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Chou OHI, Chauhan VK, Chung CTS, Lu L, Lee TTL, Ng ZMW, Wang KKW, Lee S, Liu H, Pang RTK, Kaewdech A, Cheung BMY, Tse G, Zhou J. Comparative effectiveness of sodium-glucose cotransporter-2 inhibitors for new-onset gastric cancer and gastric diseases in patients with type 2 diabetes mellitus: a population-based cohort study. Gastric Cancer 2024:10.1007/s10120-024-01512-7. [PMID: 38856768 DOI: 10.1007/s10120-024-01512-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 05/17/2024] [Indexed: 06/11/2024]
Abstract
OBJECTIVE To compare the risks of gastric cancer and other gastric diseases in patients with type-2 diabetes mellitus (T2DM) exposed to sodium-glucose cotransporter 2 inhibitors (SGLT2I), dipeptidyl peptidase-4 inhibitors (DPP4I) or glucagon-like peptide-1 receptor agonists (GLP1a). DESIGN This was a population-based cohort study of prospectively collected data on patients with T2DM prescribed SGLT2I, DPP4I or GLP1a between January 1st 2015 and December 31st 2020 from Hong Kong. The outcomes were new-onset gastric cancer, peptic ulcer (PU), acute gastritis, non-acute gastritis, and gastroesophageal reflux disease (GERD). Propensity score matching (1:1) using the nearest neighbour search was performed, and multivariable Cox regression was applied. A three-arm comparison between SGLT2I, DPP4I and GLP1a was conducted using propensity scores with inverse probability of treatment weighting. RESULTS A total of 62,858 patients (median age: 62.2 years old [SD: 12.8]; 55.93% males; SGLT2I: n = 23,442; DPP4I: n = 39,416) were included. In the matched cohort, the incidence of gastric cancer was lower in SGLT2I (Incidence rate per 1000 person-year, IR: 0.32; 95% confidence interval, CI 0.23-0.43) than in DPP4I (IR per 1000 person-year: 1.22; CI 1.03-1.42) users. Multivariable Cox regression found that SGLT2I use was associated with lower risks of gastric cancer (HR 0.30; 95% CI 0.19-0.48), PU, acute gastritis, non-acute gastritis, and GERD (p < 0.05) compared to DPP4I use. In the three-arm analysis, GLP1a use was associated with higher risks of gastric cancer and GERD compared to SGLT2I use. CONCLUSIONS The use of SGLT2I was associated with lower risks of new-onset gastric cancer, PU, acute gastritis, non-acute gastritis, and GERD after matching and adjustments compared to DPP4I use. SGLT2I use was associated with lower risks of GERD and gastric cancer compared to GLP1a use.
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Affiliation(s)
- Oscar Hou In Chou
- Division of Clinical Pharmacology, Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
- Department of Health Sciences, School of Nursing and Health Studies, Hong Kong Metropolitan University, Hong Kong, China
| | - Vinod Kumar Chauhan
- Institute of Biomedical Engineering, Department of Engendering Science, University of Oxford, Oxford, UK
- Department of Health Sciences, School of Nursing and Health Studies, Hong Kong Metropolitan University, Hong Kong, China
| | - Cheuk To Skylar Chung
- Diabetes Research Unit, Cardiovascular Analytics Group, PowerHealth Research Institute, Hong Kong, China
- Department of Health Sciences, School of Nursing and Health Studies, Hong Kong Metropolitan University, Hong Kong, China
| | - Lei Lu
- Institute of Biomedical Engineering, Department of Engendering Science, University of Oxford, Oxford, UK
- Department of Health Sciences, School of Nursing and Health Studies, Hong Kong Metropolitan University, Hong Kong, China
| | - Teddy Tai Loy Lee
- Diabetes Research Unit, Cardiovascular Analytics Group, PowerHealth Research Institute, Hong Kong, China
- Department of Health Sciences, School of Nursing and Health Studies, Hong Kong Metropolitan University, Hong Kong, China
| | - Zita Man Wai Ng
- Diabetes Research Unit, Cardiovascular Analytics Group, PowerHealth Research Institute, Hong Kong, China
- Department of Health Sciences, School of Nursing and Health Studies, Hong Kong Metropolitan University, Hong Kong, China
| | - Karin Kai Wing Wang
- Diabetes Research Unit, Cardiovascular Analytics Group, PowerHealth Research Institute, Hong Kong, China
- Department of Health Sciences, School of Nursing and Health Studies, Hong Kong Metropolitan University, Hong Kong, China
| | - Sharen Lee
- Diabetes Research Unit, Cardiovascular Analytics Group, PowerHealth Research Institute, Hong Kong, China
- Department of Health Sciences, School of Nursing and Health Studies, Hong Kong Metropolitan University, Hong Kong, China
| | - Haipeng Liu
- Research Centre for Intelligent Healthcare, Coventry University, Coventry, UK
- Department of Health Sciences, School of Nursing and Health Studies, Hong Kong Metropolitan University, Hong Kong, China
