Association of Sodium-Glucose Cotransporter 2 Inhibitor vs Dipeptidyl Peptidase-4 Inhibitor Use With Risk of Incident Obstructive Airway Disease and Exacerbation Events Among Patients With Type 2 Diabetes in Hong Kong

The Potential of Antidiabetic Medications in the Prevention of Acute Exacerbations of Chronic Obstructive Pulmonary Disease in Subjects with Type 2 Diabetes Mellitus

Type 2 diabetes mellitus (T2DM) is often recognised as a major comorbidity of chronic obstructive pulmonary disease (COPD) and is being increasingly linked with elevated risk of acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Accordingly, the potential utility of antidiabetic medication, mostly in subjects suffering from both AECOPD and T2DM, has been investigated. The most widely studied medication is metformin. Although some studies showed no particular benefit, others assessed a diminished risk of AECOPD by up to 37% and reductions in hospitalisations, re-admissions, or the use of antibiotics and/or corticosteroids. The same holds true for sulfonylureas and thiazolidinediones. Conversely, dipeptidyl-peptidase 4 inhibitors (DPP-4is) were not associated with any benefit. Data on insulin use are scarce, but insulin in AECOPD management has been linked with adverse outcomes. The strongest effect has been shown with glucagon-like peptide 1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter 2 inhibitors (SGLT-2is): the former limited severe exacerbations by 30% and the latter by 32-36%. With SGLT-2is, the incidence diminished by 46% compared with DPP-4is, while approximately three out of four emergency visits or hospitalisations were prevented. In conclusion, existing evidence suggests a benefit of antidiabetic medication in AECOPD-related outcomes, suggesting that this effect merits further investigation.

Expanding the Use of SGLT2 Inhibitors in T2D Patients Across Clinical Settings

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are currently recommended in patients with type 2 diabetes (T2D) to reduce serum glucose levels. Moreover, robust evidence has clearly demonstrated their beneficial cardiovascular and renal effects, making this class of drugs pivotal for the treatment of T2D, especially when complicated by diabetic kidney disease or heart failure. However, several other comorbidities are frequently encountered in T2D patients beyond these long-term diabetes complications, especially in the internal medicine setting. For some of these comorbidities, such as MAFLD and cognitive impairment, the association with diabetes is increasingly recognized, with the hypothesis of a common pathophysiologic background, whereas, for others, a coincident epidemiology linked to the ageing of populations, including that of T2D subjects, may be advocated. In the effort of personalizing T2D treatment, evidence on the potential effects of SGLT2i in these different clinical conditions is accumulating. The purpose of this narrative review is to update current literature on the effects of SGLT2i for the treatment of T2D in different clinical settings beyond glycaemic control, and to elucidate potential molecular mechanisms by which they exert these effects.

Comparison of SGLT2 and DPP4 inhibitors on clinical outcomes in COPD patients with diabetes: A nationwide cohort study

BACKGROUND

This study aimed to evaluate the association between sodium-glucose cotransporter 2 inhibitor (SGLT2i) use and the risk of exacerbation and mortality among patients with chronic obstructive pulmonary disease (COPD) and diabetes mellitus (DM).

METHODS

Taiwan's National Health Insurance Research Database was used to select the COPD patients with DM and those prescribed SGLT2i and dipeptidyl peptidase-4 inhibitor (DPP4i). To reduce the selection and confounding bias, an active comparator new user design was used in current study to estimate the SGLT2i effects. The risk of COPD exacerbation and mortality was calculated using Cox regression model.

RESULTS

We identified 188 SGLT2i-useres and 181 DPP4i users. SGLT2i use was associated with a significantly lower risk of overall COPD exacerbation (HR, 0.69; 95% CI, 0.52-0.92). In addition, SGLT2i users demonstrated a significantly lower risk of severe acute exacerbations with Hazard ratio of 0.35 (95% CI, 0.20-0.61) than DPP4i users. However, no significant differences in mortality were observed between groups (HR, 1.51, 95% CI, 0.53-4.25).

CONCLUSION

SGLT2i use in COPD patients with DM was associated with reduced risks of COPD exacerbation, particularly for severe acute exacerbation compared with DPP4i. This finding suggested that SGLT2i therapy may have a protective effect against severe exacerbations in COPD management.

