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Bar Ziv O, Cahn A, Jansen T, Istomin V, Kedem E, Olshtain-Pops K, Israel S, Oster Y, Orenbuch-Harroch E, Korem M, Strahilevitz J, Levy I, Valdés-Mas R, Ivanova V, Elinav E, Shahar E, Elinav H. Diagnosis and Risk Factors of Prediabetes and Diabetes in People Living with HIV- Evaluation of Clinical and Microbiome Parameters. J Infect Dis 2024:jiae167. [PMID: 38557867 DOI: 10.1093/infdis/jiae167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 03/08/2024] [Accepted: 03/28/2024] [Indexed: 04/04/2024] Open
Abstract
Diabetes is more common among people living with HIV (PLWH), as compared with healthy individuals. In a prospective multicenter study (N = 248), we identified normoglycemic (48.7%), prediabetic (44.4%) and diabetic (6.9%) PLWH. HbA1c and fasting blood glucose (FBG) sensitivity in defining dysglycemia was 96.8%, while addition of oral glucose tolerance test led to reclassification of only 4 patients. Inclusion of 93 additional PLWH with known DM enabled identification of multiple independent predictors of dysglycemia or diabetes: older age, higher BMI, Ethiopian origin, HIV duration, lower integrase inhibitor exposure and advanced disease at diagnosis. Shotgun metagenomic microbiome analysis revealed 4 species that were significantly expanded with hyperglycemia/hyperinsulinemia, and 2 species that were differentially more prevalent in prediabetic/diabetic PLWH. Collectively, we uncover multiple potential host and microbiome predictors of altered glycemic status in PLWH, while demonstrating that FBG and HbA1C likely suffice for diabetes screening. These potential diabetic predictors merit future prospective validation.
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Affiliation(s)
- Omer Bar Ziv
- Department of military Medicine and "Zameret", Faculty of Medicine, Hebrew University, Jerusalem, 9112102, Israel and Medical Corps, Israel Defense forces, Israel
| | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, 9112102, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, 9112102, Israel
| | - Tallulah Jansen
- Department of Systems Immunology, Weizmann Institute of Science, Rehovot, 7632706, Israel
| | - Valery Istomin
- HIV Service, Hillel-Yafe Medical Center, Hadera, 3842401, Israel
| | - Eynat Kedem
- Allergy, Immunology and AIDS unit, Rambam Medical Center, Haifa, 35254908, Israel
| | - Karen Olshtain-Pops
- Faculty of Medicine, Hebrew University, Jerusalem, 9112102, Israel
- Hadassah AIDS Center, Department of Clinical Microbiology and Infectious Diseases, Hadassah Medical Center. Jerusalem, 9112102, Israel
| | - Sarah Israel
- Faculty of Medicine, Hebrew University, Jerusalem, 9112102, Israel
- Hadassah AIDS Center, Department of Clinical Microbiology and Infectious Diseases, Hadassah Medical Center. Jerusalem, 9112102, Israel
| | - Yonatan Oster
- Faculty of Medicine, Hebrew University, Jerusalem, 9112102, Israel
- Hadassah AIDS Center, Department of Clinical Microbiology and Infectious Diseases, Hadassah Medical Center. Jerusalem, 9112102, Israel
| | - Efrat Orenbuch-Harroch
- Faculty of Medicine, Hebrew University, Jerusalem, 9112102, Israel
- Hadassah AIDS Center, Department of Clinical Microbiology and Infectious Diseases, Hadassah Medical Center. Jerusalem, 9112102, Israel
| | - Maya Korem
- Faculty of Medicine, Hebrew University, Jerusalem, 9112102, Israel
- Hadassah AIDS Center, Department of Clinical Microbiology and Infectious Diseases, Hadassah Medical Center. Jerusalem, 9112102, Israel
| | - Jacob Strahilevitz
- Faculty of Medicine, Hebrew University, Jerusalem, 9112102, Israel
- Hadassah AIDS Center, Department of Clinical Microbiology and Infectious Diseases, Hadassah Medical Center. Jerusalem, 9112102, Israel
| | - Itzchak Levy
- Infectious diseases unit, Sheba Medical Center, Tel Hashomer, 5262000, Israel
| | - Rafael Valdés-Mas
- Department of Systems Immunology, Weizmann Institute of Science, Rehovot, 7632706, Israel
| | - Valeria Ivanova
- Department of Systems Immunology, Weizmann Institute of Science, Rehovot, 7632706, Israel
| | - Eran Elinav
- Department of Systems Immunology, Weizmann Institute of Science, Rehovot, 7632706, Israel
- Division of Microbiome & Cancer, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, 280 69120, Germany
| | - Eduardo Shahar
- Allergy, Immunology and AIDS unit, Rambam Medical Center, Haifa, 35254908, Israel
| | - Hila Elinav
- Faculty of Medicine, Hebrew University, Jerusalem, 9112102, Israel
- Hadassah AIDS Center, Department of Clinical Microbiology and Infectious Diseases, Hadassah Medical Center. Jerusalem, 9112102, Israel
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Tsur N, Frankel M, Cahn A, Tsur A. Gestational diabetes and risk of future diabetes in a multi-ethnic population. J Diabetes Complications 2024; 38:108720. [PMID: 38452402 DOI: 10.1016/j.jdiacomp.2024.108720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 02/28/2024] [Accepted: 03/02/2024] [Indexed: 03/09/2024]
Abstract
AIM To investigate ethnic disparities in risk of gestational diabetes-mellitus (GDM) and future diabetes. METHODS A population-based retrospective cohort study of women who underwent a 100-g oral glucose-tolerance-test (oGTT) during pregnancy between 2007 and 2017 in Clalit-Health-Services of the Jerusalem district. Univariate and multivariate logistic regression analyses were used to compare the risk of GDM in Arab versus Jewish women. Further, Cox-regression analysis was used to establish the risk of future diabetes. RESULTS A total of 9875 women, 71 % of Jewish ethnicity and 29 % of Arab ethnicity were included. Arab women had a higher incidence of GDM compared to Jewish women (17.3 % vs. 10.6 %, p < 0.001), which persisted after adjusting for age, BMI, and metabolic profile (aOR 1.7; CI 1.48-2.0, P < 0.001). Additionally, Arab ethnicity was associated with an increased risk of future diabetes, even after adjusting for GDM status (aHR 5.9; 95 % CI 3.7-9.4, P < 0.001). CONCLUSIONS Women of Arab ethnicity have a higher risk for both GDM and future diabetes, a risk that is beyond the initial increased risk associated with GDM. These findings highlight the need for increased focus on preventing diabetes in women of Arab ethnicity, especially those with a history of GDM.
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Affiliation(s)
- Noa Tsur
- Department of Internal Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Meir Frankel
- Endocrinology Unit, Shaare Zedek Medical Center, Jerusalem, Israel; Department of Endocrinology and Metabolism, Clalit Health Services, Jerusalem, Israel
| | - Avivit Cahn
- The Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel; The Faculty of Medicine, Hadassah Hebrew University, Jerusalem, Israel
| | - Anat Tsur
- Department of Endocrinology and Metabolism, Clalit Health Services, Jerusalem, Israel; The Faculty of Medicine, Hadassah Hebrew University, Jerusalem, Israel.
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Ibrahim M, Ba-Essa EM, Baker J, Cahn A, Ceriello A, Cosentino F, Davies MJ, Eckel RH, Van Gaal L, Gaede P, Handelsman Y, Klein S, Leslie RD, Pozzilli P, Del Prato S, Prattichizzo F, Schnell O, Seferovic PM, Standl E, Thomas A, Tuomilehto J, Valensi P, Umpierrez GE. Cardio-renal-metabolic disease in primary care setting. Diabetes Metab Res Rev 2024; 40:e3755. [PMID: 38115715 DOI: 10.1002/dmrr.3755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 09/26/2023] [Accepted: 11/23/2023] [Indexed: 12/21/2023]
Abstract
In the primary care setting providers have more tools available than ever before to impact positively obesity, diabetes, and their complications, such as renal and cardiac diseases. It is important to recognise what is available for treatment taking into account diabetes heterogeneity. For those who develop type 2 diabetes (T2DM), effective treatments are available that for the first time have shown a benefit in reducing mortality and macrovascular complications, in addition to the well-established benefits of glucose control in reducing microvascular complications. Some of the newer medications for treating hyperglycaemia have also a positive impact in reducing heart failure (HF). Technological advances have also contributed to improving the quality of care in patients with diabetes. The use of technology, such as continuous glucose monitoring systems (CGM), has improved significantly glucose and glycated haemoglobin A1c (HbA1c) values, while limiting the frequency of hypoglycaemia. Other technological support derives from the use of predictive algorithms that need to be refined to help predict those subjects who are at great risk of developing the disease and/or its complications, or who may require care by other specialists. In this review we also provide recommendations for the optimal use of the new medications; sodium-glucose co-transporter-2 inhibitors (SGLT2i) and Glucagon-like peptide-receptor agonists 1 (GLP1RA) in the primary care setting considering the relevance of these drugs for the management of T2DM also in its early stage.
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Affiliation(s)
- Mahmoud Ibrahim
- EDC, Centre for Diabetes Education, Charlotte, North Carolina, USA
| | | | - Jason Baker
- Weill Cornell Medicine, New York, New York, USA
| | - Avivit Cahn
- The Diabetes Unit & Endocrinology and Metabolism Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | | | - Francesco Cosentino
- Unit of Cardiology, Department of Medicine Solna, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Robert H Eckel
- University of Colorado Anschutz Medical Campus and University of Colorado Hospital, Aurora, Colorado, USA
| | - Luc Van Gaal
- Department of Endocrinology, Diabetology, and Metabolism, Antwerp University Hospital, Antwerp, Belgium
| | - Peter Gaede
- Department of Cardiology and Endocrinology, Slagelse Hospital, Slagelse, Denmark
| | | | - Samuel Klein
- Washington University School of Medicine, Saint Louis, Missouri, USA
- Sansum Diabetes Research Institute, Santa Barbara, California, USA
| | - Richard David Leslie
- Blizard Institute, Centre of Immunobiology, Barts and the London School of Medicine, Queen Mary, University of London, London, UK
| | - Paolo Pozzilli
- Blizard Institute, Centre of Immunobiology, Barts and the London School of Medicine, Queen Mary, University of London, London, UK
- Campus Bio-Medico University, Rome, Italy
| | - Stefano Del Prato
- University of Pisa and Sant'Anna School of Advanced Studies, Pisa, Italy
| | | | - Oliver Schnell
- Forschergruppe Diabetes eV at the Helmholtz Centre, Munich-Neuherberg, Germany
| | - Petar M Seferovic
- Serbian Academy of Sciences and Arts, University of Belgrade Faculty of Medicine and Belgrade University Medical Center, Belgrade, Serbia
| | - Eberhard Standl
- Forschergruppe Diabetes eV at the Helmholtz Centre, Munich-Neuherberg, Germany
| | | | - Jaakko Tuomilehto
- Public Health Promotion Unit, Finnish Institute for Health and Welfare, Helsinki, Finland
- Department of Public Health, University of Helsinki, Helsinki, Finland
- Diabetes Research Unit, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Paul Valensi
- Polyclinique d'Aubervilliers, Aubervilliers and Paris Nord University, Bobigny, France
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Cahn A, Mor-Shaked H, Rosenberg-Fogler H, Pollack R, Tolhuis B, Sharma G, Schultz E, Yanovsky-Dagan S, Harel T. Complex rearrangement in TBC1D4 in an individual with diabetes due to severe insulin resistance syndrome. Eur J Hum Genet 2024; 32:232-237. [PMID: 38086948 PMCID: PMC10853276 DOI: 10.1038/s41431-023-01512-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 11/14/2023] [Accepted: 11/23/2023] [Indexed: 02/10/2024] Open
Abstract
Severe insulin resistance syndromes result from primary insulin signaling defects, adipose tissue abnormalities or other complex syndromes. Mutations in TBC1D4 lead to partial insulin signaling defects, characterized mainly by postprandial insulin resistance. We describe an individual with severe insulin-resistant diabetes unresponsive to multiple therapies, in whom exome and genome analyses identified a complex rearrangement in TBC1D4. The rearrangement was of the pattern DUP-TRP/INV-DUP, with mutational signatures suggestive of replicative repair and Alu-Alu recombination as the underlying mechanisms. TBC1D4 encodes the TBC1D4/AS160 RabGTPase activating protein (RabGAP) involved in the translocation of glucose transporter 4 (GLUT4) from the cytosol to the cell membrane. Although the precise functional mechanism underlying insulin resistance in the proband is yet to be determined, this case provides further support for the link between TBC1D4 and hereditary insulin-resistant diabetes.
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Affiliation(s)
- Avivit Cahn
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
| | - Hagar Mor-Shaked
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Genetics, Hadassah Medical Center, Jerusalem, Israel
| | - Hallel Rosenberg-Fogler
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Genetics, Hadassah Medical Center, Jerusalem, Israel
| | - Rena Pollack
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
| | | | | | | | | | - Tamar Harel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
- Department of Genetics, Hadassah Medical Center, Jerusalem, Israel.
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5
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Hershkowitz I, Cahn A, Keidar Haran T, Hershko AY. Oxycodone-Acetaminophen Abuse by Inhalation. Isr Med Assoc J 2024; 26:54-55. [PMID: 38420645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Affiliation(s)
- Isca Hershkowitz
- Department of Medicine C, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Avivit Cahn
- Department of Endocrinology and Metabolism, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Tal Keidar Haran
- Department of Pathology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Alon Y Hershko
- Department of Medicine C, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Hershkowitz I, Cahn A. Prescription patterns in people who are frail. Lancet Healthy Longev 2023; 4:e522-e523. [PMID: 37734396 DOI: 10.1016/s2666-7568(23)00177-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 08/22/2023] [Indexed: 09/23/2023] Open
Affiliation(s)
- Isca Hershkowitz
- Department of Medicine, Hadassah Medical Center, Jerusalem 91120, Israel
| | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem 91120, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
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7
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Cahn A, Shoyhet-Smoilovsky H, Fischer M, Zick A, Riahi Y, Levenberg S, Leibowitz G. Alpelisib in Intractable Non-Islet-Cell Tumor Hypoglycemia. N Engl J Med 2023; 388:1911-1913. [PMID: 37195951 DOI: 10.1056/nejmc2302935] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Affiliation(s)
- Avivit Cahn
- Hadassah Medical Center of Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Matan Fischer
- Hadassah Medical Center of Hebrew University of Jerusalem, Jerusalem, Israel
| | - Aviad Zick
- Hadassah Medical Center of Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yael Riahi
- Hadassah Medical Center of Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Gil Leibowitz
- Hadassah Medical Center of Hebrew University of Jerusalem, Jerusalem, Israel
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8
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Perzon O, Cahn A, Gellman YN, Leibovitch M, Peled S, Elishoov O, Haze A, Olshtain-Pops K, Elinav H. Enterococci in Diabetic Foot Infections: Prevalence, Clinical Characteristics, and Outcomes. Open Forum Infect Dis 2023; 10:ofad238. [PMID: 37234514 PMCID: PMC10205551 DOI: 10.1093/ofid/ofad238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 04/28/2023] [Indexed: 05/28/2023] Open
Abstract
Background Diabetic foot infections (DFIs) are frequently polymicrobial, yet the relevance of each isolated pathogen, remains ill-defined. Specifically, the prevalence and pathogenicity of enterococcal DFIs and the impact of targeted antienterococcal treatment remain elusive. Methods We collected demographic, clinical, and outcome-related data on patients admitted with DFIs to the Hadassah Medical Center diabetic foot unit between 2014 and 2019. The primary outcome was a composite of in-hospital death or major amputation. Secondary outcomes included any amputation, major amputation, length of stay (LOS), and 1-year major amputation or mortality rate. Results Enterococci were isolated in 35% of 537 eligible DFI case patients, who were notable for a higher prevalence of peripheral vascular disease, increased levels of C-reactive protein, and higher Wagner scores. Infection in enterococci-positive individuals was mostly polymicrobial (96.8% vs 61.0% in non-enterococci-infected patients; P < .001). Enterococci-infected patients were more likely to undergo amputation (72.3% vs 50.1%; P < .001) and had longer hospital stays (median LOS, 22.5 vs 17 days; P < .001), but the primary end point of major amputation or in-hospital death did not differ between groups (25.5% vs 21.0%; P = .26). Appropriate antienterococcal antibiotics were used in 78.1% of enterococci-infected patients and, compared with results in untreated patients, were associated with a trend toward a lower rate of major amputations (20.4% vs 34.1%; P = .06) but longer hospitalization (median LOS, 24 vs 18 days; P = .07). Conclusions Enterococci are common in DFIs and associated with higher rates of amputation and longer hospitalization. A reduction in major amputation rates with appropriate enterococci treatment is suggested retrospectively, meriting validation by future prospective studies.