| | - Ronald Ting Kai Pang
- School of Nursing and Health Studies, Hong Kong Metropolitan University, Hong Kong, China
- Department of Health Sciences, School of Nursing and Health Studies, Hong Kong Metropolitan University, Hong Kong, China
| | - Apichat Kaewdech
- Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
- Department of Health Sciences, School of Nursing and Health Studies, Hong Kong Metropolitan University, Hong Kong, China
| | - Bernard Man Yung Cheung
- Division of Clinical Pharmacology, Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
- Department of Health Sciences, School of Nursing and Health Studies, Hong Kong Metropolitan University, Hong Kong, China
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, 300211, China
- Kent and Medway Medical School, Canterbury Christ Church University and University of Kent, Canterbury, UK
- Department of Health Sciences, School of Nursing and Health Studies, Hong Kong Metropolitan University, Hong Kong, China
- School of Nursing and Health Studies, Hong Kong Metropolitan University, Hong Kong, China
| | - Jiandong Zhou
- Department of Family Medicine and Primary Care, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China.
- School of Public Health, Li Ka Shing, Faculty of Medicine, The University of Hong Kong, Hong Kong, China.
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong, China.
- Division of Health Science, Warwick Medical School, University of Warwick, Coventry, UK.
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McCormick N, Yokose C, Lu N, Wexler DJ, Aviña-Zubieta JA, De Vera MA, McCoy RG, Choi HK. Sodium-Glucose Cotransporter-2 Inhibitors vs Sulfonylureas for Gout Prevention Among Patients With Type 2 Diabetes Receiving Metformin. JAMA Intern Med 2024; 184:650-660. [PMID: 38619822 PMCID: PMC11019449 DOI: 10.1001/jamainternmed.2024.0376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/27/2024] [Indexed: 04/16/2024]
Abstract
Importance Sodium-glucose cotransporter type 2 inhibitors (SGLT2i) are a revolutionary treatment for type 2 diabetes (T2D) with cardiovascular, kidney, and serum urate-lowering benefits. Objective To compare risk of incident gout and rate of recurrent flares between patients with T2D initiating SGLT2i vs sulfonylurea, most common second-line glucose-lowering therapy, when added to metformin monotherapy. Design, Setting, and Participants This sequential, propensity score-matched, new-user comparative effectiveness study using target trial emulation framework included adults with T2D receiving metformin monotherapy in a Canadian general population database from January 1, 2014, to June 30, 2022. Exposures Initiation of SGLT2i vs sulfonylurea. Main Outcomes and Measures The primary outcome was incident gout diagnosis, ascertained by emergency department (ED), hospital, outpatient, and medication dispensing records. Secondary outcomes were gout-primary hospitalizations and ED visits and major adverse cardiovascular events (MACE), as well as recurrent flare rates among prevalent gout patients. Heart failure (HF) hospitalization was assessed as positive control outcome and osteoarthritis encounters as negative control. For target trial emulations, we used Cox proportional hazards and Poisson regressions with 1:1 propensity score matching (primary analysis) and overlap weighting (sensitivity analysis). The analysis was conducted from September to December, 2023. Results Among 34 604 propensity score matched adults with T2D initiating SGLT2i or sulfonylurea (20 816 [60%] male, mean [SD] age, 60 [12.4] years), incidence of gout was lower among SGLT2i initiators (4.27 events per 1000 person-years) than sulfonylurea initiators (6.91 events per 1000 person-years), with a hazard ratio (HR) of 0.62 (95% CI, 0.48-0.80) and a rate difference (RD) of -2.64 (95% CI, -3.99 to -1.29) per 1000 person-years. Associations persisted regardless of sex, age, or baseline diuretic use. SGLT2i use was also associated with fewer recurrent flares among gout patients (rate ratio, 0.67; 95% CI, 0.55-0.82; and RD, -20.9; 95% CI, -31.9 to -10.0 per 1000 person-years). HR and RD for MACE associated with SGLT2i use were 0.87 (95% CI, 0.77-0.98) and -3.58 (95% CI, -6.19 to -0.96) per 1000 person-years. For control outcomes, SGLT2i users had lower risk of HF (HR, 0.53; 95% CI, 0.38-0.76), as expected, with no difference in osteoarthritis (HR, 1.11; 95% CI, 0.94-1.34). Results were similar when applying propensity score overlap weighting. Conclusions In this population-based cohort study, the gout and cardiovascular benefits associated with SGLT2i in these target trial emulations may guide selection of glucose-lowering therapy in patients with T2D, at risk for or already with gout.