Impact of SGLT-2i on COPD exacerbations in patients with type 2 diabetes mellitus: A systematic review and meta-analysis

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) and Type 2 Diabetes Mellitus (T2DM) often coexist, leading to compounded morbidity, mortality, and healthcare burden. COPD exacerbations significantly impact patients with T2DM, with increased frequency and severity. Sodium-glucose cotransporter-2 inhibitors (SGLT-2i) have demonstrated promising benefits in managing both glycemic control and respiratory health. This systematic review and meta-analysis aim to assess the impact of SGLT-2 inhibitors on COPD exacerbations in T2DM patients.

METHODS

We conducted a systematic review and meta-analysis following PRISMA guidelines, evaluating studies published until March 2025. A broad search strategy across PubMed, Embase, and Web of Science identified relevant studies comparing SGLT-2 inhibitors with other antidiabetic agents. Studies meeting predefined eligibility criteria, including those providing quantitative data on COPD exacerbation frequency and hospitalization rates, were included in the analysis.

RESULTS

Eight studies involving 4,64,542 participants were included. The pooled hazard ratio (HR) for the impact of SGLT-2 inhibitors on COPD exacerbations was 0.646 (95 % CI: 0.470-0.889), demonstrating a 35 % decrease in exacerbations compared to other antidiabetic agents. SGLT-2 inhibitors demonstrated superior efficacy over DPP-4 inhibitors (HR: 0.618, 95 % CI: 0.462-0.827) and sulfonylureas (HR: 0.620, 95 % CI: 0.526-0.731). However, the reduction in severe exacerbations was not statistically significant (HR: 0.715, 95 % CI: 0.403-1.269). Subgroup analysis indicated that SGLT-2 inhibitors had a modest but significant advantage over GLP-1 receptor agonists (HR: 0.940, 95 % CI: 0.890-0.993).

CONCLUSIONS

SGLT-2 inhibitors significantly reduce COPD exacerbations in T2DM patients, offering dual benefits in managing both glycemic control and respiratory health. These findings support the integration of SGLT-2 inhibitors into treatment regimens for T2DM-COPD overlap. Further randomized controlled trials and long-term studies are needed to confirm the lasting efficacy and explore the underlying mechanisms.

The possible effect of anti-diabetic agents GLP-1RA and SGLT-2i on the respiratory system function

Type 2 Diabetes (T2D) is a chronic disease with increasing incidence and prevalence and serious chronic complications, especially from cardiovascular system. However, other organs can be affected too. Several studies have associated T2D, especially when poorly controlled, with multiple pulmonary diseases. T2D is a common comorbidity among patients with asthma, Chronic Obstructive Pulmonary Disease (COPD), and Obstructive Sleep Apnea Syndrome (OSAS), and it is related to higher respiratory infection incidence, prevalence and severity. Glucagon-like peptide-1 receptor agonists (GLP-1RA) and Sodium-glucose co-transporter-2 inhibitors (SGLT-2i) are novel antihyperglycaemic agents with established cardiovascular benefits. There are also limited studies indicating their potential benefit in respiratory function. The aim of this article is to review data on the impact of GLP-1RA and SGLT-2i on respiratory function and describe the possible clinical benefits. Key findings indicate that GLP-1RA significantly improve lung function in patients with COPD, evidenced by improvements in spirometry measurements. Additionally, both GLP-1RA and SGLT-2i are associated with a decreased risk of severe and moderate exacerbations in COPD patients and have shown potential in reducing the incidence of respiratory disorders, including asthma and pneumonia. The mechanisms underlying these benefits are not yet fully understood and include multiple effects, such as anti-inflammatory action and oxidative stress reduction.

The role of type 2 diabetes in the severity of adult asthma

PURPOSE OF REVIEW

This review summarizes recent basic, translational, and clinical research on type 2 diabetes (T2D) and its relationship with asthma severity in the context of T2D mechanisms and asthma outcomes.

RECENT FINDINGS

Several clinical asthma outcomes, such as lung function and exacerbations, demonstrate a strong association between T2D and asthma and support that T2D contributes to worse asthma outcomes. Multiple mechanisms underlying those observed associations, and their representative biomarkers, have been proposed. However, prospective, controlled human studies in the context of both T2D and asthma are limited.

