4111Association of DPP-4 inhibitors, GLP-1 receptor agonists and SGLT-2 inhibitors with cardiovascular events stratified by renal function: a network meta-analysis

Background

Chronic kidney disease is a frequent co-morbidity in patients with diabetes and is associated with poor outcomes and elevated cardiovascular risk. Several novel oral antidiabetic therapies have been shown to be efficacious in reducing cardiovascular events. However, the impact of baseline renal function on cardiovascular efficacy is not well-established.

Purpose

To assess the cardiovascular efficacy of Dipeptidyl Peptidase-4 inhibitors (DPP-4i), Glucagon-Like Peptide-1 Receptor Agonists (GLP-1RA) and Sodium-Glucose Cotransporter-2 inhibitors (SGLT-2i) stratified by renal function.

Methods

Cardiovascular outcome trials enrolling at least 1000 patients with type 2 diabetes for >12 months' duration were included if they reported on a composite outcome of cardiovascular mortality, nonfatal myocardial infarction and nonfatal stroke and stratified outcome data by estimated glomerular filtration rate (eGFR) of >60 mL/min/1.73m2 or <60 mL/min/1.73m2. Studies enrolling patients with recent acute coronary events were excluded. Treatment and interaction effect estimates were aggregated by random-effects Bayesian network meta-analysis.

Results

9 studies were included (2 DPP-4i; 4 GLP-1RA; 3 SGLT-2i), enrolling 92,626 patients accounting for 315,167 patient-years of follow-up. The eGFR was <60 mL/min/1.73m2 in 21,302 patients (23.0%) and >60 mL/min/1.73m2 in 71,324 patients (77.0%). The mean eGFR was 64.8 mL/min/1.73m2 in DPP-4i trials, 78.6 mL/min/1.73m2 in GLP-1RA trials and 78.6 mL/min/1.73m2 in SGLT-2i trials.

Compared to placebo, DPP4i were not associated with reductions in the primary outcome (HR 1.00, 95% credible interval [CrI] 0.89–1.13). No reductions in the primary outcome were present for either strata of renal function (eGFR >60: HR 1.00, 95% CrI 0.77–1.29; and eGFR <60: HR 0.99, 95% CrI 0.81–1.20), with no significant interaction between renal function subgroups (interaction coefficient 1.00, 95% CrI 0.72–1.41).

GLP-1RA were associated with reductions in the primary outcome overall (HR 0.85, 95% CrI 0.77–0.93). There was no significant interaction between renal function subgroups (eGFR <60: HR 0.87, 95% CrI 0.70–1.06; and eGFR >60: HR 0.83, 95% CrI 0.71–0.94; interaction coefficient 1.05, 95% CrI 0.83–1.35). Similarly, SGLT-2i were associated with reductions in the primary cardiovascular composite outcome (HR 0.88, 95% CrI 0.79–0.97), with no significant interaction between renal function subgroups (eGFR <60: HR 0.82, 95% CrI 0.65–1.05; and eGFR >60: HR 0.91, 95% CrI 0.78–1.06; interaction coefficient 0.92, 95% CrI 0.69–1.21).

Conclusions

Both SGLT-2i and GLP-RA are associated with reductions in a composite cardiovascular outcome with no evidence of interaction by renal function, while DPP-4i were not associated with reductions in events, with no evidence of interaction by renal function. These data suggest that cardiovascular efficacy of these medications is not affected by baseline renal status.

Leadership in dental public health? Wanted: a catcher in the rye

Changes in the structure of the health services have resulted in a vacuum in leadership in dental public health. The competitive model, introduced in 1993, had several serious effects on the delivery of publicly-funded dental health services. Some Crown Health Enterprises greatly reduced their expenditure by employing fewer public health dentists. This resulted in major disparities in the supervision of school dental services, and in a reduction in health-services research. Problems in publicly-funded dental health services are accumulating, but no leadership to meet these problems seems to be emerging. Because of this failure, it may now be up to the providers to assume the leadership role.

Determination of rate and equilibrium constants for the reactions between electron transfer mediators and proteins by linear sweep voltammetry

Redox proteins undergo measurable charge transfer at electrodes only under special circumstances, while they readily take part in electron transfer reactions with mediators in solution. Advantage was taken of the latter fact to develop a new method to study the kinetics and equilibria of protein-mediator electron transfer reactions. It was shown that rate and equilibrium constants for the electron exchange between electron transfer mediator and the protein can be obtained from the analysis of the perturbation of the linear sweep voltammetry (LSV) response of the mediator due to the presence of the protein. The experiments were carried out under conditions where the protein does not interact with the electrode. Theoretical data obtained by digital simulation are presented to show the conditions under which rate and equilibrium constants are accessible by the LSV technique. The electron transfer reactions between ferri- and ferrocytochrome c and N,N,N',N'-tetramethylphenylenediamine and the corresponding radical cation in phosphate-buffered saline (0.04 M phosphate, pH 7.4, 0.1 M NaCl) buffer were selected to demonstrate the technique. These studies resulted in an equilibrium constant equal to 1.0 and forward and reverse rate constants equal to 1.6 x 10(4) M-1 s-1. The data available from this method include forward and reverse rate constants for electron transfer and the formal potential for the protein redox couple.