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Affiliation(s)
- Natalie McCormick
- Rheumatology & Allergy Clinical Epidemiology Research Center, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston
- The Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Chio Yokose
- Rheumatology & Allergy Clinical Epidemiology Research Center, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston
- The Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Na Lu
- Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Deborah J. Wexler
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Diabetes Center, Massachusetts General Hospital, Boston
| | - J. Antonio Aviña-Zubieta
- Arthritis Research Canada, Vancouver, British Columbia, Canada
- Division of Rheumatology, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Mary A. De Vera
- Arthritis Research Canada, Vancouver, British Columbia, Canada
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Rozalina G. McCoy
- Division of Endocrinology, Diabetes, and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore
- University of Maryland Institute for Health Computing, Bethesda
- Division of Gerontology, Department of Medicine, University of Maryland School of Medicine, Baltimore
| | - Hyon K. Choi
- Rheumatology & Allergy Clinical Epidemiology Research Center, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston
- The Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Arthritis Research Canada, Vancouver, British Columbia, Canada
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Xu Y, Boyle TA, Lyu B, Ballew SH, Selvin E, Chang AR, Inker LA, Grams ME, Shin JI. Glucagon-like peptide-1 receptor agonists and the risk of atrial fibrillation in adults with diabetes: a real-world study. J Gen Intern Med 2024; 39:1112-1121. [PMID: 38191976 PMCID: PMC11116290 DOI: 10.1007/s11606-023-08589-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 12/22/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND Glucagon-like peptide-1 receptor agonists (GLP-1RA) have cardiovascular benefits in type 2 diabetes, but none of the cardiovascular trials studied atrial fibrillation/atrial flutter (AF) as a primary endpoint. Data from post-marketing surveillance studies remains sparse. OBJECTIVE To examine the real-world risk of AF comparing GLP-1RA with other non-insulin glucose-lowering agents. DESIGN Cohort study using de-identified electronic health record data from the Optum Labs Data Warehouse. PARTICIPANTS Adult patients with diabetes who were newly prescribed add-on non-insulin glucose-lowering agents and were on metformin between 2005-2020. EXPOSURES New users of GLP-1RA were separately compared with new users of dipeptidyl peptidase-4 inhibitors (DPP4i) and sodium-glucose cotransporter 2 inhibitors (SGLT2i), using 1:1 propensity score matching to adjust for differences in patient characteristics. MAIN MEASURES The primary outcome was incident AF, defined and captured by diagnosis code for AF. Incidence rate difference (IRD) and hazard ratio (HR) were estimated in the matched cohorts. KEY RESULTS In the matched cohort of 14,566 pairs of GLP-1RA and DPP4i followed for a median of 3.8 years, GLP-1RA use was associated with a lower risk of AF (IRD, -1.0; 95% CI, -1.8 to -0.2 per 1000 person-years; HR, 0.82; 95% CI, 0.70 to 0.96). In the matched cohort of 9,424 pairs of patients on GLP-1RA and SGLT2i with a median follow-up of 2.9 years, there was no difference in the risk for AF (IRD, 0.4; 95% CI -0.7 to 1.5 per 1000 person-years; HR, 1.12; 95% CI, 0.89 to 1.42). CONCLUSIONS In this real-word study, GLP-1RA was associated with a lower risk of AF compared with DPP4i, but no difference compared with SGLT2i, suggesting that cardiovascular benefits of GLP-1RA use may extend to prevention for AF in patients with diabetes. Our findings call for future randomized controlled trials to focus on the effects of GLP-1RA on AF prevention.
