Effects of dapagliflozin on cardiovascular and kidney events by baseline eGFR and UACR in patients with type 2 diabetes mellitus: a patient-level pooled analysis of DECLARE-TIMI 58 and DAPA-CKD trials

Background

The sodium glucose co-transporter 2 (SGLT2) inhibitor dapagliflozin reduced the risk of hospitalization for heart failure (HHF) or cardiovascular death (CVD) and the risk of kidney events in patients type 2 diabetes mellitus (T2DM) and high cardiovascular risk or chronic kidney disease in the DECLARE-TIMI 58 and DAPA-CKD trials. These events are more common at lower levels of kidney function. Combining data from the two trials creates an opportunity to examine the effect of dapagliflozin across the spectrum of baseline kidney function.

Purpose

To determine the effects of dapagliflozin on HHF/CVD and kidney endpoints across a broad range of kidney function in the combined dataset.

Methods

We conducted a post hoc analysis of pooled patient-level data from DECLARE and DAPA-CKD. The effects of dapagliflozin compared with placebo on HHF/CVD and kidney endpoints (defined as sustained eGFR decrease ≥40%, end-stage kidney disease, or renal death) were assessed in the combined cohorts and in subgroups of baseline eGFR (<45, 45-<60, 60-<90, ≥90 mL/min/1.73 m2) and urinary albumin:creatinine ratio (UACR) (<30, 30-<300, 300-<1000, ≥1000 mg/g).

Results

A total of 19,748 patients with T2DM were included. Median (IQR) follow up time was 4.1 (3.7–4.4) years. Median eGFR was 85 (65–95) mL/min/1.73 m2 and UACR 18.2 (7–135) mg/g. Overall, dapagliflozin reduced the risk of HHF/CVD by 18% (HR 0.82, 95% CI 0.73–0.92, p<0.001) and kidney endpoints by 40% (HR 0.60, 95% CI 0.52–0.69, p<0.001). Overall rates of HHF/CVD and kidney endpoints were higher with lower eGFR (p<0.001) and with higher UACR (p<0.001). There were consistent relative risk reductions in HHF/CVD and kidney events with dapagliflozin across eGFR (p-interaction 0.25 and 0.32, respectively, Figure 1) and UACR (p-interaction 0.29 and 0.83, respectively, Figure 2) subgroups. The absolute rate difference (ARD) with dapagliflozin for CVD/HHF ranged from 0.1 events per 1000 patient years in patients in normal categories of eGFR and UACR to 1.0–1.7 events in patients in the most abnormal categories. Likewise, the ARD for kidney events ranged from 0.2 events per 1000 patient years in the normal eGFR and UACR groups to 2.5–4.3 events in patients in the most abnormal categories.

Conclusion

In this pooled analysis of pts with T2DM, there was higher risk of HHF/CVD and kidney events with lower eGFR and higher UACR. Dapagliflozin consistently reduced these events regardless of baseline eGFR and UACR, with large absolute risk reductions in patients with lower eGFR and higher UACR.

Funding Acknowledgement

Type of funding sources: None.

Pharmacokinetics of apixaban in patients with end stage renal disease on hemodialysis and atrial fibrillation: results from the RENAL-AF trial

Background/Introduction

Apixaban use is increasing for stroke prevention in patients with atrial fibrillation (AF) and end stage renal disease (ESRD) on hemodialysis. There is uncertainty as to the optimal dose in this population in part related to the limited available pharmacokinetic (PK) data.

Purpose

We comprehensively evaluated the PK of apixaban collected over 1 month of apixaban dosing in 63 patients with AF and ESRD on hemodialysis.

Methods

Patients with AF and ESRD on hemodialysis were randomized to warfarin versus apixaban within the RENAL-AF trial with 5 mg BID dosing, except for 2.5 mg BID in those age ≥80 years or weight ≤60 kg. The 5 mg BID dose could be reduced to 2.5mg BID for minor bleeding. Day 1 PK data was collected on all patients pre- and post-hemodialysis. Day 3 and 1 month pre- and post-hemodialysis PK samples were collected in 49 patients. The timing of apixaban dosing and hemodialysis relative to PK samples was recorded. Dosing history, hemodialysis, and PK samples were chronologically integrated with patient specific data such as body size, age, race and gender. This dataset was combined with the ARISTOTLE dataset, and the published PK model from ARISTOTLE describing exposures in the AF population was updated to incorporate an additional clearance term for hemodialysis. The model estimated apixaban exposures (AUC) in RENAL-AF were compared to ARISTOLTE AUC values.

Results

There were 285 PK concentrations collected among 63 patients in the RENAL-AF trial. Patients had median age 69 years with 41% women (N=26) and a median weight of 84 kg (49, 157). The median AUCs for patients with ESRD on hemodialysis were 5,452 and 2,990 for patients treated with 5mg BID and 2.5mg BID doses, respectively. The median AUCs for patients treated with 5mg BID from ARISTOTLE increased from 2,802 for patients with class 1 CKD to 5,863 for class 4 CKD, while they increased from 2,392 for class 1 CKD to 2,881 for class 4 CKD in patients treated with 2.5mg BID. The median AUC for patients with ESRD on hemodialysis were within 50% of the exposure of patients from ARISTOTLE for all classes of CKD for the 2.5mg BID dose and for classes 2, 3A, 3B, and 4 CKD for the 5mg BID dose (Figure).

Conclusions

The steady state apixaban exposure data in patients with AF and ESRD on hemodialysis were modestly higher but consistent with the results of non-ESRD patients from ARISTOTLE, using 5 mg BID unless patients had age ≥80 years or weight ≤60 kg. Additional clinical outcomes data on the use of apixaban in patients with AF and ESRD on hemodialysis are needed.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Investigator sponsored grant from Bristol-Myers Squibb and Pfizer