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Affiliation(s)
- Ofer Perzon
- Correspondence: Ofer Perzon, MD, Internal Medicine B Department, Hadassah Hebrew University Medical Center and Hebrew University of Jerusalem, PO Box 12271, Ein Kerem, Jerusalem 9112102, Israel ()
| | | | - Yechiel N Gellman
- Diabetic Foot Unit, Department of Orthopedics, Hadassah Hebrew University Medical Center, Ein Kerem, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Michal Leibovitch
- Department of Military Medicine and “Tzameret,” Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Medical Corps, Israel Defense Forces, Israel
| | - Shahar Peled
- Department of Military Medicine and “Tzameret,” Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Medical Corps, Israel Defense Forces, Israel
| | - Ofer Elishoov
- Diabetic Foot Unit, Department of Orthopedics, Hadassah Hebrew University Medical Center, Ein Kerem, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Amir Haze
- Diabetic Foot Unit, Department of Orthopedics, Hadassah Hebrew University Medical Center, Ein Kerem, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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9
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Zelniker TA, Wiviott SD, Mosenzon O, Goodrich EL, Jarolim P, Cahn A, Bhatt DL, Leiter LA, McGuire DK, Wilding J, Averkov O, Budaj A, Parkhomenko A, Ray KK, Gause-Nilsson I, Langkilde AM, Fredriksson M, Raz I, Sabatine MS, Morrow DA. Association of Cardiac Biomarkers With Major Adverse Cardiovascular Events in High-risk Patients With Diabetes: A Secondary Analysis of the DECLARE-TIMI 58 Trial. JAMA Cardiol 2023; 8:503-509. [PMID: 36857035 PMCID: PMC9979005 DOI: 10.1001/jamacardio.2023.0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 01/03/2023] [Indexed: 03/02/2023]
Abstract
Importance Dapagliflozin reduces the risk of hospitalizations for heart failure and the progression of chronic kidney disease in patients with and without type 2 diabetes (T2D), whereas the effects on reducing atherosclerotic events appear less clear. Objective To explore whether N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hsTnT) levels can identify a subset of patients with T2D at higher risk and who might benefit more from dapagliflozin with regard to atherosclerotic events. Design, Setting, and Participants This was a secondary analysis of the DECLARE-TIMI 58 trial, a randomized clinical trial of dapagliflozin in patients with T2D and either multiple risk factors for atherosclerotic cardiovascular disease (ASCVD; approximately 60%) or established ASCVD (approximately 40%). All patients with available blood samples at randomization were included in these analyses. Data were collected from May 2013 to September 2018, and data were analyzed from May 2019 to June 2022. Interventions Dapagliflozin vs placebo. Main Outcomes and Measures Major adverse cardiovascular events (MACE), the composite of myocardial infarction, ischemic stroke, or cardiovascular death, which was one of dual primary outcomes of the main trial. Results Of 14 565 included patients, 9143 (62.8%) were male, and the mean (SD) age was 63.9 (6.8) years. When tested individually in a multivariable model for MACE risk, NT-proBNP and hsTnT were each significantly associated with the risk of MACE (adjusted hazard ratio [aHR] per 1 SD in log-transformed biomarker: NT-proBNP, 1.62; 95% CI, 1.49-1.76; hsTnT: 1.59; 95% CI, 1.46-1.74). The magnitude of the association was similar in patients with ASCVD (NT-proBNP: aHR, 1.60; 95% CI, 1.45-1.77; hsTnT: aHR, 1.62; 95% CI, 1.45-1.81) and multiple risk factors for ASCVD (NT-proBNP: aHR, 1.62; 95% CI, 1.40-1.88; hsTnT: aHR, 1.51; 95% CI, 1.29-1.77). Moreover, both biomarkers remained independently associated with MACE when both were included in the multivariable model (NT-proBNP: aHR, 1.46; 95% CI, 1.34-1.60; hsTnT: aHR, 1.39; 95% CI, 1.26-1.53). Modeled as a continuous variable, baseline biomarker levels did not modify the relative treatment effect of dapagliflozin vs placebo with MACE. However, the relative risk reduction numerically grew with higher biomarker levels, as did the baseline risk. Thus, MACE event rates were nominally lower in dapagliflozin-treated vs placebo-treated patients with biomarker concentrations in the top quartile (NT-proBNP: HR, 0.83; 95% CI, 0.71-0.97; absolute risk reduction [ARR], 2.4%; hsTnT: HR, 0.85; 95% CI, 0.72-0.99; ARR, 2.7%), whereas there was no significant treatment effect in patients with biomarkers levels in quartiles 1 to 3 (NT-proBNP: HR, 1.02; 95% CI, 0.88-1.18; ARR, 0%; hsTnT: HR, 0.97; 95% CI, 0.84-1.13; ARR, 0.2%). Conclusions and Relevance In this study, NT-proBNP and hsTnT levels were associated with the risk for future cardiovascular events in both primary and secondary prevention patients with T2D. Both cardiac biomarkers were helpful to identify patients at very high risk for atherosclerotic events that may derive reduction in risk of MACE with dapagliflozin. Trial Registration ClinicalTrials.gov Identifier: NCT01730534.
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Affiliation(s)
| | - Stephen D. Wiviott
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ofri Mosenzon
- The Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | - Erica L. Goodrich
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Petr Jarolim
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Avivit Cahn
- The Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | - Deepak L. Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, New York
| | - Lawrence A. Leiter
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Darren K. McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - John Wilding
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, United Kingdom
| | - Oleg Averkov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - Andrzej Budaj
- Centre of Postgraduate Medical Education, Grochowski Hospital, Warsaw, Poland
| | | | - Kausik K. Ray
- Imperial Centre for Cardiovascular Disease Prevention and Imperial Clinical Trials Unit, Imperial College London, London, United Kingdom
| | | | | | | | - Itamar Raz
- The Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | - Marc S. Sabatine
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Deputy Editor, JAMA Cardiology
| | - David A. Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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10
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Schechter M, Wiviott SD, Raz I, Goodrich EL, Rozenberg A, Yanuv I, Murphy SA, Zelniker TA, Fredriksson M, Johansson PA, Leiter LA, Bhatt DL, McGuire DK, Wilding JPH, Gause-Nilsson IAM, Cahn A, Langkilde AM, Sabatine MS, Mosenzon O. Effects of dapagliflozin on hospitalisations in people with type 2 diabetes: post-hoc analyses of the DECLARE-TIMI 58 trial. Lancet Diabetes Endocrinol 2023; 11:233-241. [PMID: 36878239 DOI: 10.1016/s2213-8587(23)00009-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND In people with type 2 diabetes at high risk of cardiovascular or kidney disease, sodium-glucose co-transporter 2 (SGLT2) inhibitors consistently reduce the risk of hospitalisations for heart failure. Less is known about their effects on hospitalisation from any cause, especially in people with type 2 diabetes without atherosclerotic cardiovascular disease, which includes most of the global population of people with type 2 diabetes. We aimed to assess the effect of the SGLT2 inhibitor, dapagliflozin, on the risks of hospitalisations for any cause and for specific causes in people with type 2 diabetes with and without atherosclerotic cardiovascular disease. METHODS The DECLARE-TIMI 58 trial was a double-blind, multicentre, randomised, placebo-controlled study. People with type 2 diabetes and either risk factors for or established atherosclerotic cardiovascular disease were randomly assigned (1:1) to receive oral dapagliflozin 10 mg or placebo once daily. In these post-hoc analyses, the effects of dapagliflozin on risks of first non-elective any-cause and cause-specific hospitalisation were assessed with Cox proportional hazards regression models overall and in the subset of participants without prevalent atherosclerotic cardiovascular disease. The risk of total (first plus subsequent) non-elective hospitalisations was assessed with Lin-Wei-Ying-Yang model. Investigator-reported System Organ Class terms were used to classify cause-specific hospitalisations. The trial is registered with ClinicalTrials.gov, NCT01730534. FINDINGS Between April 25, 2013, and Sept 18, 2018, 17 160 people (6422 [37·4%] women, 10 738 [62·6%] men; mean age 63·9 years [SD 6·8]) were enrolled in the original trial, of whom 10186 (59·4%) had multiple risk factors for but did not have established atherosclerotic cardiovascular disease, and 6835 (39·8%) had both no evidence of atherosclerotic cardiovascular disease and low KDIGO risk. Over a median follow-up of 4·2 years (IQR 3·9-4·4), dapagliflozin was associated with a lower risk of first non-elective hospitalisation for any cause (2779 [32·4%] of 8582 people in the dapagliflozin group vs 3036 [35·4%] of 8578 people in the placebo group; hazard ratio [HR] 0·89 [95% CI 0·85-0·94]) and total (first plus subsequent) non-elective hospitalisations for any cause (risk ratio 0·92 [95% CI 0·86-0·97]). The association between dapagliflozin use and the risk of first non-elective hospitalisation for any cause was consistent in subgroups of participants with (HR 0·92 [95% CI 0·85-0·99] and without (0·87 [0·81-0·94]) atherosclerotic cardiovascular disease at baseline (p interaction=0·31). Compared with the placebo group, the dapagliflozin group had lower risk of first hospitalisations due to cardiac disorders (HR 0·91 [95% CI 0·84-1·00]), metabolism and nutrition disorders (0·73 [0·60-0·89]), renal and urinary disorders (0·61 [0·49-0·77]), and due to any other cause excluding these three causes (0·90 [0·85-0·96]). Treatment with dapagliflozin was also associated with a lower risk of hospitalisations due to musculoskeletal and connective tissue disorders (HR 0·81 [0·67-0·99]) and infections and infastations (HR 0·86 [0·78-0·96]). INTERPRETATION Dapagliflozin reduced the risk of first and total non-elective hospitalisations for any cause in people with type 2 diabetes, regardless of the presence of atherosclerotic cardiovascular disease, including hospitalisations not directly attributed to cardiac, kidney, or metabolic causes. These findings might have implications on health-related quality of life for people with type 2 diabetes and on health-care costs attributable this condition. FUNDING AstraZeneca.
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Affiliation(s)
- Meir Schechter
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Stephen D Wiviott
- TIMI Study Group and Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Erica L Goodrich
- TIMI Study Group and Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Aliza Rozenberg
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ilan Yanuv
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sabina A Murphy
- TIMI Study Group and Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Thomas A Zelniker
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Martin Fredriksson
- BioPharmaceuticals Research & Development, AstraZeneca, Gothenburg, Sweden
| | - Peter A Johansson
- BioPharmaceuticals Research & Development, AstraZeneca, Gothenburg, Sweden
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, NY, USA
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Internal Medicine, Parkland Health and Hospital System, Dallas, TX, USA
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, UK
| | | | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Marc S Sabatine
- TIMI Study Group and Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
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11
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Small AM, Berg D, Raz I, Goodrich EL, Moura F, Mosenzon O, Cahn A, Bhatt DL, Leiter LA, McGuire DK, Wilding J, Gause-Nilsson I, Sabatine MS, Morrow DA, Wiviott SD. RELATIONSHIP BETWEEN CYSTATIN C, CREATININE-BASED EGFR, CARDIOVASCULAR EVENTS AND KIDNEY OUTCOMES IN DECLARETIMI 58. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)02260-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
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12
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Pollack R, Raz I, Wiviott SD, Goodrich EL, Murphy SA, Yanuv I, Rozenberg A, Mosenzon O, Langkilde AM, Gause-Nilsson IAM, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Sabatine MS, Cahn A. Efficacy and Safety of Dapagliflozin by Baseline Insulin Regimen and Dose: Post Hoc Analyses From DECLARE-TIMI 58. Diabetes Care 2023; 46:156-164. [PMID: 36399721 DOI: 10.2337/dc22-1318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/13/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The cardiorenal benefits of adding sodium-glucose cotransporter 2 (SGLT2) inhibitor therapy for patients on insulin, particularly those on intensive regimens that include short-acting (SA) insulin, have not been explored. RESEARCH DESIGN AND METHODS In Dapagliflozin Effect on Cardiovascular Events trial (DECLARE-TIMI 58), 17,160 patients with type 2 diabetes were randomized to dapagliflozin or placebo for a median follow-up of 4.2 years. Cardiovascular (CV), renal, metabolic, and safety outcomes with dapagliflozin versus placebo by insulin dose and regimen were studied with Cox regression models. RESULTS The study included 7,013 insulin users at baseline, with 4,650 (66.3%) patients on regimens including SA insulin. Insulin doses varied, with 2,443 (34.8%) patients receiving <0.5 IU/kg, 2,795 (39.9%) 0.5 to ≤1 IU/kg, and 1,339 (19.1%) >1 IU/kg. Dapagliflozin reduced CV death/hospitalization for heart failure among overall insulin users (hazard ratio [HR] 0.82 [95% CI 0.69-0.97]) and consistently in patients on insulin regimens with or without SA insulin (0.83 [0.67-1.03] and 0.78 [0.57-1.07], respectively, Pinteraction = 0.75). No heterogeneity was observed by insulin dose (Pinteraction = 0.43). The HR for major adverse CV events with dapagliflozin among insulin users (0.84 [0.74-0.97]) was similar irrespective of regimen or dose (Pinteraction = 0.75 and 0.07). Dapagliflozin reduced the rate of adverse renal outcomes overall and consistently across subgroups of insulin users. Decreases in HbA1c, weight, and systolic blood pressure with dapagliflozin were seen regardless of insulin dose or regimen. The known safety profile of dapagliflozin was unchanged in patients on intensive insulin regimens. CONCLUSIONS The benefits and safety of dapagliflozin were maintained in high-risk patients receiving high-dose or intensive insulin regimens including SA insulin.
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Affiliation(s)
- Rena Pollack
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Stephen D Wiviott
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Erica L Goodrich
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Sabina A Murphy
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Ilan Yanuv
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Aliza Rozenberg
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | | | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX
- Parkland Health and Hospital System, Dallas, TX
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, U.K
| | - Marc S Sabatine
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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13
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Gorin K, Cahn A, Leibovitch M, Peled S, Perzon O, Tzukert K, Haze A, Elishoov O, Olshtain‐Pops K, Gelman YN. Acute diabetic foot in post kidney transplantation patients receiving chronic immunosuppression-clinical presentation and outcomes. Diabetes Metab Res Rev 2022; 38:e3575. [PMID: 36036940 PMCID: PMC9788065 DOI: 10.1002/dmrr.3575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 06/22/2022] [Accepted: 07/27/2022] [Indexed: 12/30/2022]
Abstract
AIMS Data regarding diabetic foot ulcers in patients after solid organ transplantation, particularly kidney transplantation, are limited. Chronic immunosuppression may be associated with impaired wound healing and a higher risk of amputations. In this study, we characterised the clinical presentation and outcomes of patients after kidney transplantation admitted to the diabetic foot unit, compared to non-kidney-transplant patients. MATERIALS AND METHODS Data on the baseline characteristics, clinical presentation, and outcomes of all patients admitted to the diabetic foot unit of a large tertiary centre between the years 2014 and 2019 were collected. The most recent admission of each patient was considered. Primary outcomes were major amputations and 1 year mortality rate. RESULTS During the study period, 537 patients were hospitalised, 18 of them were receiving immunosuppressive therapy due to kidney transplantation. Baseline characteristics of the patients were broadly similar, except that smoking was reported by 22.0% of the non-transplant patients and by none of the post-transplant patients (p = 0.01). Post-transplant patients tended to be younger (59.4 ± 11.1 vs. 65.3 ± 12.2; p = 0.07), were more likely to have type-1 diabetes (16.7% vs. 5.2%; p = 0.07) and had lower glucose levels upon admission (9.4 ± 4.3 vs. 12.0 ± 6.4 mmol/L; p = 0.07). Overall, 30% of the patients underwent major amputation, in-patient mortality rate was 9.3%, and 1 year mortality rate was 27.2%. Rates were similar in the post-transplant versus the non-post-transplant patients (p = 0.83, 1.00, 0.59, respectively). CONCLUSIONS Post-transplant patients did not incur worse outcomes in spite of immunosuppressive therapy. Limb salvage efforts should be pursued in these patients similar to the overall population.