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Affiliation(s)
- Yunwen Xu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Thomas A Boyle
- Division of Cardiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Beini Lyu
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Shoshana H Ballew
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Elizabeth Selvin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Alexander R Chang
- Department of Nephrology, Geisinger Health System, Danville, PA, USA
| | - Lesley A Inker
- Division of Nephrology, Department of Internal Medicine, Tufts Medical Center, Boston, MA, USA
| | - Morgan E Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, New York University Grossman School of Medicine and Langone Health, New York, NY, USA
- Department of Population Health, New York University Grossman School of Medicine and Langone Health, New York, NY, USA
| | - Jung-Im Shin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Chen YY, Chang HC, Lin YJ, Chien KL, Hsieh YC, Chung FP, Lin CH, Lip GYH, Chen SA. The impact of sodium-glucose co-transporter-2 inhibitors on dementia and cardiovascular events in diabetic patients with atrial fibrillation. Diabetes Metab Res Rev 2024; 40:e3775. [PMID: 38340046 DOI: 10.1002/dmrr.3775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 11/28/2023] [Accepted: 12/12/2023] [Indexed: 02/12/2024]
Abstract
AIMS The effectiveness of sodium-glucose co-transporter-2 inhibitors (SGLT2i) on incident dementia in patients with diabetes and atrial fibrillation (AF) remains unknown. This study aimed to investigate the association between SGLT2i and the risk of incident dementia in diabetic patients with AF, and to explore the interactions with oral anticoagulants or dipeptidyl peptidase-4 inhibitors (DPP4i). MATERIALS AND METHODS We conducted a cohort study using Taiwan's National Health Insurance Research Database. Patients with diabetes and AFwithout a prior history of established cardiovascular diseases, were identified. Using propensity score matching, 810 patients receiving SGLT2i were matched with 1620 patients not receiving SGLT2i. The primary outcome was incident dementia, and secondary outcomes included composite cardiovascular events and mortality. RESULTS After up to 5 years of follow-up, SGLT2i use was associated with a significantly lower risk of incident dementia (hazard: 0.71, 95% confidence interval: 0.51-0.98), particularly vascular dementia (HR: 0.44, 95% CI: 0.24-0.82). SGLT2i was related to reduced risks of AF-related hospitalisation (HR: 0.72, 95% CI: 0.56-0.93), stroke (HR: 0.75, 95% CI: 0.60-0.94), and all-cause death (HR: 0.33, 95% CI: 0.24-0.44). The protective effects were consistent irrespective of the concurrent use of non-vitamin K antagonist oral anticoagulants (NOACs) or DPP4i. CONCLUSIONS In diabetic patients with AF, SGLT2i was associated with reduced risks of incident dementia, AF-related hospitalisation, stroke, and all-cause death. The protective effects were independent of either concurrent use of NOACs or DPP4i.
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Affiliation(s)
- Yun-Yu Chen
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Post-Baccalaureate Medicine and College of Life Sciences, National Chung Hsing University, Taichung, Taiwan
| | - Hao-Chih Chang
- Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Medicine, Taipei Veterans General Hospital Taoyuan Branch, Taoyuan, Taiwan
| | - Yenn-Jiang Lin
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Kuo-Liong Chien
- Institute of Epidemiology and Preventive Medicine College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Yu-Cheng Hsieh
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Fa-Po Chung
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ching-Heng Lin
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Shih-Ann Chen
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
- Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
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Vart P, Butt JH, Jongs N, Schechter M, Chertow GM, Wheeler DC, Pecoits-Filho R, Langkilde AM, Correa-Rotter R, Rossing P, McMurray JJV, Heerspink HJL. Efficacy and Safety of Dapagliflozin in Patients With Chronic Kidney Disease Across the Spectrum of Frailty. J Gerontol A Biol Sci Med Sci 2024; 79:glad181. [PMID: 37527836 PMCID: PMC10809037 DOI: 10.1093/gerona/glad181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND A sizeable proportion of patients with chronic kidney disease (CKD) are reported to be frail. Here we examined the safety and efficacy of dapagliflozin in patients with CKD by frailty level. METHODS Adults with CKD, with/without type 2 diabetes, with an estimated glomerular filtration rate (eGFR) of 25-75 mL/min/1.73 m2, and urinary albumin-to-creatinine ratio 200-5 000 mg/g were randomized to