul, 442-723 Republic of Korea
| | - Seung-Hyun Ko
- Department of Internal Medicine, Division of Endocrinology and Metabolism, College of Medicine, The Catholic University of Korea, St. Vincent’s Hospital, 93 Jungbu − daero, Paldal − gu, Suwon, Gyeonggi − do, Seoul, 442-723 Republic of Korea
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Targeting endothelial metaflammation to counteract diabesity cardiovascular risk: Current and perspective therapeutic options. Pharmacol Res 2017; 120:226-241. [PMID: 28408314 DOI: 10.1016/j.phrs.2017.04.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 03/21/2017] [Accepted: 04/07/2017] [Indexed: 02/08/2023]
Abstract
The association of obesity and diabetes, termed "diabesity", defines a combination of primarily metabolic disorders with insulin resistance as the underlying common pathophysiology. Cardiovascular disorders associated with diabesity represent the leading cause of morbidity and mortality in the Western world. This makes diabesity, with its rising impacts on both health and economics, one of the most challenging biomedical and social threats of present century. The emerging comprehension of the genes whose alteration confers inter-individual differences on risk factors for diabetes or obesity, together with the potential role of genetically determined variants on mechanisms controlling responsiveness, effectiveness and safety of anti-diabetic therapy underlines the need of additional knowledge on molecular mechanisms involved in the pathophysiology of diabesity. Endothelial cell dysfunction, resulting from the unbalanced production of endothelial-derived vascular mediators, is known to be present at the earliest stages of insulin resistance and obesity, and may precede the clinical diagnosis of diabetes by several years. Once considered as a mere consequence of metabolic abnormalities, it is now clear that endothelial dysfunctional activity may play a pivotal role in the progression of diabesity. In the vicious circle where vascular defects and metabolic disturbances worsen and reinforce each other, a low-grade, chronic, and 'cold' inflammation (metaflammation) has been suggested to serve as the pathophysiological link that binds endothelial and metabolic dysfunctions. In this paradigm, it is important to consider how traditional antidiabetic treatments (specifically addressing metabolic dysregulation) may directly impact on inflammatory processes or cardiovascular function. Indeed, not all drugs currently available to treat diabetes possess the same anti-inflammatory potential, or target endothelial cell function equally. Perspective strategies pointing at reducing metaflammation or directly addressing endothelial dysfunction may disclose beneficial consequences on metabolic regulation. This review focuses on existing and potential new approaches ameliorating endothelial dysfunction and vascular inflammation in the context of diabesity.
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McGovern A, Feher M, Munro N, de Lusignan S. Sodium-Glucose Co-Transporter-2 (SGLT2) Inhibitors: Comparing Trial and Real World Use (Study Protocol). Diabetes Ther 2017; 8:355-363. [PMID: 28138853 PMCID: PMC5380492 DOI: 10.1007/s13300-017-0229-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Sodium-glucose co-transporter-2 (SGLT2) inhibitors (gliflozins) are the newest class of medication available to treat type 2 diabetes (T2DM). Recent findings from the first complete cardiovascular safety trial in SGLT2 inhibitors, the Empagliflozin, Cardiovascular Outcomes, and Mortality in type 2 diabetes (EMPA-REG OUTCOMES) trial, demonstrated reduced cardiovascular outcomes in people with high cardiovascular risk. How to apply these findings to clinical practice remains unclear, with questions remaining on who will reap this cardiovascular benefit. AIM To describe the proportion of people in the real world currently treated with SGLT2 inhibitors who meet the inclusion criteria of the EMPA-REG trial and therefore could expect the cardiovascular benefit identified by the trial. Similarly, to describe the proportion of people from the whole T2DM population who could also expect this same benefit. DESIGN AND SETTING Routinely collected data from UK primary care in the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) database will be used. The study population will include all people with T2DM within this database (approximately 60,000). We will perform a cross-sectional investigation to describe the characteristics of people currently using SGTL2 inhibitors compared with the population of the EMPA-REG trail. We will similarly compare the characteristics of the RCGP RSC T2DM cohort with the inclusion criteria of the EMPA-REG trial. METHOD People with T2DM using a pre-existing verified clinical ontological process will be identified, as will people with prescriptions for SGLT2 inhibitors and other medications using Read coded and other proprietary coding systems. Descriptive statistics will be used to characterise the key clinical characteristics of people with T2DM using SGLT2 inhibitors and to compare these characteristics to people included in EMPA-REG trial; the proportion of people who match the trial criteria will be reported. PLANNED OUTPUTS Peer review publication reporting the real world lessons for clinical practice. FUNDING AstraZeneca.