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Affiliation(s)
- Kobi Gorin
- Internal Medicine DivisionHadassah‐Hebrew University Medical CenterJerusalemIsrael
- The Faculty of MedicineHebrew UniversityJerusalemIsrael
| | - Avivit Cahn
- The Faculty of MedicineHebrew UniversityJerusalemIsrael
- Department of Endocrinology and MetabolismDiabetes UnitHadassah‐Hebrew University Medical CenterJerusalemIsrael
| | - Michal Leibovitch
- The Faculty of MedicineHebrew UniversityJerusalemIsrael
- Department of Military Medicine and ‘Tzameret’Medical CorpsIsrael Defense ForcesJerusalemIsrael
| | - Shachar Peled
- The Faculty of MedicineHebrew UniversityJerusalemIsrael
| | - Ofer Perzon
- Internal Medicine DivisionHadassah‐Hebrew University Medical CenterJerusalemIsrael
- The Faculty of MedicineHebrew UniversityJerusalemIsrael
| | - Keren Tzukert
- The Faculty of MedicineHebrew UniversityJerusalemIsrael
- Department of Nephrology and HypertensionHadassah‐Hebrew University Medical CenterJerusalemIsrael
| | - Amir Haze
- The Faculty of MedicineHebrew UniversityJerusalemIsrael
- Orthopedic DivisionFoot and Ankle UnitHadassah‐Hebrew University Medical CenterJerusalemIsrael
| | - Ofer Elishoov
- Orthopedic DivisionFoot and Ankle UnitHadassah‐Hebrew University Medical CenterJerusalemIsrael
| | - Karen Olshtain‐Pops
- The Faculty of MedicineHebrew UniversityJerusalemIsrael
- Division of Microbiology and Infectious DiseasesHadassah‐Hebrew University Medical CenterJerusalemIsrael
| | - Yechiel Nisan Gelman
- The Faculty of MedicineHebrew UniversityJerusalemIsrael
- Orthopedic DivisionFoot and Ankle UnitHadassah‐Hebrew University Medical CenterJerusalemIsrael
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14
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Mosenzon O, Raz I, Wiviott SD, Schechter M, Goodrich EL, Yanuv I, Rozenberg A, Murphy SA, Zelniker TA, Langkilde AM, Gause-Nilsson IAM, Fredriksson M, Johansson PA, Wilding JPH, McGuire DK, Bhatt DL, Leiter LA, Cahn A, Dwyer JP, Heerspink HJL, Sabatine MS. Dapagliflozin and Prevention of Kidney Disease Among Patients With Type 2 Diabetes: Post Hoc Analyses From the DECLARE-TIMI 58 Trial. Diabetes Care 2022; 45:2350-2359. [PMID: 35997319 PMCID: PMC9862307 DOI: 10.2337/dc22-0382] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 07/05/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVE In patients with moderate to severe albuminuric kidney disease, sodium-glucose cotransporter 2 inhibitors reduce the risk of kidney disease progression. These post hoc analyses assess the effects of dapagliflozin on kidney function decline in patients with type 2 diabetes (T2D), focusing on populations with low kidney risk. RESEARCH DESIGN AND METHODS In the Dapagliflozin Effect on Cardiovascular Events-Thrombolysis in Myocardial Infarction 58 (DECLARE-TIMI 58) trial, patients with T2D at high cardiovascular risk were randomly assigned to dapagliflozin versus placebo. Outcomes were analyzed by treatment arms, overall, and by Kidney Disease: Improving Global Outcomes (KDIGO) risk categories. The prespecified kidney-specific composite outcome was a sustained decline ≥40% in the estimated glomerular filtration rate (eGFR) to <60 mL/min/1.73 m2, end-stage kidney disease, and kidney-related death. Other outcomes included incidence of categorical eGFR decline of different thresholds and chronic (6 month to 4 year) or total (baseline to 4 year) eGFR slopes. RESULTS Most participants were in the low-moderate KDIGO risk categories (n = 15,201 [90.3%]). The hazard for the kidney-specific composite outcome was lower with dapagliflozin across all KDIGO risk categories (P-interaction = 0.97), including those at low risk (hazard ratio [HR] 0.54, 95% CI 0.38-0.77). Risks for categorical eGFR reductions (≥57% [in those with baseline eGFR ≥60 mL/min/1.73 m2], ≥50%, ≥40%, and ≥30%) were lower with dapagliflozin (HRs 0.52, 0.57, 0.55, and 0.70, respectively; P < 0.05). Slopes of eGFR decline favored dapagliflozin across KDIGO risk categories, including the low KDIGO risk (between-arm differences of 0.87 [chronic] and 0.55 [total] mL/min/1.73 m2/year; P < 0.0001). CONCLUSIONS Dapagliflozin mitigated kidney function decline in patients with T2D at high cardiovascular risk, including those with low KDIGO risk, suggesting a role of dapagliflozin in the early prevention of diabetic kidney disease.
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Affiliation(s)
- Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Meir Schechter
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Erica L Goodrich
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Ilan Yanuv
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Aliza Rozenberg
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Thomas A Zelniker
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | | | | | | | | | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, U.K
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX.,Parkland Health and Hospital System, Dallas, TX
| | | | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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15
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Oyama K, Raz I, Cahn A, Goodrich EL, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Gause-Nilsson IAM, Mosenzon O, Sabatine MS, Wiviott SD. Efficacy and Safety of Dapagliflozin According to Background Use of Cardiovascular Medications in Patients With Type 2 Diabetes: A Prespecified Secondary Analysis of a Randomized Clinical Trial. JAMA Cardiol 2022; 7:914-923. [PMID: 35857296 DOI: 10.1001/jamacardio.2022.2006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Dapagliflozin was shown to reduce the cardiovascular (CV) and kidney outcomes in patients with type 2 diabetes. However, data are limited on the relationship of the effect and safety with the concurrent use of CV medications in patients with type 2 diabetes. Objective To assess whether the cardiorenal efficacy and safety of dapagliflozin were consistent with and without background use of CV medications commonly used for heart failure (HF) and kidney disease in patients with type 2 diabetes. Design, Setting, and Participants This study is a prespecified secondary analysis of DECLARE-TIMI 58, which was a randomized trial of dapagliflozin vs placebo in 17 160 patients with type 2 diabetes and either atherosclerotic disease or multiple risk factors for CV disease. Patients were stratified by baseline use of the following CV medications: angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers (ACEI/ARBs), β-blockers, diuretics, and mineralocorticoid receptor antagonists (MRAs). The study was conducted from May 2013 to September 2018, and data were evaluated for this analysis from February 2021 to May 2022. Interventions Dapagliflozin or placebo. Main Outcomes and Measures The outcomes of interest were the composite of CV death or hospitalization for HF (HHF), HHF alone, and a kidney-specific composite outcome (persistent ≥40% decrease in estimated glomerular filtration rate [eGFR], end-stage kidney disease, or kidney-related death). Results Among 17 160 patients, 13 950 (81%) used ACEI/ARBs, 9030 (53%) used β-blockers, 6205 (36%) used diuretics, and 762 (4%) used MRAs at baseline. Changes in blood pressure and eGFR at 48 months with dapagliflozin compared with placebo did not differ regardless of concurrent therapy (placebo-corrected change, -1.6 mm Hg [95% CI, -4.2 to 1.0] to -2.6 mm Hg [95% CI, -3.3 to -2.9]; P > .05 for each interaction). Dapagliflozin consistently reduced the risk of CV death/HHF, HHF alone, and the kidney-specific composite outcome regardless of background use of selected medications (hazard ratio [HR] range: HR, 0.50; 95% CI, 0.39-0.63; to HR, 0.82; 95% CI, 0.72-0.95; P > .05 for each interaction). In patients receiving ACEI/ARBs + β-blockers + diuretics (n = 4243), dapagliflozin reduced the risk of CV death/HHF and of the kidney-specific outcome by 24% (HR, 0.76; 95% CI, 0.62-0.93) and 38% (HR, 0.62; 95% CI, 0.44-0.87), respectively. There were no significant treatment interactions with the concomitant CV medications for adverse events of volume depletion, acute kidney injury, or hyperkalemia (range: HR, 0.12; 95% CI, 0.02-0.99; to HR, 1.04; 95% CI, 0.83-1.32; P > .05 for each interaction). Conclusions and Relevance Dapagliflozin consistently reduced the risk of CV and kidney outcomes irrespective of background use of various CV medications without any treatment interaction for key safety events. These data show the clinical benefit and safety of dapagliflozin in a broad range of patients with type 2 diabetes regardless of background therapy. Trial Registration ClinicalTrials.gov Identifier: NCT01730534.
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Affiliation(s)
- Kazuma Oyama
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Erica L Goodrich
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, United Kingdom
| | | | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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16
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Furtado RHM, Raz I, Goodrich EL, Murphy SA, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Aylward P, Dalby AJ, Dellborg M, Dimulescu D, Nicolau JC, Oude Ophuis AJM, Cahn A, Mosenzon O, Gause-Nilsson I, Langkilde AM, Sabatine MS, Wiviott SD. Efficacy and Safety of Dapagliflozin in Type 2 Diabetes According to Baseline Blood Pressure: Observations From DECLARE-TIMI 58 Trial. Circulation 2022; 145:1581-1591. [PMID: 35510542 DOI: 10.1161/circulationaha.121.058103] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Dapagliflozin improved heart failure and kidney outcomes in patients with type 2 diabetes mellitus (T2DM) with or at high risk for cardiovascular disease in the DECLARE-TIMI 58 trial. Here, the aim was to analyze efficacy and safety of dapagliflozin stratified according to baseline systolic blood pressure (SBP). Methods: The DECLARE-TIMI 58 trial randomized patients with T2DM and either prior atherosclerotic cardiovascular disease (ASCVD) or ASCVD risk factors to dapagliflozin or placebo. Patients were categorized by baseline SBP levels: < 120, 120-129, 130-139, 140-159 and ≥ 160 mmHg (respectively, normal, elevated, stage 1, stage 2 and severe hypertension). Efficacy outcomes of interest were hospitalization for heart failure (HHF) and a renal-specific composite outcome (sustained decrease in estimated glomerular filtration rate by 40%, progression to end-stage renal disease or renal death). Safety outcomes included symptoms of volume depletion, lower extremity amputations and acute kidney injury. Results: The trial comprised 17,160 patients; mean age of 64.0 ± 6.8 years ; 37.4% women; median duration of T2DM 11 years; 40.6% with prevalent CVD. Overall, dapagliflozin reduced SBP by 2.4 mmHg (95% CI 1.9-2.9; p < 0.0001) compared with placebo at 48 months. The beneficial effects of dapagliflozin on HHF and renal outcomes were consistent across all baseline SBP categories, with no evidence of modification of treatment effect (p-interactions = 0.28 and 0.52, respectively). Among normotensive patients, the HR´s were 0.66 (95% CI 0.42-1.05) and 0.39 (95% CI 0.19-0.78), respectively for HHF and the renal specific outcome. Events of volume depletion, amputation and acute kidney injury did not differ with dapagliflozin overall or within any baseline SBP group. Conclusions: In patients with T2DM with or at high ASCVD risk, dapagliflozin reduced risk for HHF and renal outcomes regardless of baseline systolic blood pressure, with no difference in adverse events of interest at any level of baseline SBP. These results indicate that dapagliflozin provides important cardiorenal benefit in patients with T2DM at high ASCVD risk, independent of baseline blood pressure.
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Affiliation(s)
- Remo H M Furtado
- Academic Research Organization, Hospital Israelita Albert Einstein, Sao Paulo, Brazil; Instituto do Coracao (InCor), Hospital das Clinicas da Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil; TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Harvard Medical School, Boston, MA
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Erica L Goodrich
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Harvard Medical School, Boston, MA
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Harvard Medical School, Boston, MA
| | - Deepak L Bhatt
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Harvard Medical School, Boston, MA
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center and Parkland Health and Hospital System, Dallas, TX
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Philip Aylward
- South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, Australia
| | | | - Mikael Dellborg
- Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Doina Dimulescu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - José C Nicolau
- Instituto do Coracao (InCor), Hospital das Clinicas da Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | | | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Harvard Medical School, Boston, MA
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Harvard Medical School, Boston, MA
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Pollack R, Koch N, Mazeh H, Cahn A, Katz L, Appelbaum L. Consistency of TI-RADS Reporting in Community-Based Imaging Centers vs. a Large Tertiary Hospital. Endocr Pract 2022; 28:754-759. [PMID: 35452816 DOI: 10.1016/j.eprac.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 04/06/2022] [Accepted: 04/12/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE In our country, thyroid nodules are sonographically evaluated in health maintenance organization (HMO) imaging centers, and patients are referred to tertiary hospitals for ultrasound-guided fine needle aspiration (FNA) biopsy when indicated. We evaluated the concordance in Thyroid Imaging Reporting and Data System (TI-RADS) classification reporting between these sites. METHODS We conducted a retrospective cohort study reviewing the sonographic features of thyroid nodules evaluated both at the HMO and a large tertiary center between January 2018 and December 2019. The primary outcome was concordance between the TI-RADS classification at both sites. Additional endpoints included correlation of TI-RADS to the Bethesda category following FNA and correlation of TI-RADS with malignancy on final pathology at each site. RESULTS The records of 336 patients with 370 nodules were reviewed. The level of concordance was poor (19.8%), with 277 (74.8%) nodules demonstrating higher TI-RADS and 20 (5.4%) lower TI-RADS at the HMO compared to the hospital (p<0.001, weighted Kappa = 0.120). FNA results were available for 236 (63.8%) nodules. The Bethesda category strongly correlated with the hospital TI-RADS (p<0.001), yet not with HMO TI-RADS (p=0.123). In the 57 nodules surgically removed, a strong correlation was identified between malignancy on final pathology and TI-RADS documented at the hospital (p<0.001), yet not at the HMO (p=0.259). CONCLUSIONS There is poor agreement between TI-RADS classification on ultrasound performed in the HMO compared to a tertiary hospital. The hospital TI-RADS strongly correlated with Bethesda category and final risk of malignancy unlike the HMO.
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Affiliation(s)
- Rena Pollack
- Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel; The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Noam Koch
- The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Haggi Mazeh
- The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Department of Surgery, Hadassah Medical Center, Jerusalem, Israel
| | - Avivit Cahn
- Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel; The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Liat Appelbaum
- The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Department of Radiology, Hadassah Medical Center, Jerusalem, Israel
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18
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Cahn A, Wiviott SD, Mosenzon O, Goodrich EL, Murphy SA, Yanuv I, Rozenberg A, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Gause-Nilsson IAM, Langkilde AM, Sabatine MS, Raz I. Association of Baseline HbA1c With Cardiovascular and Renal Outcomes: Analyses From DECLARE-TIMI 58. Diabetes Care 2022; 45:938-946. [PMID: 35015847 DOI: 10.2337/dc21-1744] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 11/28/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Current guidelines recommend prescribing SGLT2 inhibitors to patients with type 2 diabetes and established or at high risk for atherosclerotic cardiovascular disease (ASCVD), irrespective of HbA1c levels. We studied the association of HbA1c with cardiovascular and renal outcomes and whether the benefit of dapagliflozin varies by baseline HbA1c. RESEARCH DESIGN AND METHODS In the Dapagliflozin Effect on Cardiovascular Events trial (DECLARE-TIMI 58), 17,160 patients with type 2 diabetes were randomly assigned to dapagliflozin or placebo for a median follow-up of 4.2 years. Cardiovascular and renal outcomes by baseline HbA1c in the overall population and with dapagliflozin versus placebo in HbA1c subgroups were studied by Cox regression models. RESULTS In the overall population, higher baseline HbA1c was associated with a higher risk of cardiovascular death or hospitalization for heart failure (HHF); major adverse cardiovascular events (MACE), including cardiovascular death, myocardial infarction, and ischemic stroke; and cardiorenal outcomes (adjusted hazard ratios 1.12 [95% CI 1.06-1.19], 1.08 [1.04-1.13], and 1.17 [1.11-1.24] per 1% higher level, respectively). Elevated HbA1c was associated with a greater increased risk for MACE and cardiorenal outcomes in patients with multiple risk factors (MRF) than in established ASCVD (P-interaction = 0.0064 and 0.0093, respectively). Compared with placebo, dapagliflozin decreased the risk of cardiovascular death/HHF, HHF, and cardiorenal outcomes, with no heterogeneity by baseline HbA1c (P-interaction > 0.05). CONCLUSIONS Higher HbA1c levels were associated with greater cardiovascular and renal risk, particularly in the MRF population, yet the benefits of dapagliflozin were observed in all subgroups irrespective of baseline HbA1c, including patients with HbA1c <7%.