dapagliflozin (10 mg/day) or placebo. The primary endpoint was a composite of sustained ≥50% eGFR decline, end-stage kidney disease (ESKD), or death from kidney or cardiovascular (CV) causes. RESULTS Frailty index (FI), assessed by Rockwood cumulative deficit approach, was calculable in 4 303/4 304 (99.9%) patients: 1 162 (27.0%) in not-to-mildly frail (FI ≤0.210), 1 642 (38.2%) in moderately frail (FI 0.211-0.310), and 1 499 (34.8%) in severely frail categories (FI >0.311). Dapagliflozin reduced the risk of the primary composite endpoint across all FI categories (hazard ratios [95% confidence interval {CI}]: 0.50 [0.33-0.76], 0.62 [0.45-0.85], and 0.64 [0.49--0.83], respectively; p-interaction = 0.67). Results were similar for secondary outcomes including kidney composite outcome (sustained ≥50% eGFR decline, ESKD or death from kidney cause; p-interaction = 0.44), CV endpoint (heart failure hospitalization or CV death; p-interaction = 0.63), and all-cause mortality (p-interaction p = .42). Results were consistent when using FI as a continuous variable. Occurrence of serious adverse events was numerically lower in patients receiving dapagliflozin versus placebo in all FI categories (16.9% vs 20.1%, 26.3% vs 30.7%, and 42.9% vs 47.8%, in not-to-mildly, moderately, and severely frail categories, respectively). CONCLUSIONS The relative benefit of dapagliflozin for all outcomes was consistent across all frailty categories, with no difference in associated safety.
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Affiliation(s)
- Priya Vart
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jawad H Butt
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Meir Schechter
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Glenn M Chertow
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK
| | - Roberto Pecoits-Filho
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
- School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Brazil
| | | | - Ricardo Correa-Rotter
- The National Medical Science and Nutrition Institute Salvador Zubiran, Mexico City, Mexico
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - John J V McMurray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- The George Institute for Global Health, Sydney, New South Wales, Australia
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Li J, Yu Y, Sun Y, Yu B, Tan X, Wang B, Lu Y, Wang N. SGLT2 inhibition, circulating metabolites, and atrial fibrillation: a Mendelian randomization study. Cardiovasc Diabetol 2023; 22:278. [PMID: 37848934 PMCID: PMC10583416 DOI: 10.1186/s12933-023-02019-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 10/09/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND Sodium-glucose cotransporter 2 (SGLT2) inhibitors have shown promise in reducing the risk of atrial fibrillation (AF). However, the results are controversial and the underlying metabolic mechanism remains unclear. Emerging evidence implied that SGLT2 inhibitors have extra beneficial metabolic effects on circulating metabolites beyond glucose control, which might play a role in reducing the risk of AF. Hence, our study aimed to investigate the effect of circulating metabolites mediating SGLT2 inhibition in AF by Mendelian randomization (MR). METHODS A two-sample and two-step MR study was conducted to evaluate the association of SGLT2 inhibition with AF and the mediation effects of circulating metabolites linking SGLT2 inhibition with AF. Genetic instruments for SGLT2 inhibition were identified as genetic variants, which were both associated with the expression of SLC5A2 gene and glycated hemoglobin level (HbA1c). Positive control analysis on type 2 diabetes mellitus (T2DM) was conducted to validate the selection of genetic instruments. RESULTS Genetically predicted SGLT2 inhibition (per 1 SD decrement in HbA1c) was associated with reduced risk of T2DM (odds ratio [OR] = 0.63 [95% CI 0.45, 0.88], P = 0.006) and AF (0.51 [0.27, 0.97], P = 0.039). Among 168 circulating metabolites, two metabolites were both associated with SGLT2 inhibition and AF. The effect of SGLT2 inhibition on AF through the total concentration of lipoprotein particles (0.88 [0.81, 0.96], P = 0.004) and the concentration of HDL particles (0.89 [0.82, 0.97], P = 0.005), with a mediated proportion of 8.03% (95% CI [1.20%, 14.34%], P = 0.010) and 7.59% ([1.09%, 13.34%], P = 0.011) of the total effect, respectively. CONCLUSIONS This study supported the association of SGLT2 inhibition with a reduced risk of AF. The total concentration of lipoprotein particles and particularly the concentration of HDL particles might mediate this association. Further mechanistic and clinical studies research are needed to understand the mediation effects of circulating metabolites especially blood lipids in the association between SGLT2 inhibition and AF.