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Affiliation(s)
- Andrew McGovern
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK.
| | - Michael Feher
- Beta Cell Centre for Diabetes, Chelsea and Westminster Hospital, 369 Fulham Road, London, UK
- Warwick Medical School, Warwick University, Coventry, UK
| | - Neil Munro
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Simon de Lusignan
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
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Fioretto P, Avogaro A. Dapagliflozin: potential beneficial effects in the prevention and treatment of renal and cardiovascular complications in patients with type 2 diabetes. Expert Opin Pharmacother 2017; 18:517-527. [PMID: 28277831 DOI: 10.1080/14656566.2017.1300253] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Diabetic kidney disease is the leading cause of end-stage renal disease, a significant contributor to cardiovascular (CV) disease, responsible for much of the morbidity and mortality in patients with type 2 diabetes (T2DM). Strategies to slow or prevent the onset and progression of diabetic kidney disease are critical for effectively managing T2DM and reducing CV risk. Sodium-glucose cotransporter 2 (SGLT2) inhibitors are effective antidiabetic agents, which may provide nephroprotective and CV protective effects. Areas covered: This review examines the role of the kidney in glucose homeostasis, discusses renal hemodynamic changes in diabetes, and outlines the major hypotheses regarding the mechanisms underlying renal injury in diabetes. The potential benefits of SGLT2 inhibitors in the prevention and treatment of CV complications in patients with T2DM are reviewed, with particular focus on dapagliflozin. Expert opinion: Dapagliflozin and other SGLT2 inhibitors have the capacity to decrease hyperglycemia and visceral fat, components of the metabolic syndrome particularly associated with the progression of CV disease. However, the mechanisms of action of SGLT2 inhibitors resulting in their positive CV effects remain unclear. Furthermore, the mechanism of action of SGLT2 inhibitors on heart function in non-diabetic patients with decompensated heart failure remains to be explored.
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Affiliation(s)
- Paola Fioretto
- a Department of Medicine , University of Padua , Padua , Italy
| | - Angelo Avogaro
- b Unit of Metabolic Diseases, Department of Medicine , University of Padua , Padua , Italy
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Hankins M, Tsai K, Kim J, Hammar N. Early drug use of dapagliflozin prescribed by general practitioners and diabetologists in Germany. Diabetes Res Clin Pract 2017; 125:29-38. [PMID: 28131071 DOI: 10.1016/j.diabres.2016.10.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 10/12/2016] [Accepted: 10/30/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Dapagliflozin is an inhibitor of the human sodium-glucose co-transporter 2 (SGLT2) that has been shown to improve glycaemic control in patients with type 2 diabetes mellitus (T2DM). This study aimed to evaluate the characteristics and treatment patterns of dapagliflozin users in comparison to users of other anti-diabetic (AD) treatments in Germany. METHODS Data from patients with T2DM initiating at least one prescription for dapagliflozin or other AD therapy between November 2012 and April 2014 were collected from the IMS German Disease Analyzer database. RESULTS The use of dapagliflozin combination therapy (n=1034; 74%) was more common than monotherapy (n=371; 26%). In comparison with other AD therapy users, a higher percentage of dapagliflozin users were ⩽64years of age (62.3% vs. 36.4%), and a higher proportion were male (59.1% vs. 53.6%). The average duration of diabetes was comparable between dapagliflozin patients and other AD therapy users (5.7yearsvs. 5.5years), however higher levels of HbA1c were found in dapagliflozin users (8.2% (66mmol/mol) vs. 7.5% (58mmol/mol). For the vast majority (71.5% of 10mg dapagliflozin users and 88.9% of 5mg users), dapagliflozin was prescribed in combination with other AD therapy. CONCLUSIONS Patients starting on dapagliflozin differed in several demographic and health-related respects to patients starting another AD therapy during the same period. Dapagliflozin was predominantly used as a component of combination therapy, adding on to existing therapy. After initiation, switching to other AD treatments or adding to therapy was comparatively rare during the first year.