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Affiliation(s)
- Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Erica L Goodrich
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Ilan Yanuv
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Aliza Rozenberg
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, and Parkland Health and Hospital System, Dallas, TX
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, U.K
| | | | | | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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19
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Berg D, Wiviott SD, Raz I, Jarolim P, Goodrich EL, Mosenzon O, Cahn A, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Gause-Nilsson I, Hammarstedt A, Oscarsson J, Sabatine MS, Morrow DA. FIBROBLAST GROWTH FACTOR-23, CARDIORENAL OUTCOMES, AND EFFICACY OF DAPAGLIFLOZIN IN PATIENTS WITH TYPE 2 DIABETES MELLITUS: AN ANALYSIS FROM DECLARE-TIMI 58. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)02517-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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20
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Cahn A, Zuker I, Eilenberg R, Uziel M, Tsadok MA, Raz I, Lutski M. Machine learning based study of longitudinal HbA1c trends and their association with all-cause mortality: Analyses from a National Diabetes Registry. Diabetes Metab Res Rev 2022; 38:e3485. [PMID: 34233382 DOI: 10.1002/dmrr.3485] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 06/05/2021] [Accepted: 06/19/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The association of long-term HbA1c variability with mortality has been previously suggested. However, the significance of HbA1c variability and trends in different age and HbA1c categories is unclear. RESEARCH DESIGN AND METHODS Data on patients with diabetes listed in the Israeli National Diabetes Registry during years 2012-2016 (observation period) were collected. Patients with >4 HbA1c measurements, type 1 diabetes, eGFR < 30mg/ml/min, persistent HbA1c < 6% or malignancy were excluded. Utilizing machine learning methods, patients were classified into clusters according to their HbA1c trend (increasing, stable, decreasing). Mortality risk during 2017-2019 was calculated in subgroups defined by age (35-54, 55-69, 70-89 years) and last HbA1c (≤7% and >7%) at end of observation period. Models were adjusted for demographic, clinical and laboratory measurements including HbA1c, standard deviation (SD) of HbA1c and HbA1c trend. RESULTS This historical cohort study included 293,314 patients. Increased HbA1c variability (high SD) during the observation period was an independent predictor of mortality in patients aged more than 55 years (p < 0.01). The HbA1c trend was another independent predictor of mortality. Patients with a decreasing versus stable HbA1c trend had a greater mortality risk; this association persisted in all age groups in patients with HbA1c > 7% at the end of the observation period (p = 0.02 in age 35-54; p < 0.01 in aged >55). Patients with an increasing versus stable HbA1c trend had a greater mortality risk only in the elderly group (>70), yet in both HbA1c categories (p < 0.01). CONCLUSIONS HbA1c variability and trend are important determinants of mortality risk and should be considered when adjusting glycaemic targets.
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Affiliation(s)
- Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Hebrew University Hospital, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Inbar Zuker
- Israel Center for Disease Control, Ministry of Health, Ramat Gan, Israel
- Department of Epidemiology and Preventive Medicine, Sackler Faculty of Medicine, School of Public Health, Tel Aviv University, Tel-Aviv, Israel
| | - Roni Eilenberg
- TIMNA-Israel Ministry of Health's Big Data Platform, Ministry of Health, Jerusalem, Israel
| | - Moshe Uziel
- TIMNA-Israel Ministry of Health's Big Data Platform, Ministry of Health, Jerusalem, Israel
| | - Meytal Avgil Tsadok
- TIMNA-Israel Ministry of Health's Big Data Platform, Ministry of Health, Jerusalem, Israel
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Hebrew University Hospital, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Miri Lutski
- Israel Center for Disease Control, Ministry of Health, Ramat Gan, Israel
- Department of Epidemiology and Preventive Medicine, Sackler Faculty of Medicine, School of Public Health, Tel Aviv University, Tel-Aviv, Israel
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21
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Berg DD, Wiviott SD, Scirica BM, Zelniker TA, Goodrich EL, Jarolim P, Mosenzon O, Cahn A, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Johanson P, Langkilde AM, Raz I, Braunwald E, Sabatine MS, Morrow DA. A Biomarker-Based Score for Risk of Hospitalization for Heart Failure in Patients With Diabetes. Diabetes Care 2021; 44:2573-2581. [PMID: 34535469 PMCID: PMC8546278 DOI: 10.2337/dc21-1170] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/25/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Heart failure (HF) is an impactful complication of type 2 diabetes mellitus (T2DM). We aimed to develop and validate a risk score for hospitalization for HF (HHF) incorporating biomarkers and clinical factor(s) in patients with T2DM. RESEARCH DESIGN AND METHODS We derived a risk score for HHF using clinical data, high-sensitivity troponin T (hsTnT), and N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) from 6,106 placebo-treated patients with T2DM in SAVOR-TIMI 53 (Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with Diabetes Mellitus-Thrombolysis in Myocardial Infarction 53). Candidate variables were assessed using Cox regression. The strongest indicators of HHF risk were included in the score using integer weights. The score was externally validated in 7,251 placebo-treated patients in DECLARE-TIMI 58 (Dapagliflozin Effect on CardiovascuLAR Events-Thrombolysis in Myocardial Infarction 58). The effect of dapagliflozin on HHF was assessed by risk category in DECLARE-TIMI 58. RESULTS The strongest indicators of HHF risk were NT-proBNP, prior HF, and hsTnT (each P < 0.001). A risk score using these three variables identified a gradient of HHF risk (P-trend <0.001) in the derivation and validation cohorts, with C-indices of 0.87 (95% CI, 0.84-0.89) and 0.84 (0.81-0.86), respectively. Whereas there was no significant effect of dapagliflozin versus placebo on HHF in the low-risk group (hazard ratio [HR] 0.98 [95% CI 0.50-1.92]), dapagliflozin significantly reduced HHF in the intermediate-, high-, and very-high-risk groups (HR 0.64 [0.43-0.95], 0.63 [0.43-0.94], and 0.72 [0.54-0.96], respectively). Correspondingly, absolute risk reductions (95% CI) increased across these latter 3 groups: 1.0% (0.0-1.9), 3.0% (0.7-5.3), and 4.4% (-0.2 to 8.9) (P-trend <0.001). CONCLUSIONS We developed and validated a risk score for HHF in T2DM that incorporated NT-proBNP, prior HF, and hsTnT. The risk score identifies patients at higher risk of HHF who derive greater absolute benefit from dapagliflozin.
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Affiliation(s)
- David D Berg
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Benjamin M Scirica
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Thomas A Zelniker
- Division of Cardiology, Vienna General Hospital and Medical University of Vienna, Austria
| | - Erica L Goodrich
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Petr Jarolim
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ofri Mosenzon
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
| | - Avivit Cahn
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Darren K McGuire
- University of Texas Southwestern Medical Center and Parkland Health and Hospital System, Dallas, TX
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, Aintree University Hospital, University of Liverpool, Liverpool, U.K
| | | | | | - Itamar Raz
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
| | - Eugene Braunwald
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - David A Morrow
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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22
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Oyama K, Raz I, Cahn A, Goodrich E, Bhatt D, Leiter L, McGuire D, Wilding J, Gause-Nilsson I, Mosenzon O, Sabatine M, Wiviott S. Influence of cardiovascular drugs on the efficacy and safety of dapagliflozin in patients with type 2 diabetes mellitus in the DECLARE-TIMI 58 trial. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
In DECLARE-TIMI 58, the sodium glucose co-transporter 2 inhibitor (SGLT2i) dapagliflozin reduced the risk of the composite of cardiovascular (CV) death or hospitalization for heart failure (HHF) in a broad range of patients with type 2 diabetes mellitus (T2DM). SGLT2i are known to have diuretic and anti-hypertensive effects. However, whether concomitant CV drugs influence the efficacy and safety of dapagliflozin in these populations is less well known.
Purpose
We examined whether dapagliflozin consistently reduced the risk of CV outcomes and whether the safety of dapagliflozin was similar with or without the concurrent use of various CV drugs.
Methods
DECLARE–TIMI 58 was a randomized trial of dapagliflozin versus placebo in patients with T2DM and either atherosclerotic cardiovascular disease (ASCVD) or multiple risk factors for CV disease followed for a median of 4.2 years. We stratified patients by the use of CV drugs at baseline commonly used for heart failure: angiotensin-converting-enzyme inhibitors or angiotensin-receptor blockers (ACEi/ARB), beta-blockers, diuretics, and mineralocorticoid receptor antagonists (MRA). Efficacy outcomes of interest were the composite of CV death/HHF and HHF alone. We used the Cox proportional-hazard model for these analyses.
Results
Of 17,160 patients, 13,950 (81%) used ACEi/ARB, 9,030 (53%) used beta-blockers, 6,967 (41%) used diuretics, and 762 (4%) used MRA at baseline. All were balanced by randomized treatment groups. Patients using CV drugs at baseline had a greater prevalence of atherosclerotic risk factors and established CV disease than those without. Dapagliflozin consistently reduced the risk of CV death/HHF regardless of the use of CV medications (Figure). For HHF alone, similar results were seen with no significant interactions for any of the classes. There were no significant treatment interactions by the concomitant use of any of CV drugs for adverse events including symptoms of volume depletion or acute kidney injury.
Conclusions
In this analysis from the DECLARE–TIMI 58 trial, dapagliflozin consistently reduced the risk of CV death/HHF and HHF alone irrespective of the concurrent use of various CV drugs without any treatment interaction for key safety events.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): The DECLARE–TIMI 58 trial was supported by AstraZeneca.
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Affiliation(s)
- K Oyama
- Brigham and Women's Hospital, Harvard Medical School, Division of Cardiovascular Medicine, Boston, United States of America
| | - I Raz
- Hadassah-Hebrew University Medical Center, Diabetes Unit, Jerusalem, Israel
| | - A Cahn
- Hadassah-Hebrew University Medical Center, Diabetes Unit, Jerusalem, Israel
| | - E Goodrich
- Brigham and Women's Hospital, Harvard Medical School, Division of Cardiovascular Medicine, Boston, United States of America
| | - D Bhatt
- Brigham and Women's Hospital, Harvard Medical School, Division of Cardiovascular Medicine, Boston, United States of America
| | - L Leiter
- University of Toronto, Toronto, Canada
| | - D McGuire
- University of Texas Southwestern Medical Center, Division of Cardiology, Dallas, United States of America
| | - J Wilding
- University of Liverpool, Department of Cardiovascular and Metabolic Medicine, Liverpool, United Kingdom
| | | | - O Mosenzon
- Hadassah-Hebrew University Medical Center, Diabetes Unit, Jerusalem, Israel
| | - M Sabatine
- Brigham and Women's Hospital, Harvard Medical School, Division of Cardiovascular Medicine, Boston, United States of America
| | - S Wiviott
- Brigham and Women's Hospital, Harvard Medical School, Division of Cardiovascular Medicine, Boston, United States of America
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Leibovitch M, Gellman YN, Haze A, Olshtain-Pops K, Peled S, Elishov O, Cahn A. [HOSPITALIZATIONS DUE TO ACUTE DIABETIC FOOT: ANNUAL TRENDS AND PREDICTORS OF MORBIDITY AND MORTALITY - 5-YEARS EXPERIENCE OF A MULTIDISCIPLINARY UNIT]. Harefuah 2021; 160:651-656. [PMID: 34689434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Since 2012, patients presenting to our hospital with an acute diabetic foot are hospitalized in a dedicated unit. This study describes patients' characteristics and trends in amputations, procedures and mortality during the years 2014-2018. METHODS We retrospectively reviewed the electronic medical records of 694 patients admitted to the unit during the study period. We collected demographic, clinical and laboratory data, procedures and outcomes. Annual trends were studied as well as predictors to any or major amputation and to mortality within 1 year following discharge. RESULTS The mean age was 63.8±12.7 years and 75.4% of the patients were male. There was a high prevalence of neuropathy, peripheral artery disease and ischemic heart disease (55.3%, 66.1% and 44.2% respectively). Previous hospitalization was noted for 62.0% of the patients and 38.3% had undergone a previous amputation. The majority of the patients had chronic kidney disease and 19.0% were dialysis patients. During hospitalization, 54.3% of the patients underwent any amputation, 25.2% had a major amputation and 6.2% died. The mortality rate within 1 year of discharge was 24.5%. There were no changes in patient demographics, characteristics or outcomes during the study years, although an increase in the proportion of patients who had undergone previous amputation, and of current smokers in recent years was noted. Moreover, in recent years more vascular procedures and surgical procedures in the operating room were performed. Older age, recent hospitalization, previous amputation, neuropathy, ischemic heart disease, peripheral vascular disease, chronic renal insufficiency, elevated inflammatory markers, a progressive ulcer, and a midfoot or hindfoot (vs. forefoot) ulcer were all associated with major amputations. CONCLUSIONS During the study period, patients' characteristics remained generally stable as did amputation and mortality rates. The high 1-year mortality rate of this population is indicative of these patients' significant morbidity.
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Affiliation(s)
- Michal Leibovitch
- Department of Military Medicine and "Tzameret", Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel, and Medical Corps, Israel Defense Forces, Israel
| | - Yechiel N Gellman
- Diabetic Foot Unit, Department Of Orthopedics, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | - Amir Haze
- Diabetic Foot Unit, Department Of Orthopedics, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | - Keren Olshtain-Pops
- Infectious Disease Department, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | - Shahar Peled
- Department of Military Medicine and "Tzameret", Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel, and Medical Corps, Israel Defense Forces, Israel
| | - Ofer Elishov
- Diabetic Foot Unit, Department Of Orthopedics, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
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Cahn A, Kulikovsky M, Zucker I. [DIABETIC FOOT IN ISRAEL - CURRENT STATUS AND FUTURE PERSPECTIVES]. Harefuah 2021; 160:679-684. [PMID: 34689439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Diabetic foot ulcers and amputations are the most dreaded diabetes complications. The annual incidence of diabetic foot ulcers in Israel is estimated at 1.8% of all patients with diabetes. The number of patients with diabetes undergoing major amputation in the recent decade has been relatively stable in Israel, and in 2018, 887 patients with diabetes had undergone a major amputation. The proportion of patients undergoing a vascular intervention in the year prior to a major amputation has remained steady over the recent decade, and ranges between 20-40% depending on the patient's age. Aiming to reduce amputation rate, efforts should be made at three levels: 1) Primary care - increasing awareness of patients and health care teams to diabetic foot complications, the means to avoid them, and the delivery of preliminary care. Efforts to further increase awareness should be undertaken. Identification of the foot at-risk and incorporation of professional teams in the care of these patients, as well as provision of appropriate preventive offloading footwear should be sought. 2) Secondary clinics - these multidisciplinary clinics tend to all complications which cannot be adequately addressed in primary care. The professional standard of these clinics should be determined, and the access to these clinics improved. Adequate equipment in these clinics is mandatory as well. 3) Tertiary hospitals - care for the patients who require hospitalization. A national standard for inpatient diabetic foot care should be implemented and multi-disciplinary departments incorporating internists, orthopedists and vascular surgeons should be established aiming to address the medical and surgical complexity of these patients. Qualified nursing staff as well as additional health care professionals including physiotherapists, dieticians, clinical pharmacists, social workers, occupational therapists and others should also be included. Documentation of diabetic foot ulcers is lacking, both in the community and in hospitals. Use of uniform diagnostic codes should be implemented to enable close monitoring of disease trends.
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Affiliation(s)
- Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem
- Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | | | - Inbar Zucker
- Israel Center for Disease Control (ICDC), Ministry of Health, Israel
- School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Israel
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Assis A, Gellman YN, Cahn A, Haze A, Camargo S, Mitrani E. Angiogenic potential of mesenchymal stem cells derived from patients with diabetes seeded on decellularized micro fragments. J Diabetes Complications 2021; 35:108001. [PMID: 34391637 DOI: 10.1016/j.jdiacomp.2021.108001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 05/31/2021] [Accepted: 07/25/2021] [Indexed: 01/13/2023]
Abstract
Mesenchymal stem cells (MSCs) are a potential source of angiogenic factors which may promote wound healing in poorly vascularized diabetic foot ulcers. We demonstrate that MSCs of patients with diabetic foot ulcers seeded on decellularized micro-fragments transcribe and secrete angiogenic factors in amounts comparable to MSCs derived from healthy individuals.
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Affiliation(s)
- Assaf Assis
- Department of Cell and Developmental Biology, The Alexander Silberman Institute of Life Sciences, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yechiel N Gellman
- Diabetic Foot Unit, Department of Orthopedics, Hadassah Medical Center, Jerusalem, Israel; The Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Avivit Cahn
- The Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel; Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
| | - Amir Haze
- Diabetic Foot Unit, Department of Orthopedics, Hadassah Medical Center, Jerusalem, Israel; The Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sandra Camargo
- Department of Cell and Developmental Biology, The Alexander Silberman Institute of Life Sciences, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Eduardo Mitrani
- Department of Cell and Developmental Biology, The Alexander Silberman Institute of Life Sciences, The Hebrew University of Jerusalem, Jerusalem, Israel..