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Affiliation(s)
- Jiang Li
- Institute and Department of Endocrinology and Metabolism, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuefeng Yu
- Institute and Department of Endocrinology and Metabolism, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ying Sun
- Institute and Department of Endocrinology and Metabolism, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bowei Yu
- Institute and Department of Endocrinology and Metabolism, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiao Tan
- School of Public Health, Zhejiang University, Hangzhou, China
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Bin Wang
- Institute and Department of Endocrinology and Metabolism, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yingli Lu
- Institute and Department of Endocrinology and Metabolism, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ningjian Wang
- Institute and Department of Endocrinology and Metabolism, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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McCormick N, Yokose C, Wei J, Lu N, Wexler DJ, Aviña-Zubieta JA, De Vera MA, Zhang Y, Choi HK. Comparative Effectiveness of Sodium-Glucose Cotransporter-2 Inhibitors for Recurrent Gout Flares and Gout-Primary Emergency Department Visits and Hospitalizations : A General Population Cohort Study. Ann Intern Med 2023; 176:1067-1080. [PMID: 37487215 DOI: 10.7326/m23-0724] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Sodium-glucose cotransporter-2 inhibitors (SGLT2is) decrease serum urate levels, but whether this translates into prevention of recurrent flares among patients with gout and gout-primary emergency department (ED) visits or hospitalizations is unknown. OBJECTIVE To compare gout flares and cardiovascular events among patients with gout initiating SGLT2is versus dipeptidyl peptidase 4 inhibitors (DPP-4is), another second-line glucose-lowering agent not associated with serum urate levels or cardiovascular risk. DESIGN Propensity score-matched, new-user cohort study. SETTING General population database from 1 January 2014 to 30 June 2022. PARTICIPANTS Patients with gout and type 2 diabetes. MEASUREMENTS The primary outcome was recurrent gout flare counts ascertained by ED, hospitalization, outpatient, and medication dispensing records. Secondary outcomes included myocardial infarction and stroke; genital infection (positive control) and osteoarthritis encounter (negative control) were also assessed. Poisson and Cox proportional hazards regressions were used with 1:1 propensity score matching (primary analysis) and overlap weighting (sensitivity analysis). RESULTS After propensity score matching, the flare rate was lower among SGLT2i initiators than DPP-4i initiators (52.4 and 79.7 events per 1000 person-years, respectively), with a rate ratio (RR) of 0.66 (95% CI, 0.57 to 0.75) and a rate difference (RD) of -27.4 (CI, -36.0 to -18.7) per 1000 person-years. The corresponding RR and RD for gout-primary ED visits and hospitalizations were 0.52 (CI, 0.32 to 0.84) and -3.4 (CI, -5.8 to -0.9) per 1000 person-years, respectively. The corresponding hazard ratio (HR) and RD for myocardial infarction were 0.69 (CI, 0.54 to 0.88) and -7.6 (CI, -12.4 to -2.8) per 1000 person-years; the HR for stroke was 0.81 (CI, 0.62 to 1.05). Those who initiated SGLT2is showed higher risk for genital infection (HR, 2.15 [CI, 1.39 to 3.30]) and no altered risk for osteoarthritis encounter (HR, 1.07 [CI, 0.95 to 1.20]). Results were similar when propensity score overlap weighting was applied. LIMITATION Participants had concurrent type 2 diabetes. CONCLUSION Among patients with gout, SGLT2is may reduce recurrent flares and gout-primary ED visits and hospitalizations and may provide cardiovascular benefits. PRIMARY FUNDING SOURCE National Institute of Arthritis and Musculoskeletal and Skin Diseases.
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Affiliation(s)
- Natalie McCormick
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts; The Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts; and Arthritis Research Canada, Vancouver, British Columbia, Canada (N.M., H.K.C.)
| | - Chio Yokose
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital; The Mongan Institute, Department of Medicine, Massachusetts General Hospital; and Department of Medicine, Harvard Medical School, Boston, Massachusetts (C.Y., Y.Z.)
| | - Jie Wei
- Health Management Center, Department of Orthopaedics, National Clinical Research Center of Geriatric Disorders, and Key Laboratory of Aging-related Bone and Joint Diseases Prevention and Treatment, Ministry of Education, Xiangya Hospital, and Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China (J.W.)
| | - Na Lu
- Arthritis Research Canada, Vancouver, British Columbia, Canada (N.L.)