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Affiliation(s)
- Matthew Hankins
- Real World Evidence Solutions, QuintilesIMS, London, UK; Institute of Pharmaceutical Science, King's College, London.
| | - Katherine Tsai
- Medical Evidence & Observational Research, Global Medical Affairs, AstraZeneca, Gaithersburg, USA
| | - Joseph Kim
- Real World Evidence Solutions, QuintilesIMS, London, UK; Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | - Niklas Hammar
- Medical Evidence & Observational Research, Global Medical Affairs, AstraZeneca, Mölndal, Sweden; Department of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
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Trujillo JM, Nuffer WA. Impact of Sodium-Glucose Cotransporter 2 Inhibitors on Nonglycemic Outcomes in Patients with Type 2 Diabetes. Pharmacotherapy 2017; 37:481-491. [PMID: 28102030 PMCID: PMC5412678 DOI: 10.1002/phar.1903] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The efficacy of the sodium‐glucose cotransporter 2 (SGLT2) inhibitors canagliflozin, dapagliflozin, and empagliflozin in reducing hyperglycemia in patients with type 2 diabetes is well documented. In addition, positive effects have been observed with these agents on nonglycemic variables, such as reductions in body weight and blood pressure, which may confer additional health benefits. SGLT2 inhibitors are also associated with evidence of renal‐protecting benefits. Furthermore, during the landmark Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes (EMPA‐REG OUTCOME) trial, a substantial reduction in major adverse cardiovascular outcomes was demonstrated with empagliflozin therapy. In view of the complex pathogenesis of cardiovascular disease in patients with diabetes, a pharmacologic intervention for type 2 diabetes that produces a multifaceted reduction in cardiovascular disease risk, separate from glycemic control alone, would be advantageous. Although SGLT2 inhibitors are generally well tolerated, they are associated with an increased risk of genital mycotic infections, as well as the potential risk for serious adverse events such as dehydration, development of diabetic ketoacidosis, serious urinary tract infections, and bone fractures. The findings of ongoing research will help to determine the magnitude and clinical importance of these adverse events and whether the findings of EMPA‐REG OUTCOME represent a class effect for SGLT2 inhibition or are specific to empagliflozin and will further elucidate the future role of SGLT2 inhibitors in the individualized management of patients with type 2 diabetes. In this article, we discuss the nonglycemic outcomes associated with SGLT2 inhibitor therapy in patients with type 2 diabetes as well as the clinical implications of these agents.