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26
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Tamir O, Afek A, Shani M, Cahn A, Raz I. Five years into the Israeli National Diabetes Program - are we on the right track? Diabetes Metab Res Rev 2021; 37:e3421. [PMID: 33175454 DOI: 10.1002/dmrr.3421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 08/29/2020] [Accepted: 10/25/2020] [Indexed: 11/06/2022]
Abstract
Diabetes mellitus poses major public health and economic challenges which necessitate national-level intervention. The ultimate goal of the Israel National Diabetes Program is to ensure that all people with diabetes, or at high risk of developing diabetes, will live well and have access to high-quality services that meet their individual needs. The integrated National Diabetes Program in Israel was established in 2014. Prevailing needs were identified and working groups assigned to delineate deficiencies and propose mode of action. Program leaders summarized and prioritized the needs, and identified main targets of action for the preliminary years. The program was achieved by a combined approach: top-bottom, having the Director General of the Ministry of Health (MoH) personally involved, and bottom-up, by routine meetings with representatives of the health organizations, clinical experts, patient representatives and other stakeholders. Main achievements during the first five years of the program included setting up a novel funding mechanism for diabetes prevention, substantiating the field of diabetes education in Israel, designing the infrastructure of diabetic foot care in Israel, updating the national health-budget allocation formula with incentives to improve provision of services, and promoting a mandatory system for judgemental labelling of food products. The program is in progress with ongoing monitoring, evaluation and improvement with particular emphasis on translational learning. Although there is much to be done, diabetes care in Israel has taken an enormous step forward in the past five years.
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Affiliation(s)
- Orly Tamir
- The Pesach Segal Israeli Center for Diabetes Research and Policy, Sheba Medical Center, Ramat Gan, Israel
- National Diabetes Council, Ministry of Health, Jerusalem, Israel
| | - Arnon Afek
- Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mordechai Shani
- Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah University Hospital, Jerusalem, Israel
| | - Itamar Raz
- National Diabetes Council, Ministry of Health, Jerusalem, Israel
- D-Cure Foundation, Petah-Tikva, Israel
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Oyama K, Raz I, Cahn A, Kuder J, Murphy SA, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Park KS, Goudev A, Diaz R, Špinar J, Gause-Nilsson IAM, Mosenzon O, Sabatine MS, Wiviott SD. Obesity and effects of dapagliflozin on cardiovascular and renal outcomes in patients with type 2 diabetes mellitus in the DECLARE-TIMI 58 trial. Eur Heart J 2021; 43:2958-2967. [PMID: 34427295 DOI: 10.1093/eurheartj/ehab530] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/11/2021] [Accepted: 08/02/2021] [Indexed: 01/03/2023] Open
Abstract
AIMS We investigated the associations between obesity, cardiorenal events, and benefits of dapagliflozin in patients with type 2 diabetes mellitus (T2DM). METHODS AND RESULTS DECLARE-TIMI 58 randomized patients with T2DM and either atherosclerotic cardiovascular (CV) disease or multiple risk factors to dapagliflozin vs. placebo. Patients were stratified by body mass index (BMI, kg/m2): normal (18.5 to <25), overweight (25 to <30), moderately obese (30 to <35), severely obese (35 to <40), and very-severely obese (≥40). Outcomes analysed were CV death, hospitalization for heart failure (HHF), renal-specific composite outcome, and atrial fibrillation or flutter (AF/AFL). Of 17 134 patients, 9.0% had a normal BMI, 31.5% were overweight, 32.4% were moderately, 17.2% severely, and 9.8% were very-severely obese. Higher BMI was associated with a higher adjusted risk of HHF and AF/AFL (hazard ratio 1.30 and 1.28, respectively, per 5 kg/m2; P < 0.001 for all). Dapagliflozin reduced body weight by similar relative amounts consistently across BMI categories (percent difference: -1.9 to -2.4%). Although relative risk reductions in CV and renal-specific composite outcomes with dapagliflozin did not significantly differ across the range of BMI (P for interaction ≥0.20 for all outcomes), obese patients (BMI ≥ 30 kg/m2) tended to derive greater absolute risk reduction in HHF and AF/AFL (P for interaction 0.02 and 0.09, respectively) than non-obese patients. CONCLUSIONS In DECLARE-TIMI 58, patients with T2DM and higher BMI were more likely to have HHF and AF/AFL. Whereas relative risk reductions in CV and renal outcomes with dapagliflozin were generally consistent across the range of BMI, absolute risk reduction in obesity-related outcomes including HHF and AF/AFL tended to be larger in obese patients with T2DM. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifiers: NCT01730534.
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Affiliation(s)
- Kazuma Oyama
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA.,Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Kiryat Hadassah 12000, Jerusalem 91200, Israel
| | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Kiryat Hadassah 12000, Jerusalem 91200, Israel
| | - Julia Kuder
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, 36 Queen St. East, Toronto, ON M5B 1W8, Canada
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, 5323 Harry Hines Blvd. Dallas, TX 75390, USA
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, 6 West Derby Street, Liverpool, L7 8TX, UK
| | - Kyong-Soo Park
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu Seoul 03080, Republic of Korea
| | - Assen Goudev
- Department of Cardiology, Queen Giovanna University Hospital, 8# Bialo More street, Sofia 1527, Bulgaria
| | - Rafael Diaz
- Estudios Clínicos Latino America, Paraguay 160, Rosario, Santa Fe 2000, Argentina
| | - Jindřich Špinar
- Internal Cardiology Department, St. Ann University Hospital, Masaryk University, Pekařská 53 Brno 65691, Czech Republic
| | | | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Kiryat Hadassah 12000, Jerusalem 91200, Israel
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
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28
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Mosenzon O, Wiviott SD, Heerspink HJL, Dwyer JP, Cahn A, Goodrich EL, Rozenberg A, Schechter M, Yanuv I, Murphy SA, Zelniker TA, Gause-Nilsson IAM, Langkilde AM, Fredriksson M, Johansson PA, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Sabatine MS, Raz I. The Effect of Dapagliflozin on Albuminuria in DECLARE-TIMI 58. Diabetes Care 2021; 44:1805-1815. [PMID: 34233928 PMCID: PMC8385472 DOI: 10.2337/dc21-0076] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 05/14/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Sodium-glucose cotransporter 2 inhibitors (SGLT2i) improve albuminuria in patients with high cardiorenal risk. We report albuminuria change in the Dapagliflozin Effect on Cardiovascular Events (DECLARE-TIMI 58) cardiovascular outcome trial, which included populations with lower cardiorenal risk. RESEARCH DESIGN AND METHODS DECLARE-TIMI 58 randomized 17,160 patients with type 2 diabetes, creatinine clearance >60 mL/min, and either atherosclerotic cardiovascular disease (CVD; 40.6%) or risk-factors for CVD (59.4%) to dapagliflozin or placebo. Urinary albumin-to-creatinine ratio (UACR) was tested at baseline, 6 months, 12 months, and yearly thereafter. The change in UACR over time was measured as a continuous and categorical variable (≤15, >15 to <30, ≥30 to ≤300, and >300 mg/g) by treatment arm. The composite cardiorenal outcome was a ≥40% sustained decline in the estimated glomerular filtration rate (eGFR) to <60 mL/min/1.73 m2, end-stage kidney disease, and cardiovascular or renal death; specific renal outcome included all except cardiovascular death. RESULTS Baseline UACR was available for 16,843 (98.15%) participants: 9,067 (53.83%) with ≤15 mg/g, 2,577 (15.30%) with >15 to <30 mg/g, 4,030 (23.93%) with 30-300 mg/g, and 1,169 (6.94%) with >300 mg/g. Measured as a continuous variable, UACR improved from baseline to 4.0 years with dapagliflozin, compared with placebo, across all UACR and eGFR categories (all P < 0.0001). Sustained confirmed ≥1 category improvement in UACR was more common in dapagliflozin versus placebo (hazard ratio 1.45 [95% CI 1.35-1.56], P < 0.0001). Cardiorenal outcome was reduced with dapagliflozin for subgroups of UACR ≥30 mg/g (P < 0.0125, P interaction = 0.033), and the renal-specific outcome was reduced for all UACR subgroups (P < 0.05, P interaction = 0.480). CONCLUSIONS In DECLARE-TIMI 58, dapagliflozin demonstrated a favorable effect on UACR and renal-specific outcome across baseline UACR categories, including patients with normal albumin excretion. The results suggest a role for SGLT2i also in the primary prevention of diabetic kidney disease.
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Affiliation(s)
- Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel .,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Stephen D Wiviott
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Hiddo J L Heerspink
- University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Erica L Goodrich
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Aliza Rozenberg
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Meir Schechter
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ilan Yanuv
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sabina A Murphy
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Thomas A Zelniker
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.,Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | | | | | | | | | - Deepak L Bhatt
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX.,Parkland Health and Hospital System, Dallas, TX
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, U.K
| | - Marc S Sabatine
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Zelniker TA, Raz I, Mosenzon O, Dwyer JP, Heerspink HHJL, Cahn A, Goodrich EL, Im K, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Gause-Nilsson I, Langkilde AM, Sabatine MS, Wiviott SD. Effect of Dapagliflozin on Cardiovascular Outcomes According to Baseline Kidney Function and Albuminuria Status in Patients With Type 2 Diabetes: A Prespecified Secondary Analysis of a Randomized Clinical Trial. JAMA Cardiol 2021; 6:801-810. [PMID: 33851953 DOI: 10.1001/jamacardio.2021.0660] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Importance Sodium-glucose cotransporter 2 inhibitors, such as dapagliflozin, promote renal glucose excretion and reduce cardiovascular (CV) deaths and hospitalizations for heart failure (HHF) among patients with type 2 diabetes. The relative CV efficacy and safety of dapagliflozin according to baseline kidney function and albuminuria status are unknown. Objective To assess the CV efficacy and safety of dapagliflozin according to baseline estimated glomerular filtration rate (eGFR) and urinary albumin to creatinine ratio (UACR). Design, Setting, and Participants This secondary analysis of the randomized clinical trial Dapagliflozin Effect on Cardiovascular Events-Thrombolysis in Myocardial Infarction 58 compared dapagliflozin vs placebo in 17 160 patients with type 2 diabetes and a baseline creatinine clearance of 60 mL/min or higher. Patients were categorized according to prespecified subgroups of baseline eGFR (<60 vs ≥60 mL/min/1.73 m2), urinary albumin to creatinine ratio (UACR; <30 vs ≥30 mg/g), and of chronic kidney disease (CKD) markers using these subgroups (0, 1, or 2). The study was conducted from May 2013 to September 2018. Interventions Dapagliflozin vs placebo. Main Outcomes and Measures The dual primary end points were major adverse cardiovascular events (myocardial infarction, stroke, and CV death) and the composite of CV death or HHF. Results At baseline, 1265 patients (7.4%) had an eGFR below 60 mL/min/1.73 m2, and 5199 patients (30.9%) had albuminuria. Among patients having data for both eGFR and UACR, 10 958 patients (65.1%) had an eGFR equal to or higher than 60 mL/min/1.73 m2 and an UACR below 30 mg/g (mean [SD] age, 63.7 [6.7] years; 40.1% women), 5336 patients (31.7%) had either an eGFR below 60 mL/min/1.73 m2 or albuminuria (mean [SD] age, 64.1 [7.1] years; 32.6% women), and 548 patients (3.3%) had both (mean [SD] age, 66.8 [6.9] years; 30.5% women). In the placebo group, patients with more CKD markers had higher event rates at 4 years as assessed using the Kaplan-Meier approach for the composite of CV death or HHF (3.9% for 0 markers, 8.3% for 1 marker, and 17.4% for 2 markers) and major adverse cardiovascular events (7.5% for 0 markers, 11.6% for 1 marker, and 18.9% for 2 markers). Estimates for relative risk reductions for the composite of CV death or HHF and for major adverse cardiovascular events were generally consistent across subgroups (both P > .24 for interaction), although greater absolute risk reductions were observed with more markers of CKD. The absolute risk difference for the composite of CV death or HHF was greater for patients with more markers of CKD (0 markers, -0.5%; 1 marker, -1.0%; and 2 markers, -8.3%; P = .02 for interaction). The numbers of amputations, cases of diabetic ketoacidosis, fractures, and major hypoglycemic events were balanced or numerically lower with dapagliflozin compared with placebo for patients with an eGFR below 60 mL/min/1.73 m2 and an UACR of 30 mg/g or higher. Conclusions and Relevance The effect of dapagliflozin on the relative risk for CV events was consistent across eGFR and UACR groups, with the greatest absolute benefit for the composite of CV death or HHF observed among patients with both reduced eGFR and albuminuria. Trial Registration ClinicalTrials.gov Identifier: NCT01730534.
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Affiliation(s)
- Thomas A Zelniker
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Itamar Raz
- The Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | - Ofri Mosenzon
- The Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | - Jamie P Dwyer
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hiddo H J L Heerspink
- University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.,The George Institute for International Health, Sydney, Australia
| | - Avivit Cahn
- The Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | - Erica L Goodrich
- The Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | - Kyungah Im
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Deepak L Bhatt
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Ontario, Canada
| | - Darren K McGuire
- Division of Cardiology, The University of Texas Southwestern Medical Center, Dallas
| | - John P H Wilding
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, United Kingdom
| | | | | | - Marc S Sabatine
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stephen D Wiviott
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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O'Donoghue ML, Kato ET, Mosenzon O, Murphy SA, Cahn A, Herrera M, Tankova T, Šmahelová A, Merlini P, Gause-Nilsson I, Langkilde AM, McGuire DK, Wilding JPH, Leiter LA, Bhatt DL, Raz I, Sabatine MS, Wiviott SD. The efficacy and safety of dapagliflozin in women and men with type 2 diabetes mellitus. Diabetologia 2021; 64:1226-1234. [PMID: 33611623 DOI: 10.1007/s00125-021-05399-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 12/09/2020] [Indexed: 01/24/2023]
Abstract
AIMS/HYPOTHESIS Women remain underrepresented in clinical trials and those with type 2 diabetes mellitus are at high risk for cardiovascular (CV) events. The sodium-glucose cotransporter 2 (SGLT2) inhibitor dapagliflozin reduces the risk of CV death or heart failure hospitalisations in individuals with type 2 diabetes. Here, we performed a pre-specified analysis to examine whether sex modifies these effects. METHODS The DECLARE-TIMI 58 trial randomised 17,160 patients with type 2 diabetes with or at risk for atherosclerotic disease to dapagliflozin or placebo (median follow-up 4.2 years). The dual efficacy outcomes were CV death or heart failure hospitalisations, and major adverse cardiovascular events (MACE; CV death, myocardial infarction or ischaemic stroke). The renal-specific composite outcome was a sustained ≥40% drop in eGFR to <60 ml min-1 [1.73 m]-2, new end-stage renal disease or renal death. Cox models were run separately by sex with treatment-by-sex interaction testing for each outcome. RESULTS At baseline, women (n = 6422, 37.4%) had higher HbA1c, longer type 2 diabetes duration, and were on fewer glucose-lowering medications. There was no evidence of modification of the effect of dapagliflozin by sex for (1) CV death or heart failure hospitalisations: women (3.8% vs 4.5%; HR 0.84, 95% CI 0.66, 1.07) and men (5.3% vs 6.4%; HR 0.83, 95% CI 0.71, 0.96; pinteraction = 0.90); (2) MACE: women (6.3% vs 6.8%; HR 0.93, 95% CI 0.77, 1.12) and men (10.0% vs 10.7%; HR 0.93, 95% CI 0.83, 1.05; pinteraction = 0.99); or (3) renal-specific composite: women (1.4% vs 2.8%; HR 0.50, 95% CI 0.35, 0.70) and men (1.5% vs 2.5%; HR 0.55, 95% CI 0.42, 0.73; pinteraction = 0.64). The overall safety profile of dapagliflozin was similar for women and men. CONCLUSIONS/INTERPRETATION Dapagliflozin offers comparable CV and renal benefits and a comparable safety profile in women and men. FUNDING AstraZeneca. TRIAL REGISTRATION clinicaltrials.gov NCT01730534.