| | - Deborah J Wexler
- Department of Medicine, Harvard Medical School, and Diabetes Center, Massachusetts General Hospital, Boston, Massachusetts (D.J.W.)
| | - J Antonio Aviña-Zubieta
- Arthritis Research Canada, and Division of Rheumatology, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada (J.A.A.)
| | - Mary A De Vera
- Arthritis Research Canada, and Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada (M.A.D.V.)
| | - Yuqing Zhang
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital; The Mongan Institute, Department of Medicine, Massachusetts General Hospital; and Department of Medicine, Harvard Medical School, Boston, Massachusetts (C.Y., Y.Z.)
| | - Hyon K Choi
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts; The Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts; and Arthritis Research Canada, Vancouver, British Columbia, Canada (N.M., H.K.C.)
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Leopoulou M, Theofilis P, Kordalis A, Papageorgiou N, Sagris M, Oikonomou E, Tousoulis D. Diabetes mellitus and atrial fibrillation-from pathophysiology to treatment. World J Diabetes 2023; 14:512-527. [PMID: 37273256 PMCID: PMC10236990 DOI: 10.4239/wjd.v14.i5.512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/21/2023] [Accepted: 04/07/2023] [Indexed: 05/15/2023] Open
Abstract
Type 2 diabetes mellitus (T2DM) is a leading risk factor for cardiovascular complications around the globe and one of the most common medical conditions. Atrial fibrillation (AF) is the most common supraventricular arrhythmia, with a rapidly increasing prevalence. T2DM has been closely associated with the risk of AF development, identified as an independent risk factor. Regarding cardio-vascular complications, both AF and T2DM have been linked with high mortality. The underlying pathophysiology has not been fully determined yet; however, it is multifactorial, including structural, electrical, and autonomic pathways. Novel therapies include pharmaceutical agents in sodium-glucose cotransporter-2 inhibitors, as well as antiarrhythmic strategies, such as cardioversion and ablation. Of interest, glucose-lowering therapies may affect the prevalence of AF. This review presents the current evidence regarding the connection between the two entities, the pathophysiological pathways that link them, and the therapeutic options that exist.
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Affiliation(s)
- Marianna Leopoulou
- 1st Cardiology Clinic, ‘Hippokration’ General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens 11527, Greece
| | - Panagiotis Theofilis
- 1st Cardiology Clinic, ‘Hippokration’ General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens 11527, Greece
| | - Athanasios Kordalis
- 1st Cardiology Clinic, ‘Hippokration’ General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens 11527, Greece
| | - Nikolaos Papageorgiou
- 1st Cardiology Clinic, ‘Hippokration’ General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens 11527, Greece
| | - Marios Sagris
- 1st Cardiology Clinic, ‘Hippokration’ General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens 11527, Greece
| | - Evangelos Oikonomou
- 3rd Cardiology Clinic, ‘Sotiria’ Chest Diseases Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens 11527, Greece
| | - Dimitris Tousoulis
- 1st Cardiology Clinic, ‘Hippokration’ General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens 11527, Greece
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Sato T, Kouzu H, Yano T, Sakuma I, Furuhashi M, Tohse N. Potential favorable action of sodium-glucose cotransporter-2 inhibitors on sudden cardiac death: a brief overview. Front Cardiovasc Med 2023; 10:1159953. [PMID: 37252114 PMCID: PMC10214280 DOI: 10.3389/fcvm.2023.1159953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 04/21/2023] [Indexed: 05/31/2023] Open
Abstract
The primary pharmacological action of sodium-glucose co-transporter 2 (SGLT2) inhibitors is to inhibit the reabsorption of glucose and sodium ions from the proximal tubules of the kidney and to promote urinary glucose excretion. Notably, several clinical trials have recently demonstrated potent protective effects of SGLT2 inhibitors in patients with heart failure (HF) or chronic kidney disease (CKD), regardless of the presence or absence of diabetes. However, the impact of SGLT2 inhibitors on sudden cardiac death (SCD) or fatal ventricular arrhythmias (VAs), the pathophysiology of which is partly similar to that of HF and CKD, remains undetermined. The cardiorenal protective effects of SGLT2 inhibitors have been reported to include hemodynamic improvement, reverse remodeling of the failing heart, amelioration of sympathetic hyperactivity, correction of anemia and impaired iron metabolism, antioxidative effects, correction of serum electrolyte abnormalities, and antifibrotic effects, which may lead to prevent SCD and/or VAs. Recently, as possible direct cardiac effects of SGLT2 inhibitors, not only inhibition of Na+/H+ exchanger (NHE) activity, but also suppression of late Na+ current have been focused on. In addition to the indirect cardioprotective mechanisms of SGLT2 inhibitors, suppression of aberrantly increased late Na+ current may contribute to preventing SCD and/or VAs via restoration of the prolonged repolarization phase in the failing heart. This review summarizes the results of previous clinical trials of SGLT2 inhibitors for prevention of SCD, their impact on the indices of electrocardiogram, and the possible molecular mechanisms of their anti-arrhythmic effects.