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Affiliation(s)
- Jennifer M Trujillo
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO
| | - Wesley A Nuffer
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO
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Hayashi T, Fukui T, Nakanishi N, Yamamoto S, Tomoyasu M, Osamura A, Ohara M, Yamamoto T, Ito Y, Hirano T. Dapagliflozin decreases small dense low-density lipoprotein-cholesterol and increases high-density lipoprotein 2-cholesterol in patients with type 2 diabetes: comparison with sitagliptin. Cardiovasc Diabetol 2017; 16:8. [PMID: 28086872 PMCID: PMC5237208 DOI: 10.1186/s12933-016-0491-5] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 12/26/2016] [Indexed: 12/16/2022] Open
Abstract
Background The sodium-glucose co-transporter-2 (SGLT-2) inhibitors have been reported to increase both low-density lipoprotein (LDL) and high-density lipoprotein (HDL)-cholesterol (C). This study aimed to determine how SGLT-2 inhibitors affect LDL and HDL-C subspecies. Methods This single center, open-label, randomized, prospective study included 80 patients with type 2 diabetes taking prescribed oral hypoglycemic agents. Patients were allocated to receive dapagliflozin (n = 40) or sitagliptin (n = 40) as add-on treatment. Fasting blood samples were collected before and 12 weeks after this intervention. Small dense (sd) LDL-C, large buoyant (lb) LDL-C, HDL2-C, and HDL3-C levels were determined using our established homogeneous assays. Statistical comparison of blood parameters before and after treatment was performed using the paired t test. Results Dapagliflozin and sitagliptin comparably decreased HbA1c (0.75 and 0.63%, respectively). Dapagliflozin significantly decreased body weight, systolic blood pressure, plasma triglycerides and liver transaminases, and increased adiponectin; sitagliptin did not alter these measurements. LDL-C and apolipoprotein (apo) B were not significantly changed by dapagliflozin, whereas HDL-C and apo AI were increased. Dapagliflozin did not alter concentrations of LDL-C, but sd LDL-C decreased by 20% and lb LDL-C increased by 18%. Marked elevation in lb LDL-C (53%) was observed in individuals (n = 20) whose LDL-C was elevated by dapagliflozin. However, sd LDL-C remained suppressed (20%). Dapagliflozin increased HDL2-C by 18% without affecting HDL3-C. Sitagliptin did not alter plasma lipids or lipoprotein subspecies. Conclusions A SGLT-2 inhibitor, dapagliflozin suppresses potent atherogenic sd LDL-C and increased HDL2-C, a favorable cardiometabolic marker. Although LDL-C levels are elevated by treatment with dapagliflozin, this was due to increased concentrations of the less atherogenic lb LDL-C. However, these findings were not observed after treatment with dipeptidyl peptidase-4 inhibitor, sitagliptin. Trial registration UMIN Clinical Trials Registry (UMIN000020984) Electronic supplementary material The online version of this article (doi:10.1186/s12933-016-0491-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Toshiyuki Hayashi
- Division of Diabetes, Metabolism, and Endocrinology, Department of Medicine, Showa University School of Medicine, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan.
| | - Tomoyasu Fukui
- Division of Diabetes, Metabolism, and Endocrinology, Department of Medicine, Showa University School of Medicine, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Noriko Nakanishi
- Division of Diabetes, Metabolism, and Endocrinology, Department of Medicine, Showa University School of Medicine, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Saki Yamamoto
- Division of Diabetes, Metabolism, and Endocrinology, Department of Medicine, Showa University School of Medicine, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Masako Tomoyasu
- Division of Diabetes, Metabolism, and Endocrinology, Department of Medicine, Showa University School of Medicine, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Anna Osamura
- Division of Diabetes, Metabolism, and Endocrinology, Department of Medicine, Showa University School of Medicine, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Makoto Ohara
- Division of Diabetes, Metabolism, and Endocrinology, Department of Medicine, Showa University School of Medicine, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Takeshi Yamamoto
- Division of Diabetes, Metabolism, and Endocrinology, Department of Medicine, Showa University School of Medicine, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Yasuki Ito
- Reagent R&D department, Denka Seiken Co., Ltd., Nihonbashi Mitsui Tower, 1-1, Nihonbashi-Muromachi 2-chome, Chuo-ku, Tokyo, 103-8338, Japan
| | - Tsutomu Hirano
- Division of Diabetes, Metabolism, and Endocrinology, Department of Medicine, Showa University School of Medicine, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan.