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Affiliation(s)
- Michelle L O'Donoghue
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA.
| | - Eri T Kato
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ofri Mosenzon
- Diabetes Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Sabina A Murphy
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Avivit Cahn
- Diabetes Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | | | | | - Alena Šmahelová
- Faculty Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Piera Merlini
- 2nd Division of Cardiology, Ca' Granda Niguarda Hospital, Milan, Italy
| | | | | | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, and Parkland Health and Hospital System, Dallas, TX, USA
| | - John P H Wilding
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Larry A Leiter
- Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Deepak L Bhatt
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Itamar Raz
- Diabetes Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Marc S Sabatine
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Stephen D Wiviott
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
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Berg D, Wiviott S, Goodrich E, Murphy S, Mosenzon O, Bhatt D, Cahn A, Leiter L, McGuire D, Wilding J, Gause-Nilsson I, Hammarstedt A, Karlsson C, Johansson P, Langkilde AM, Raz I, Sabatine M. MEDIATION ANALYSIS FOR DAPAGLIFLOZIN AND THE REDUCTION IN HOSPITALIZATION FOR HEART FAILURE IN DECLARE-TIMI 58. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)02228-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Cahn A, Raz I, Leiter LA, Mosenzon O, Murphy SA, Goodrich EL, Yanuv I, Rozenberg A, Bhatt DL, McGuire DK, Wilding JPH, Gause-Nilsson IAM, Langkilde AM, Sabatine MS, Wiviott SD. Cardiovascular, Renal, and Metabolic Outcomes of Dapagliflozin Versus Placebo in a Primary Cardiovascular Prevention Cohort: Analyses From DECLARE-TIMI 58. Diabetes Care 2021; 44:1159-1167. [PMID: 33653824 DOI: 10.2337/dc20-2492] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 01/31/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE International guidelines propose prescribing sodium-glucose cotransporter 2 (SGLT2) inhibitors to patients with type 2 diabetes (T2D) as secondary prevention in patients with established atherosclerotic cardiovascular disease (ASCVD) or for primary prevention of cardiovascular events in high-risk patients with multiple risk factors (MRF) for ASCVD. The current analyses expand on the cardiovascular renal and metabolic effects of SGLT2 inhibitors in MRF patients. RESEARCH DESIGN AND METHODS In DECLARE-TIMI 58, 17,160 patients with T2D and MRF (59.4%) or established ASCVD (40.6%) were randomized to dapagliflozin versus placebo; patients were followed for a median of 4.2 years. The cardiovascular and renal outcomes in the MRF cohort were studied across clinically relevant subgroups for treatment effect and subgroup-based treatment interaction. RESULTS Among patients with MRF, the reduction with dapagliflozin in risk of cardiovascular death or hospitalization for heart failure (CVD/HHF) (hazard ratio [HR] 0.84, 95% CI 0.67-1.04) and the renal-specific outcome (HR 0.51, 95% CI 0.37-0.69) did not differ from that for patients with ASCVD (P interaction 0.99 and 0.72, respectively). The effect on CVD/HHF was entirely driven by a reduction in HHF (HR 0.64, 95% CI 0.46-0.88). The benefits of dapagliflozin on HHF and on the renal-specific outcome, among the subset with MRF, were directionally consistent across clinically relevant subgroups. At 48 months, HbA1c, weight, systolic blood pressure, and urinary albumin-to-creatinine ratio were lower with dapagliflozin versus placebo and estimated glomerular filtration rate was higher (P < 0.001). CONCLUSIONS In patients with T2D and MRF, dapagliflozin reduced the risk of HHF and adverse renal outcomes regardless of baseline characteristics. These analyses support the benefit of dapagliflozin for important outcomes in a broad primary prevention population.
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Affiliation(s)
- Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, and The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, and The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, and The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Erica L Goodrich
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Ilan Yanuv
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, and The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Aliza Rozenberg
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, and The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX.,Parkland Health and Hospital System, Dallas, TX
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, U.K
| | | | | | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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McEwan P, Morgan AR, Boyce R, Bergenheim K, Gause‐Nilsson IA, Bhatt DL, Leiter LA, Johansson PA, Mosenzon O, Cahn A, Wilding JP. The cost-effectiveness of dapagliflozin in treating high-risk patients with type 2 diabetes mellitus: An economic evaluation using data from the DECLARE-TIMI 58 trial. Diabetes Obes Metab 2021; 23:1020-1029. [PMID: 33368855 PMCID: PMC8048502 DOI: 10.1111/dom.14308] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 12/16/2020] [Accepted: 12/20/2020] [Indexed: 12/14/2022]
Abstract
AIM To undertake a cost-effectiveness analysis of dapagliflozin in treating high-risk patients with type 2 diabetes mellitus (T2DM), using both directly observed events in the DECLARE-TIMI 58 trial and surrogate risk factors to predict endpoints not captured within the trial. METHODS An established T2DM model was adapted to integrate survival curves derived from the DECLARE-TIMI 58 trial, and extrapolated over a lifetime for all-cause mortality, hospitalization for heart failure, stroke, myocardial infarction, hospitalization for unstable angina, and end-stage kidney disease. The economic analysis considered the overall DECLARE trial population, as well as reported patient subgroups. Total and incremental costs, life-years and quality-adjusted life-years associated with dapagliflozin versus placebo were estimated from the perspective of the UK healthcare payer. RESULTS In the UK setting, treatment with dapagliflozin compared to placebo was estimated to be dominant, with an expected increase in quality-adjusted life-years from 10.43 to 10.48 (+0.06) and a reduction in lifetime total costs from £39 451 to £36 899 (-£2552). Across all patient subgroups, dapagliflozin was estimated to be dominant, with the greatest absolute benefit in the prior heart failure subgroup (incremental lifetime costs -£4150 and quality-adjusted life-years +0.11). CONCLUSIONS The results of this study demonstrate that dapagliflozin compared to placebo appears to be cost-effective, when considering evidence reported from the DECLARE-TIMI 58 trial, at established UK willingness-to-pay thresholds. The findings highlight the potential of dapagliflozin to have a meaningful impact in reducing the economic burden of T2DM and its associated complications across a broad T2DM population.
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Affiliation(s)
- Phil McEwan
- Health Economics and Outcomes Research LtdCardiffUK
| | | | | | | | | | - Deepak L. Bhatt
- TIMI Study Group, Division of Cardiovascular MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Lawrence A. Leiter
- Li Ka Shing Knowledge Institute, St Michael's HospitalUniversity of TorontoTorontoOntarioCanada
| | | | - Ofri Mosenzon
- Hadassah Medical Center, Faculty of MedicineHebrew University of JerusalemJerusalemIsrael
| | - Avivit Cahn
- Hadassah Medical Center, Faculty of MedicineHebrew University of JerusalemJerusalemIsrael
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Akirov A, Cahn A, Del Prato S, Home P, Van Gaal L, Chan J, Ning G, Raz I. Tackling obesity during the COVID-19 pandemic. Diabetes Metab Res Rev 2021; 37:e3393. [PMID: 32797666 PMCID: PMC7435354 DOI: 10.1002/dmrr.3393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/02/2020] [Accepted: 08/10/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Amit Akirov
- Institute of EndocrinologyBeilinson HospitalPetach TikvaIsrael
- Sackler School of MedicineTel Aviv UniversityTel AvivIsrael
| | - Avivit Cahn
- Diabetes UnitDepartment of Endocrinology and MetabolismFaculty of MedicineHadassah Hebrew University Medical CenterJerusalemIsrael
| | - Stefano Del Prato
- Department of Clinical & Experimental MedicineSection of Metabolic Diseases and DiabetesUniversity of PisaPisaItaly
| | - Philip Home
- Translational and Clinical Research InstituteNewcastle UniversityNewcastle upon TyneUK
| | - Luc Van Gaal
- Department of Endocrinology & MetabolismAntwerp University HospitalEdegem‐AntwerpBelgium
| | - Juliana Chan
- Department of Medicine and TherapeuticsPrince of Wales HospitalChinese University of Hong KongHong KongChina
- Hong Kong Institute of Diabetes and ObesityPrince of Wales HospitalChinese University of Hong KongHong KongChina
- Li Ka Shing Institute of Health SciencePrince of Wales HospitalChinese University of Hong KongHong KongChina
| | - Guang Ning
- Key Laboratory for Endocrine and Metabolic Diseases of Ministry of HealthDepartment of Endocrine and Metabolic DiseasesRui‐Jin HospitalShanghai Jiao‐Tong University School of MedicineShanghaiChina
| | - Itamar Raz
- Diabetes UnitDepartment of Endocrinology and MetabolismFaculty of MedicineHadassah Hebrew University Medical CenterJerusalemIsrael
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Tsur A, Dreyfuss E, Ness-Abramof R, Pollack R, Cahn A. Role of Cannulated Prolactin Test in Evaluation of Hyperprolactinemia - A Retrospective Study. Endocr Pract 2021; 26:1304-1311. [PMID: 33471661 DOI: 10.4158/ep-2020-0260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 06/24/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE While guidelines propose a single elevated prolactin measurement drawn without excess venipuncture stress as sufficient for diagnosing hyperprolactinemia, this may lead to unnecessary evaluation in the setting of stress-induced hyperprolactinemia. In this study, we aimed to define the role of the cannulated prolactin test in confirming hyperprolactinemia. METHODS We conducted a retrospective review of 757 patients with unexplained hyperprolactinemia who performed a cannulated prolactin test in a community-based referral endocrine clinic between 2000-2015. The prolactin test consisted of "test-baseline" levels taken at rest (T0), and cannulated measurements at 60 and 90 minutes (T60 and T90) without repeated venipuncture. The most recent prolactin level performed prior to the test (referral-prolactin) was collected. RESULTS Referral-prolactin was available for 621 (82%) patients, of whom 324 (52.2%) normalized at T0. The probability of normoprolactinemia at T0 was 50% if referral-prolactin was 2.0-fold the upper-limit-of-normal (ULN), yet only 5% if referral-prolactin was 5.0-fold the ULN. Of the 359 patients with hyperprolactinemia at T0, prolactin normalized at T60 and/or T90 in 99 (27.6%) patients. The probability of normoprolactinemia was low (<5%) in those with T0 prolactin levels >2.4-fold ULN. Overall, of 757 prolactin tests performed, only 260 (34.3%) patients had persistent hyperprolactinemia. CONCLUSION Patients with referral-prolactin levels >5.0-fold the ULN, or a rested-prolactin (T0) >2.4-fold the ULN are unlikely to normalize during the cannulated test and consideration should be made to proceed directly with pituitary imaging. In patients with prolactin levels below these thresholds, the cannulated prolactin test may considerably reduce unnecessary investigations, treatment, and cost.
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Affiliation(s)
- Anat Tsur
- From the Department of Endocrinology and Metabolism, Clalit Health Services, Jerusalem, Israel; Hebrew University, The Faculty of Medicine, Jerusalem, Israel.
| | | | - Rosane Ness-Abramof
- the Department of Endocrinology and Metabolism, Clalit Health Services, Tel Aviv district, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rena Pollack
- Hebrew University, The Faculty of Medicine, Jerusalem, Israel; the Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
| | - Avivit Cahn
- Hebrew University, The Faculty of Medicine, Jerusalem, Israel; the Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
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Cahn A, Wiviott SD, Mosenzon O, Murphy SA, Goodrich EL, Yanuv I, Rozenberg A, Wilding JPH, Leiter LA, Bhatt DL, McGuire DK, Litwak L, Kooy A, Gause-Nilsson IAM, Fredriksson M, Langkilde AM, Sabatine MS, Raz I. Cardiorenal outcomes with dapagliflozin by baseline glucose-lowering agents: Post hoc analyses from DECLARE-TIMI 58. Diabetes Obes Metab 2021; 23:29-38. [PMID: 32844557 DOI: 10.1111/dom.14179] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 08/20/2020] [Accepted: 08/20/2020] [Indexed: 02/06/2023]
Abstract
AIM To assess the associations between baseline glucose-lowering agents (GLAs) and cardiorenal outcomes with dapagliflozin versus placebo in the DECLARE-TIMI 58 study. MATERIALS AND METHODS DECLARE-TIMI 58 assessed the cardiorenal outcomes of dapagliflozin versus placebo in patients with type 2 diabetes. This post hoc analysis elaborates the efficacy and safety outcomes by baseline GLA for treatment effect and GLA-based treatment interaction. RESULTS At baseline, 14 068 patients (82.0%) used metformin, 7322 (42.7%) sulphonylureas, 2888 (16.8%) dipeptidyl peptidase-4 inhibitors, 750 (4.4%) glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and 7013 (40.9%) insulin. Dapagliflozin reduced the composite of cardiovascular death (CVD) and hospitalization for heart failure (HHF) versus placebo regardless of baseline GLA, with greater benefit in the small group of patients with baseline use of GLP-1 RAs (HR [95% CI] 0.37 [0.18, 0.78] vs. 0.86 [0.75, 0.98] in GLP-1 RA users vs. non-users, Pinteraction = .03). The overall HR for major adverse cardiovascular events (CVD, myocardial infarction or ischaemic stroke) was 0.93 (95% CI 0.84, 1.03) with dapagliflozin versus placebo, with no interaction by baseline GLA (Pinteraction > .05). The renal-specific outcome was reduced with dapagliflozin versus placebo in the overall cohort (HR [95%CI] 0.53[0.43-0.66]), with no interaction by baseline GLA (Pinteraction > .05). All of these outcomes were similar in those with versus those without baseline metformin use. CONCLUSIONS The effects of dapagliflozin on cardiorenal outcomes were generally consistent regardless of baseline GLA, with consistent benefits regardless of baseline metformin use. The potential clinical benefit of combining sodium-glucose co-transporter-2 inhibitors with GLP-1 RAs, given some evidence of cardiovascular risk reduction with both classes, should be explored further.
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Affiliation(s)
- Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Stephen D Wiviott
- Division of Cardiovascular Medicine, TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Sabina A Murphy
- Division of Cardiovascular Medicine, TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Erica L Goodrich
- Division of Cardiovascular Medicine, TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ilan Yanuv
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
| | - Aliza Rozenberg
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Lawrence A Leiter
- Department of Medicine, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, and Parkland Health and Hospital System, Dallas, Texas
| | - Leon Litwak
- Endocrinology Unit, Diabetes Section, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Adriaan Kooy
- University Medical Center Groningen and Bethesda Diabetes Research Center, Groningen, the Netherlands
| | | | | | | | - Marc S Sabatine
- Division of Cardiovascular Medicine, TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Israel
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Tsur A, Cahn A, Israel M, Feldhamer I, Hammerman A, Pollack R. Impact of flash glucose monitoring on glucose control and hospitalization in type 1 diabetes: A nationwide cohort study. Diabetes Metab Res Rev 2021; 37:e3355. [PMID: 32469094 DOI: 10.1002/dmrr.3355] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/21/2020] [Accepted: 05/12/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND We evaluated the impact of flash continuous glucose monitoring (FCGM) on glycemic control and healthcare burden in a large real-world cohort of patients with type 1 diabetes (T1D) initiating FCGM technology. METHODS In this retrospective cohort study, we included adults (age ≥18 years) with T1D from a large Health Maintenance Organization in Israel, who initiated FCGM during 2018. Primary outcomes included change in HbA1c ≥3 months following FCGM commencement and change in rate of internal-medicine hospitalization. Additional outcomes included changes in glucose test strip purchases, diabetes related outpatient health care visits and hospitalization for diabetic ketoacidosis (DKA) and/or severe hypoglycemia. RESULTS The study included 3490 patients, followed for a median of 14 (inter-quartile range 11-15) months after FCGM commencement. Among 2682 patients with an HbA1c measured both at baseline and ≥3 months after FCGM initiation, average HbA1c declined from 8.1% ± 1.46% to 7.9% ± 1.31% (P < .001) at first measurement and was maintained during follow up. Specifically, in those with HbA1c ≥8%, a mean decline of 0.5% (P < .001) was observed. A clinically significant HbA1c reduction of ≥0.5% was experienced by 25.5% of the patients. The rate of internal medicine hospitalization, visits to primary care, or visits to endocrine/diabetes specialists in the period following FCGM commencement vs the 6 months prior was significantly reduced (P < .001). Hospitalization for DKA and/or hypoglycemia declined as well (P = .004). CONCLUSIONS FCGM was associated with significant and durable improvement in glycemic control as well as reduced consumption of healthcare services.