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Affiliation(s)
- Tatsuya Sato
- Department of Cellular Physiology and Signal Transduction, Sapporo Medical University School of Medicine, Sapporo, Japan
- Department of Cardiovascular, Renal, and Metabolic Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Hidemichi Kouzu
- Department of Cardiovascular, Renal, and Metabolic Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Toshiyuki Yano
- Department of Cardiovascular, Renal, and Metabolic Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Ichiro Sakuma
- Caress Sapporo Hokko Memorial Clinic, Sapporo, Japan
| | - Masato Furuhashi
- Department of Cardiovascular, Renal, and Metabolic Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Noritsugu Tohse
- Department of Cellular Physiology and Signal Transduction, Sapporo Medical University School of Medicine, Sapporo, Japan
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Lui DTW, Tang EHM, Wu T, Au ICH, Lee CH, Woo YC, Tan KCB, Wong CKH. Risks of stroke, its subtypes and atrial fibrillation associated with glucagon-like peptide 1 receptor agonists versus sodium-glucose cotransporter 2 inhibitors: a real-world population-based cohort study in Hong Kong. Cardiovasc Diabetol 2023; 22:40. [PMID: 36829226 PMCID: PMC9960638 DOI: 10.1186/s12933-023-01772-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 02/14/2023] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND There are limited data on head-to-head comparative risk of stroke between sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA). We compared risk of stroke with its subtypes and incident atrial fibrillation (AF) between them. METHODS A population-based, retrospective cohort of patients with type 2 diabetes between 2008 and 2020 were identified from the electronic health records of Hong Kong Hospital Authority. Patients who received SGLT2i or GLP-1RA were matched pairwise by propensity score. Risks of stroke and AF were evaluated by hazard ratios (HRs) from the Cox proportional hazard regression models. RESULTS A total of 5840 patients (2920 SGLT2i users; 2920 GLP-1RA users) were included (mean age 55.5 years, 56.1% men, mean HbA1c 8.9% and duration of diabetes 13.7 years). Upon median follow-up of 17 months, there were 111 (1.9%) events of stroke (SGLT2i: 62, 2.1%; GLP-1RA: 49 1.7%). SGLT2i users had comparable risk of all stroke as GLP-1RA users (HR 1.46, 95% CI 0.99-2.17, p = 0.058). SGLT2i users had higher risk of ischemic stroke (HR 1.53, 95% CI 1.01-2.33, p = 0.044) but similar risk of hemorrhagic stroke compared to GLP-1RA users. Although SGLT2i was associated with lower risk of incident AF (HR 0.43, 95% CI 0.23-0.79, p = 0.006), risk of cardioembolic stroke was similar. CONCLUSIONS Our real-world study demonstrated that GLP-1RA use was associated with lower risk of ischemic stroke, despite the association between SGLT2i use and lower risk of incident AF. There was no significant difference in hemorrhagic stroke risk. GLP-1RA may be the preferred agent for patients with type 2 diabetes at risk of ischemic stroke.
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Affiliation(s)
- David Tak Wai Lui
- Division of Endocrinology and Metabolism, Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Eric Ho Man Tang
- Department of Family Medicine and Primary Care, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Tingting Wu
- Department of Family Medicine and Primary Care, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Ivan Chi Ho Au
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Chi Ho Lee
- Division of Endocrinology and Metabolism, Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Yu Cho Woo
- Division of Endocrinology and Metabolism, Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Kathryn Choon Beng Tan
- Division of Endocrinology and Metabolism, Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Carlos King Ho Wong
- Department of Family Medicine and Primary Care, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China. .,Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China. .,Laboratory of Data Discovery for Health Limited (D24H), Hong Kong Science Park, New Territories, Hong Kong SAR, China.
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