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Bell KF, Katz A, Sheehan JJ. Quality measure attainment with dapagliflozin plus metformin extended-release as initial combination therapy in patients with type 2 diabetes: a post hoc pooled analysis of two clinical studies. Risk Manag Healthc Policy 2016; 9:231-241. [PMID: 27790048 PMCID: PMC5072521 DOI: 10.2147/rmhp.s108586] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background The use of quality measures attempts to improve safety and health outcomes and to reduce costs. In two Phase III trials in treatment-naive patients with type 2 diabetes, dapagliflozin 5 or 10 mg/d as initial combination therapy with metformin extended-release (XR) significantly reduced glycated hemoglobin (A1C) from baseline to 24 weeks and allowed higher proportions of patients to achieve A1C <7% vs dapagliflozin or metformin monotherapy. Objective A pooled analysis of data from these two studies assessed the effect of dapagliflozin 5 or 10 mg/d plus metformin XR (combination therapy) compared with placebo plus metformin XR (metformin monotherapy) on diabetes quality measures. Quality measures include laboratory measures of A1C and low-density lipoprotein cholesterol (LDL-C) as well as vital status measures of blood pressure (BP) and body mass index (BMI). The proportion of patients achieving A1C, BP, and LDL-C individual and composite measures was assessed, as was the proportion with baseline BMI ≥25 kg/m2 who lost ≥4.5 kg. Subgroup analyses by baseline BMI were also performed. Results A total of 194 and 211 patients were treated with dapagliflozin 5- or 10-mg/d combination therapy, respectively, and 409 with metformin monotherapy. Significantly higher proportions of patients achieved A1C ≤6.5%, <7%, or <8% with combination therapy vs metformin monotherapy (P<0.02). Significantly higher proportions of patients achieved BP <140/90 mmHg (P<0.02 for each dapagliflozin dose) and BP <130/80 mmHg (P<0.02 with dapagliflozin 5 mg/d only) with combination therapy vs metformin monotherapy. Similar proportions (29%–33%) of patients had LDL-C <100 mg/dL across treatment groups. A higher proportion of patients with baseline BMI ≥25 kg/m2 lost ≥4.5 kg with combination therapy. Combination therapy had a more robust effect on patients with higher baseline BMI. Conclusion Initial combination therapy with dapagliflozin 5 or 10 mg/d and metformin improved quality measures relevant to clinical outcomes and diabetes care.
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Abstract
Inhibitors of sodium-glucose cotransporters type 2 (SGLT2) reduce hyperglycemia by increasing urinary glucose excretion. They have been evaluated in patients with type 2 diabetes treated with diet/exercise, metformin, dual oral therapy or insulin. Three agents are available in Europe and the USA (canagliflozin, dapagliflozin, empagliflozin) and others are commercialized in Japan or in clinical development. SGLT2 inhibitors reduce glycated hemoglobin, with a minimal risk of hypoglycemia. They exert favorable effects beyond glucose control with consistent body weight, blood pressure, and serum uric acid reductions. Empagliflozin showed remarkable reductions in cardiovascular/all-cause mortality and in hospitalization for heart failure in patients with previous cardiovascular disease. Positive renal outcomes were also shown with empagliflozin. Mostly reported adverse events are genital mycotic infections, while urinary tract infections and events linked to volume depletion are rather rare. Concern about a risk of ketoacidosis and bone fractures has been recently raised, which deserves caution and further evaluation.
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Affiliation(s)
- André J Scheen
- Division of Clinical Pharmacology, Center for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium.
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège, Belgium.
- Department of Medicine, CHU Sart Tilman (B35), B-4000, Liege 1, Belgium.
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Carlson CJ, Santamarina ML. Update review of the safety of sodium-glucose cotransporter 2 inhibitors for the treatment of patients with type 2 diabetes mellitus. Expert Opin Drug Saf 2016; 15:1401-12. [PMID: 27449721 DOI: 10.1080/14740338.2016.1216100] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Curt J. Carlson
- Lloyd L. Gregory School of Pharmacy, Palm Beach Atlantic University, West Palm Beach, FL, USA
| | - Marile L. Santamarina
- Lloyd L. Gregory School of Pharmacy, Palm Beach Atlantic University, West Palm Beach, FL, USA
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