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Affiliation(s)
- Anat Tsur
- Department of Endocrinology and Metabolism, Clalit Health Services, Jerusalem, Israel
- The Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Avivit Cahn
- The Faculty of Medicine, Hebrew University, Jerusalem, Israel
- Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
| | - Meirav Israel
- Department of Pharmacy and Quality Assurance, Clalit Health Services, Israel
- Faculty of Health Sciences, School of Pharmacy, Ben-Gurion University, Beersheba, Israel
| | - Ilan Feldhamer
- Department of Research and Information, Planning Division, Clalit Health Services, Tel Aviv, Israel
| | - Ariel Hammerman
- Department of Pharmaceutical Technology Assessment, Clalit Health Services, Tel-Aviv, Israel
| | - Rena Pollack
- The Faculty of Medicine, Hebrew University, Jerusalem, Israel
- Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
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Ibrahim M, Baker J, Cahn A, Eckel RH, El Sayed NA, Fischl AH, Gaede P, Leslie RD, Pieralice S, Tuccinardi D, Pozzilli P, Richelsen B, Roitman E, Standl E, Toledano Y, Tuomilehto J, Weber SL, Umpierrez GE. Hypoglycaemia and its management in primary care setting. Diabetes Metab Res Rev 2020; 36:e3332. [PMID: 32343474 DOI: 10.1002/dmrr.3332] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/30/2020] [Accepted: 04/20/2020] [Indexed: 12/14/2022]
Abstract
Hypoglycaemia is common in patients with type 1 diabetes and type 2 diabetes and constitutes a major limiting factor in achieving glycaemic control among people with diabetes. While hypoglycaemia is defined as a blood glucose level under 70 mg/dL (3.9 mmol/L), symptoms may occur at higher blood glucose levels in individuals with poor glycaemic control. Severe hypoglycaemia is defined as an episode requiring the assistance of another person to actively administer carbohydrate, glucagon, or take other corrective actions to assure neurologic recovery. Hypoglycaemia is the most important safety outcome in clinical studies of glucose lowering agents. The American Diabetes Association Standards of Medical Care recommends that a management protocol for hypoglycaemia should be designed and implemented by every hospital, along with a clear prevention and treatment plan. A tailored approach, using clinical and pathophysiologic disease stratification, can help individualize glycaemic goals and promote new therapies to improve quality of life of patients. Data from recent large clinical trials reported low risk of hypoglycaemic events with the use of newer anti-diabetic drugs. Increased hypoglycaemia risk is observed with the use of insulin and/or sulphonylureas. Vulnerable patients with T2D at dual risk of severe hypoglycaemia and cardiovascular outcomes show features of "frailty." Many of such patients may be better treated by the use of GLP-1 receptor agonists or SGLT2 inhibitors rather than insulin. Continuous glucose monitoring (CGM) should be considered for all individuals with increased risk for hypoglycaemia, impaired hypoglycaemia awareness, frequent nocturnal hypoglycaemia and with history of severe hypoglycaemia. Patients with impaired awareness of hypoglycaemia benefit from real-time CGM. The diabetes educator is an invaluable resource and can devote the time needed to thoroughly educate the individual to reduce the risk of hypoglycaemia and integrate the information within the entire construct of diabetes self-management. Conversations about hypoglycaemia facilitated by a healthcare professional may reduce the burden and fear of hypoglycaemia among patients with diabetes and their family members. Optimizing insulin doses and carbohydrate intake, in addition to a short warm up before or after the physical activity sessions may help avoiding hypoglycaemia. Several therapeutic considerations are important to reduce hypoglycaemia risk during pregnancy including administration of rapid-acting insulin analogues rather than human insulin, pre-conception initiation of insulin analogues, and immediate postpartum insulin dose reduction.
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Affiliation(s)
| | - Jason Baker
- Weill Cornell Medicine, New York, New York, USA
| | - Avivit Cahn
- The Diabetes Unit & Endocrinology and Metabolism Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Robert H Eckel
- University of Colorado Denver Anschutz Medical Campus and University of Colorado Hospital, Denver, Colorado, USA
| | - Nuha Ali El Sayed
- Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Amy Hess Fischl
- University of Chicago Kovler Diabetes Center, Chicago, Illinois, USA
| | - Peter Gaede
- Department of Cardiology and Endocrinology, Slagelse Hospital, Slagelse, Denmark
| | - R David Leslie
- Blizard Institute, Queen Mary, University of London, London, UK
- Centre of Immunobiology, Barts and the London School of Medicine, Queen Mary, University of London, London, UK
| | - Silvia Pieralice
- Unit of Endocrinology and Diabetes, Campus Bio-Medico University, Rome, Italy
| | - Dario Tuccinardi
- Unit of Endocrinology and Diabetes, Campus Bio-Medico University, Rome, Italy
| | - Paolo Pozzilli
- Centre of Immunobiology, Barts and the London School of Medicine, Queen Mary, University of London, London, UK
- Unit of Endocrinology and Diabetes, Campus Bio-Medico University, Rome, Italy
| | - Bjørn Richelsen
- Steno Diabetes Center Aarhus and Department of Endocrinology, Aarhus University Hospital, Aarhus, Denmark
| | - Eytan Roitman
- Institute of Diabetes, Technology and Research, Clalit Health Services, Herzelia, Israel
| | - Eberhard Standl
- Forschergruppe Diabetes eV at Munich Helmholtz Centre, Munich, Germany
| | - Yoel Toledano
- Division of Maternal Fetal Medicine, Helen Schneider Women's Hospital, Rabin Medical Center, Petah Tikva, Israel
| | | | - Sandra L Weber
- Greenville Health System, University of South Carolina School of Medicine-Greenville, Greenville, South Carolina, USA
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Pollack R, Ashash A, Cahn A, Rottenberg Y, Stern H, Dresner-Pollak R. Immune Checkpoint Inhibitor-induced Thyroid Dysfunction Is Associated with Higher Body Mass Index. J Clin Endocrinol Metab 2020; 105:5872027. [PMID: 32668461 DOI: 10.1210/clinem/dgaa458] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/10/2020] [Indexed: 02/04/2023]
Abstract
CONTEXT Obesity is a proinflammatory metabolic state that may play a role in the development of immune-related adverse events (irAEs) associated with immune checkpoint inhibitor therapy. OBJECTIVE To characterize the association between body mass index (BMI) and thyroid irAEs. METHODS We performed a single-center, retrospective analysis of 185 cancer patients treated with anti-PD-1/L1 from January 2014 to December 2018. Patients with normal thyroid function at baseline and available BMI were included. MAIN OUTCOME MEASURES The primary endpoint was difference in BMI in patients who developed overt thyroid dysfunction versus those who remained euthyroid following anti-PD-1/L1 initiation. Additional endpoints included any (overt or subclinical) thyroid dysfunction, overt thyrotoxicosis or overt hypothyroidism, and time to development of dysfunction according to BMI. RESULTS Any thyroid dysfunction developed in 72 (38.9%) patients and 41 (22.1%) developed overt thyroid dysfunction. Mean BMI was higher in those with overt thyroid dysfunction versus euthyroid (27.3 ± 6.0 vs 24.9 ± 4.5, P = .03). Development of overt thyrotoxicosis versus remaining euthyroid was associated with higher BMI (28.9 ± 5.9 vs 24.9 ± 4.5; P < .01), whereas overt hypothyroidism was not (26.7 ± 5.5 vs 24.9 ± 4.5, P = .10). Overt thyrotoxicosis developed within 57.5 (interquartile range [IQR] 31.8-78.8) days of treatment in the low-normal BMI group, 38.0 (IQR 26.8-40.5) days in the overweight group, and 23.0 (IQR 21.0-28.0) days in the obese group (P = .02). CONCLUSIONS Patients treated with PD-1/L1 inhibitors were more likely to develop thyroid irAEs, specifically overt thyrotoxicosis, with increasing BMI. Overt thyrotoxicosis occurred earlier in obese versus leaner patients. These data highlight the complex interplay between obesity and immune response in immune checkpoint inhibitor-treated patients.
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Affiliation(s)
- Rena Pollack
- Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Hebrew University, The Faculty of Medicine, Jerusalem, Israel
| | - Amit Ashash
- Hebrew University, The Faculty of Medicine, Jerusalem, Israel
| | - Avivit Cahn
- Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Hebrew University, The Faculty of Medicine, Jerusalem, Israel
| | - Yakir Rottenberg
- Department of Oncology, Sharett Institute, Hadassah Medical Center, Jerusalem, Israel
| | - Hagay Stern
- Hebrew University, The Faculty of Medicine, Jerusalem, Israel
| | - Rivka Dresner-Pollak
- Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Hebrew University, The Faculty of Medicine, Jerusalem, Israel
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Bonaca MP, Wiviott SD, Zelniker TA, Mosenzon O, Bhatt DL, Leiter LA, McGuire DK, Goodrich EL, De Mendonca Furtado RH, Wilding JPH, Cahn A, Gause-Nilsson IAM, Johanson P, Fredriksson M, Johansson PA, Langkilde AM, Raz I, Sabatine MS. Dapagliflozin and Cardiac, Kidney, and Limb Outcomes in Patients With and Without Peripheral Artery Disease in DECLARE-TIMI 58. Circulation 2020; 142:734-747. [PMID: 32795086 DOI: 10.1161/circulationaha.119.044775] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with peripheral artery disease (PAD) are at heightened risk of cardiovascular complications. The sodium-glucose cotransporter 2 inhibitor dapagliflozin reduces the risk for hospitalization for heart failure (HHF) and kidney events in patients with type 2 diabetes mellitus. An increased risk of amputation has been observed with canagliflozin in 1 previous trial. We examined cardiovascular and kidney efficacy and the risk of limb-related events in patients with and without PAD in an exploratory analysis. METHODS A total of 17 160 patients with type 2 diabetes mellitus, including 1025 (6%) with PAD, were randomized. Key efficacy outcomes were MACE (cardiovascular [CV] death, myocardial infarction, stroke), CV death/HHF, and progression of kidney disease. Amputations, peripheral revascularization, and limb ischemic adverse events were site-reported and categorized by a blinded reviewer. RESULTS Patients in the placebo arm with PAD versus those without tended to have higher adjusted risk of CV death, myocardial infarction, or stroke (adjusted hazard ratio [HR], 1.23 [95% CI, 0.97-1.56], P=0.094) and significantly higher adjusted risk of CV death/HHF (adjusted HR, 1.60 [95% CI, 1.21-2.12], P=0.0010) and progression of kidney disease (adjusted HR, 1.51 [95% CI, 1.13 - 2.03], P=0.0058), and limb adverse events (adjusted HR, 8.37, P<0.001). The relative risk reductions with dapagliflozin for CV death/HHF (HR, 0.86, PAD; HR, 0.82, no-PAD; P-interaction=0.79) and progression of kidney disease (HR, 0.78, PAD; HR, 0.76, no-PAD; P-interaction=0.84) were consistent regardless of PAD. There were 560 patients who had at least 1 limb ischemic event, 454 patients with at least 1 peripheral revascularization, and 236 patients with at least 1 amputation, with a total of 407 amputations reported. Overall, there were no significant differences in any limb outcome with dapagliflozin versus placebo including limb ischemic adverse events (HR, 1.07 [95% CI, 0.90-1.26]) and amputation (HR, 1.09 [95% CI, 0.84-1.40]), with no significant interactions by a history of PAD versus not (P-interactions=0.30 and 0.093, respectively). CONCLUSIONS Patients with versus without PAD are at a higher risk of CV death of CV death, HHF, and kidney outcomes, and have a consistent benefits for CV death/HHF and progression of kidney disease with dapagliflozin. Patients with PAD had a higher risk of limb events, with no consistent pattern of incremental risk observed with dapagliflozin. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01730534.
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Affiliation(s)
- Marc P Bonaca
- TIMI (Thrombolysis in Myocardial Infarction) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Harvard Medical School, Boston, MA (M.P.B., S.D.W., T.A.Z., D.L.B., E.L.G., M.S.S.)
| | - Stephen D Wiviott
- TIMI (Thrombolysis in Myocardial Infarction) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Harvard Medical School, Boston, MA (M.P.B., S.D.W., T.A.Z., D.L.B., E.L.G., M.S.S.)
| | - Thomas A Zelniker
- TIMI (Thrombolysis in Myocardial Infarction) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Harvard Medical School, Boston, MA (M.P.B., S.D.W., T.A.Z., D.L.B., E.L.G., M.S.S.)
| | - Ofri Mosenzon
- Diabetes Unit, Hadassah Medical Center, Hebrew University of Jerusalem, Israel (O.M., A.C., I.R.)
| | - Deepak L Bhatt
- TIMI (Thrombolysis in Myocardial Infarction) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Harvard Medical School, Boston, MA (M.P.B., S.D.W., T.A.Z., D.L.B., E.L.G., M.S.S.)
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Ontario, Canada (L.A.L.)
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (D.K.M.)
| | - Erica L Goodrich
- TIMI (Thrombolysis in Myocardial Infarction) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Harvard Medical School, Boston, MA (M.P.B., S.D.W., T.A.Z., D.L.B., E.L.G., M.S.S.)
| | - Remo Holanda De Mendonca Furtado
- Hospital Albert Einstein and Instituto do Coracao da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil (R.H.D.M.F.)
| | - John P H Wilding
- Institute of Ageing and Chronic Disease, University of Liverpool, United Kingdom (J.P.H.W.)
| | - Avivit Cahn
- Diabetes Unit, Hadassah Medical Center, Hebrew University of Jerusalem, Israel (O.M., A.C., I.R.)
| | | | - Per Johanson
- AstraZeneca Gothenburg, Mölndal, Sweden (I.A.M.G.-N., P.J., M.F., P.A.J., A.M.L.)
| | - Martin Fredriksson
- AstraZeneca Gothenburg, Mölndal, Sweden (I.A.M.G.-N., P.J., M.F., P.A.J., A.M.L.)
| | - Peter A Johansson
- AstraZeneca Gothenburg, Mölndal, Sweden (I.A.M.G.-N., P.J., M.F., P.A.J., A.M.L.)
| | - Anna Maria Langkilde
- AstraZeneca Gothenburg, Mölndal, Sweden (I.A.M.G.-N., P.J., M.F., P.A.J., A.M.L.)
| | - Itamar Raz
- Diabetes Unit, Hadassah Medical Center, Hebrew University of Jerusalem, Israel (O.M., A.C., I.R.)
| | - Marc S Sabatine
- TIMI (Thrombolysis in Myocardial Infarction) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Harvard Medical School, Boston, MA (M.P.B., S.D.W., T.A.Z., D.L.B., E.L.G., M.S.S.)
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Cahn A, Raz I, Bonaca M, Mosenzon O, Murphy SA, Yanuv I, Rozenberg A, Wilding JPH, Bhatt DL, McGuire DK, Gause-Nilsson IAM, Fredriksson M, Johansson PA, Jermendy G, Hadjadj S, Langkilde AM, Sabatine MS, Wiviott SD, Leiter LA. Safety of dapagliflozin in a broad population of patients with type 2 diabetes: Analyses from the DECLARE-TIMI 58 study. Diabetes Obes Metab 2020; 22:1357-1368. [PMID: 32239659 DOI: 10.1111/dom.14041] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/26/2020] [Accepted: 03/26/2020] [Indexed: 02/06/2023]
Abstract
AIMS To evaluate comprehensively the safety of dapagliflozin in patients with type 2 diabetes (T2DM), with emphasis placed on potential safety concerns related to the sodium-glucose co-transporter-2 inhibitor class. METHODS In the Dapagliflozin Effect on Cardiovascular Events - Thrombolysis in Myocardial Infarction 58 (DECLARE-TIMI 58) study, 17 160 patients with T2DM were randomized to dapagliflozin or placebo and followed for a median of 4.2 years. Safety was evaluated in 17 143 patients receiving at least one dose of study drug. RESULTS Acute kidney injury occurred less frequently with dapagliflozin, and adverse events suggestive of volume depletion were balanced between treatment groups, both irrespective of baseline estimated glomerular filtration rate, blood pressure, diuretic or loop diuretic use (interaction P values >0.05). Fractures and malignancies were balanced between the groups, irrespective of sex, diabetes duration or smoking (interaction P values >0.05) and fewer cases of bladder cancer occurred in the dapagliflozin versus the placebo group. Diabetic ketoacidosis was very rare, but more frequent with dapagliflozin versus placebo (27 vs. 12 patients with events; P = 0.02), yet signs, symptoms and contributing factors were similar in the two groups. Major hypoglycaemia occurred less frequently with dapagliflozin versus placebo, regardless of baseline use of either insulin or sulphonylureas (interaction P values >0.05). There were more adverse events of genital infections leading to discontinuation of study drug in the dapagliflozin versus the placebo group, but serious genital infections were few and balanced between treatment groups. Urinary tract infections, acute pyelonephritis and urosepsis were also balanced between treatment groups. CONCLUSIONS Dapagliflozin was well tolerated. The long duration and large number of patient-years in DECLARE-TIMI 58 comprehensively addressed previous safety questions, confirming the robust safety profile of dapagliflozin.
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Affiliation(s)
- Avivit Cahn
- Diabetes Unit, Department of Endocinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel
| | - Itamar Raz
- Diabetes Unit, Department of Endocinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel
| | - Marc Bonaca
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ilan Yanuv
- Diabetes Unit, Department of Endocinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel
| | - Aliza Rozenberg
- Diabetes Unit, Department of Endocinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel
| | - John P H Wilding
- Institute of Ageing and Chronic Disease, Faculty of Health and Life Science, University of Liverpool, Liverpool, UK
| | - Deepak L Bhatt
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Centre, Dallas, Texas
| | | | | | | | - Gyorgy Jermendy
- 3rd Medical Department, Bajcsy-Zsilinszky Teaching Hospital, Budapest, Hungary
| | - Samy Hadjadj
- L'institut du thorax, INSERM, CNRS, UNIV Nantes, CHU Nantes, Department of Endocrinology, Diabetes and Nutrition, Nantes, France
| | | | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Canada
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Bajaj HS, Raz I, Mosenzon O, Murphy SA, Rozenberg A, Yanuv I, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Gause-Nilsson IAM, Sabatine MS, Wiviott SD, Cahn A. Cardiovascular and renal benefits of dapagliflozin in patients with short and long-standing type 2 diabetes: Analysis from the DECLARE-TIMI 58 trial. Diabetes Obes Metab 2020; 22:1122-1131. [PMID: 32090404 DOI: 10.1111/dom.14011] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 02/15/2020] [Accepted: 02/18/2020] [Indexed: 01/07/2023]
Abstract
AIM To investigate whether the cardiovascular and renal benefits observed with dapagliflozin in the DECLARE-TIMI 58 trial are also observed in patients with short and long-standing diabetes. MATERIALS AND METHODS This post hoc analysis studied the dual primary efficacy endpoints, a composite of cardiovascular death or hospitalization for heart failure (CVD/HHF) and major adverse cardiovascular events (MACE; CVD, myocardial infarction [MI], ischaemic stroke) by diabetes duration. RESULTS Of the 17 160 patients, 3836 had diabetes duration of ≤5 years, 4731 >5-10 years, 3952 >10-15 years, 2433 >15-20 years and 2206 >20 years. Dapagliflozin reduced the risk of CVD/HHF by a similar amount across diabetes duration subgroups, ranging from HR 0.79 (0.58-1.06) in patients with diabetes duration of ≤5 years to 0.75 (0.55-1.03) in those patients with diabetes duration of >20 years (interaction trend P-value 0.76). Hazard ratios (HRs) for MACE ranged from 1.08 (0.87-1.35) in patients with diabetes duration of ≤5 years to 0.67 (0.52-0.86) in those patients with diabetes duration of >20 years (interaction trend P-value 0.004). This was driven by greater reductions in the risk of MI and ischaemic stroke with dapagliflozin in patients with long-standing diabetes (interaction trend P-values 0.019 and 0.015, respectively). The duration-based MACE heterogeneity was apparent in those with or without a history of prior MI and in those with multiple risk factors. The renal-specific outcome was reduced with dapagliflozin with HRs ranging from 0.79 (0.47-1.34) in patients with diabetes duration of ≤5 years to 0.42 (0.25-0.72) in those patients with diabetes duration of >20 years (interaction trend P-value 0.084). CONCLUSIONS Dapagliflozin reduced the risk of CVD/HHF consistently, regardless of diabetes duration, whereas the treatment effect for MACE differed by duration subgroups, with significant reductions with dapagliflozin in patients with long-standing diabetes.
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Affiliation(s)
- Harpreet S Bajaj
- LMC Diabetes and Endocrinology, Brampton, Ontario, Canada
- Leadership Sinai Center for Diabetes, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sabina A Murphy
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Aliza Rozenberg
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ilan Yanuv
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Deepak L Bhatt
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - John P H Wilding
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | | | - Marc S Sabatine
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stephen D Wiviott
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Pollack R, Ashash A, Cahn A, Dresner-Pollak R. OR28-07 Increased BMI Is Associated With Anti PD-1/PD-L1-Induced Thyroid Immune-Related Adverse Events. J Endocr Soc 2020. [PMCID: PMC7208668 DOI: 10.1210/jendso/bvaa046.2062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background: Immune checkpoint inhibitors have revolutionized cancer therapy, however, are associated with immune related adverse events (irAEs). Obesity is a pro-inflammatory metabolic state that may play a role in the development of irAEs. Hypothesis: We hypothesized that likelihood of developing thyroid irAEs following anti-PD-1/L1 therapy increases with increasing body mass index (BMI). Methods: We retrospectively analyzed data of 187 cancer patients who initiated anti-PD-1/L1 at our institution between 01/2014-12/2018, had normal thyroid function tests at baseline and had baseline BMI data available. Results: Overall, 97 (52.2%) patients were with low-normal BMI (<25 kg/m2), 52 (28.0%) overweight (≥25-30 kg/m2) and 37 (19.9%) obese (≥30 kg/m2). Thyroid dysfunction (hyper or hypo, overt or subclinical) developed in 72/187 (38.7%) patients, of whom 29/97 (29.9%) had low-normal BMI, 22/52 (42.3%) were overweight and 21/37 (56.8%) obese (p=0.14). With every 1 kg/m2 increase in BMI, the likelihood of thyroid dysfunction increased by 8.8% (p=0.004). Overt hyperthyroidism occurred in 32/186 (9.1%) of the patients - in 4.1% of patients with low-normal BMI, 11.5% of overweight patients and 18.9% of obese (p=0.006). Overt hypothyroidism occurred in 32/186 (17.2%) of the patients and was not significantly associated with BMI. Hyperthyroidism followed by overt hypothyroidism, consistent with thyroiditis, occurred in 13/186 (7.0%) of patients and was significantly associated with increasing BMI category (p=0.03). Conclusions: Increased BMI was associated with increased thyroid irAEs in patients treated with PD-1/L1 inhibitors. Further exploration of the interaction between obesity and immunotherapy may provide insight into the role of inflammation in mediating immune response.
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Affiliation(s)
- Rena Pollack
- Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Amit Ashash
- The Hebrew University School of Medicine, Jerusalem, Israel
| | - Avivit Cahn
- Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Oyama K, Raz I, Cahn A, Kuder J, Murphy S, Bhatt D, Leiter LA, McGuire DK, Wilding J, Park KS, Goudev A, Diaz R, Špinar J, Gause-Nilsson I, Mosenzon O, Sabatine M, Wiviott SD. EFFECTS OF DAPAGLIFLOZIN ON CARDIOVASCULAR OUTCOMES ACROSS BODY MASS INDEX CATEGORIES IN PATIENTS WITH TYPE 2 DIABETES MELLITUS IN THE DECLARE TIMI 58 TRIAL. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)31287-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Khanh TQ, Hao PN, Roitman E, Raz I, Marganitt B, Cahn A. Digital Diabetes Care System Observations from a Pilot Evaluation Study in Vietnam. Int J Environ Res Public Health 2020; 17:ijerph17030937. [PMID: 32028707 PMCID: PMC7037177 DOI: 10.3390/ijerph17030937] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 01/31/2020] [Accepted: 02/01/2020] [Indexed: 11/29/2022]
Abstract
Digital technologies are gaining an important role in the management of patients with diabetes. We assessed clinical outcomes and user satisfaction of incorporating a digital diabetes care system in diabetes clinics of a developing country. The system integrated a wireless blood glucose monitor that communicates data to any smartphone utilizing a patented acoustic data transfer method, a mobile-app, and cloud-based software that stores, analyzes, and presents data. Five hospital endocrinology clinics in Vietnam sequentially recruited all patients willing to join the study, providing they had a smartphone and access to internet connectivity. Face-to-face visits were conducted at baseline and at 12 weeks, with monthly digital visits scheduled in the interim and additional digital visits performed as needed. HbA1c levels were measured at baseline and at 12 weeks (±20 days). The study included 300 patients of whom 279 completed the evaluation. Average glucose levels declined from 170.4 ± 64.6 mg/dL in the first 2 weeks to 150.8 ± 53.2 mg/dL in the last 2 weeks (n = 221; p < 0.001). HbA1c levels at baseline and 12 weeks declined from 8.3% ± 1.9% to 7.6% ± 1.3% (n = 126; p < 0.001). The digital solution was broadly accepted by both patients and healthcare professionals and improved glycemic outcomes. The durability, scalability, and cost-effectiveness of this approach merits further study.
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Affiliation(s)
- Tran Quang Khanh
- Head of Endocrinology Department, University of Medicine and Pharmacy, Ho Chi Minh City 72000, Vietnam;
| | - Pham Nhu Hao
- Department of Endocrinology, University of Medicine and Pharmacy, Ho Chi Minh City 72000, Vietnam;
| | - Eytan Roitman
- Head Diabetes Technologies Clinic, Diabetes consultant to the Clalit Health Services, Tel Aviv 6209804, Israel;
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem 91120, Israel;
| | | | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem 91120, Israel;
- Correspondence: ; Tel.: 97-226-776-498; Fax: 97-226-437-940
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Cahn A, Mosenzon O, Wiviott SD, Rozenberg A, Yanuv I, Goodrich EL, Murphy SA, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Gause-Nilsson IAM, Fredriksson M, Johansson PA, Langkilde AM, Sabatine MS, Raz I. Efficacy and Safety of Dapagliflozin in the Elderly: Analysis From the DECLARE-TIMI 58 Study. Diabetes Care 2020; 43:468-475. [PMID: 31843945 DOI: 10.2337/dc19-1476] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 11/17/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Data regarding the effects of sodium-glucose cotransporter 2 inhibitors in the elderly (age ≥65 years) and very elderly (age ≥75 years) are limited. RESEARCH DESIGN AND METHODS The Dapagliflozin Effect on Cardiovascular Events (DECLARE)-TIMI 58 assessed cardiac and renal outcomes of dapagliflozin versus placebo in patients with type 2 diabetes. Efficacy and safety outcomes were studied within age subgroups for treatment effect and age-based treatment interaction. RESULTS Of the 17,160 patients, 9,253 were <65 years of age, 6,811 ≥65 to <75 years, and 1,096 ≥75 years. Dapagliflozin reduced the composite of cardiovascular death or hospitalization for heart failure consistently, with a hazard ratio (HR) of 0.88 (95% CI 0.72, 1.07), 0.77 (0.63, 0.94), and 0.94 (0.65, 1.36) in age-groups <65, ≥65 to <75, and ≥75 years, respectively (interaction P value 0.5277). Overall, dapagliflozin did not significantly decrease the rates of major adverse cardiovascular events, with HR 0.93 (95% CI 0.81, 1.08), 0.97 (0.83, 1.13), and 0.84 (0.61, 1.15) in age-groups <65, ≥65 to <75, and ≥75 years, respectively (interaction P value 0.7352). The relative risk reduction for the secondary prespecified cardiorenal composite outcome ranged from 18% to 28% in the different age-groups with no heterogeneity. Major hypoglycemia was less frequent with dapagliflozin versus placebo, with HR 0.97 (95% CI 0.58, 1.64), 0.50 (0.29, 0.84), and 0.68 (0.29, 1.57) in age-groups <65, ≥65 to <75, and ≥75 years, respectively (interaction P value 0.2107). Safety outcomes, including fractures, volume depletion, cancer, urinary tract infections, and amputations were balanced with dapagliflozin versus placebo, and acute kidney injury was reduced, all regardless of age. Genital infections that were serious or led to discontinuation of the study drug and diabetic ketoacidosis were uncommon, yet more frequent with dapagliflozin versus placebo, without heterogeneity (interaction P values 0.1058 and 0.8433, respectively). CONCLUSIONS The overall efficacy and safety of dapagliflozin are consistent regardless of age.
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Affiliation(s)
- Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Aliza Rozenberg
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | - Ilan Yanuv
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | - Erica L Goodrich
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Deepak L Bhatt
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | | | - John P H Wilding
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, U.K
| | | | | | | | | | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
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Cahn A, Shoshan A, Sagiv T, Yesharim R, Goshen R, Shalev V, Raz I. Prediction of progression from pre-diabetes to diabetes: Development and validation of a machine learning model. Diabetes Metab Res Rev 2020; 36:e3252. [PMID: 31943669 DOI: 10.1002/dmrr.3252] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 11/17/2019] [Accepted: 11/19/2019] [Indexed: 12/24/2022]
Abstract
AIMS Identification, a priori, of those at high risk of progression from pre-diabetes to diabetes may enable targeted delivery of interventional programmes while avoiding the burden of prevention and treatment in those at low risk. We studied whether the use of a machine-learning model can improve the prediction of incident diabetes utilizing patient data from electronic medical records. METHODS A machine-learning model predicting the progression from pre-diabetes to diabetes was developed using a gradient boosted trees model. The model was trained on data from The Health Improvement Network (THIN) database cohort, internally validated on THIN data not used for training, and externally validated on the Canadian AppleTree and the Israeli Maccabi Health Services (MHS) data sets. The model's predictive ability was compared with that of a logistic-regression model within each data set. RESULTS A cohort of 852 454 individuals with pre-diabetes (glucose ≥ 100 mg/dL and/or HbA1c ≥ 5.7) was used for model training including 4.9 million time points using 900 features. The full model was eventually implemented using 69 variables, generated from 11 basic signals. The machine-learning model demonstrated superiority over the logistic-regression model, which was maintained at all sensitivity levels - comparing AUC [95% CI] between the models; in the THIN data set (0.865 [0.860,0.869] vs 0.778 [0.773,0.784] P < .05), the AppleTree data set (0.907 [0.896, 0.919] vs 0.880 [0.867, 0.894] P < .05) and the MHS data set (0.925 [0.923, 0.927] vs 0.876 [0.872, 0.879] P < .05). CONCLUSIONS Machine-learning models preserve their performance across populations in diabetes prediction, and can be integrated into large clinical systems, leading to judicious selection of persons for interventional programmes.
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Affiliation(s)
- Avivit Cahn
- Diabetes Unit, Dept. of Endocrinology and Metabolism, Hadassah University Hospital, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | | | - Tal Sagiv
- Medial EarlySign, Hod Hasharon, Israel
| | | | | | - Varda Shalev
- Medical Division, Maccabi Healthcare services, Tel Aviv, Israel
| | - Itamar Raz
- Diabetes Unit, Dept. of Endocrinology and Metabolism, Hadassah University Hospital, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
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Çavuşoğlu Y, Altay H, Cahn A, Celik A, Demir S, Kılıçaslan B, Nalbantgil S, Raz I, Temizhan A, Yıldırımtürk Ö, Yılmaz MB. [Sodium glucose co-transporter 2 inhibitors in heart failure therapy]. Turk Kardiyol Dern Ars 2020; 48:330-354. [PMID: 32281958 DOI: 10.5543/tkda.2020.74332] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Yüksel Çavuşoğlu
- Eskişehir Osmangazi Üniversitesi Tıp Fakültesi, Kardiyoloji Anabilim Dalı, Eskişehir
| | - Hakan Altay
- Başkent Üniversitesi, Kardiyoloji Anabilim Dalı, İstanbul
| | - Avivit Cahn
- Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Ahmet Celik
- Mersin Üniversitesi Tıp Fakültesi, Kardiyoloji Anabilim Dalı, Mersin
| | | | - Barış Kılıçaslan
- Tepecik Eğitim ve Araştırma Hastanesi, Kardiyoloji Kliniği, İzmir
| | | | - Itamar Raz
- Başkent Üniversitesi, Kardiyoloji Anabilim Dalı, İstanbul
| | - Ahmet Temizhan
- Sağlık Bilimleri Üniversitesi, Ankara Şehir Hastanesi, Kardiyoloji Anabilim Dalı, Ankara
| | - Özlem Yıldırımtürk
- Sağlık Bilimleri Üniversitesi, Dr. Siyami Ersek Göğüs Kalp ve Damar Cerrahisi Eğitim ve Araştırma Hastanesi, Kardiyoloji Bölümü, İstanbul
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Affiliation(s)
- Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Hebrew University Hospital, The Faculty of Medicine, Jerusalem, Israel
| | - Simona Cernea
- Department M4, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureş, Târgu-Mures, Romania
- Diabetes, Nutrition and Metabolic Diseases Outpatient Unit, Emergency County Clinical Hospital, Târgu Mureş, Romania
| | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Hebrew University Hospital, The Faculty of Medicine, Jerusalem, Israel
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Cahn A, Cernea S, Raz I. The SONAR study-is there a future for endothelin receptor antagonists in diabetic kidney disease? Ann Transl Med 2019; 7:S330. [PMID: 32016048 DOI: 10.21037/atm.2019.09.117] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Avivit Cahn
- The Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew Univercity of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | - Simona Cernea
- Department M3/Internal Medicine IV, University of Medicine, Pharmacy, Science and Technology of Târgu Mureş, Romania.,Diabetes, Nutrition and Metabolic Diseases Outpatient Unit, Emergency County Clinical Hospital, Târgu Mureş, Romania
| | - Itamar Raz
- The Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew Univercity of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
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