SUMMARY

T2D is associated with worse asthma outcomes and more severe asthma. Yet patients with more severe or uncontrolled asthma are also at a higher risk for systemic steroid exposure, which worsens glycemic control and metabolic dysregulation. Preclinical and translational studies point to metabolic dysregulation as a driver of airway inflammation. Addressing these metabolic pathways through T2D treatment may, in turn, directly or indirectly improve clinical asthma outcomes. While additional research is needed to identify biomarkers of risk and treatment response in metabolic asthma, this review highlights the importance of considering T2D as a clinically relevant asthma comorbidity.

CXCL12 is a potential therapeutic target for type 2 diabetes mellitus complicated by chronic obstructive pulmonary disease

OBJECTIVES

To identify the key genes and immunological pathways shared by type 2 diabetes mellitus (T2DM) and chronic obstructive pulmonary disease (COPD) and explore the potential therapeutic targets of T2DM complicated by COPD.

METHODS

GEO database was used for analyzing the gene expression profiles in T2DM and COPD to identify the common differentially expressed genes (DEGs) in the two diseases. A protein-protein interaction network was constructed to identify the candidate hub genes, which were validated in datasets and disease sets to obtain the target genes. The diagnostic accuracy of these target genes was assessed with ROC analysis, and their expression levels and association with pulmonary functions were investigated using clinical data and blood samples of patients with T2DM and COPD. The abundance of 22 immune cells was analyzed with CIBERSORT algorithm, and their relationship with the target genes was examined using correlation analysis. DGIdb database was used for analyzing the drug-gene interactions and the druggable genes followed by gene set enrichment analysis.

RESULTS

We identified a total of 175 common DEGs in T2DM and COPD, mainly enriched in immune- and inflammation-related pathways. Among these genes, CXCL12 was identified as the final target gene, whose expression was elevated in both T2DM and COPD (P<0.05) and showed good diagnostic efficacy. Immune cell infiltration correlation analysis showed significant correlations of CXCL12 with various immune cells (P<0.01). GESA analysis showed that high CXCL12 expression was significantly correlated with "cytokine-cytokine receptor interaction". Drug-gene analysis showed that most of CXCL12-related drugs were not targeted drugs with significant cytotoxicity.

CONCLUSIONS

CXCL12 is a potential common key pathogenic gene of COPD and T2DM, and small-molecule targeted drugs against CXCL12 can provide a new strategy for treatment T2DM complicated by COPD.

Diabetes-inducing effects of bronchial asthma

BACKGROUND

The relationship between diabetes mellitus (DM) and asthma is complex and can impact disease trajectories.

AIM

To explore the bidirectional influences between the two conditions on clinical outcomes and disease control.

METHODS

We systematically reviewed the literature on the relationship between DM and asthma, focusing on their impacts, mechanisms, and therapeutic implications. Various studies were assessed, which investigated the effect of glycemic control on asthma outcomes, lung function, and exacerbations. The study highlighted the role of specific diabetes medications in managing asthma.

RESULTS

The results showed that poor glycemic control in diabetes can exacerbate asthma, increase hospitalizations, and reduce lung function. Conversely, severe asthma, especially in obese individuals, can complicate diabetes management and make glycemic control more difficult. The diabetes-associated mechanisms, such as inflammation, microangiopathy, and oxidative stress, can exacerbate asthma and decrease lung function. Some diabetes medications exhibit anti-inflammatory effects that show promise in mitigating asthma exacerbations.

CONCLUSION

The complex interrelationship between diabetes and asthma suggests bidirectional influences that affect disease course and outcomes. Inflammation and microvascular complications associated with diabetes may worsen asthma outcomes, while asthma severity, especially in obese individuals, complicates diabetes control. However, the current research has limitations, and more diverse longitudinal studies are required to establish causal relationships and identify effective treatment strategies for individuals with both conditions.

Sodium-glucose co-transporter-2 inhibitors versus dipeptidyl peptidase-4 inhibitors on in-hospital mortality following pneumonia without heart failure: A retrospective cohort study of older adults with diabetes

BACKGROUND

Sodium-glucose co-transporter-2 inhibitors (SGLT2i) may contribute to better clinical outcomes in adults with diabetes and pneumonia owing to their potential anti-inflammatory effects. To investigate whether SGLT2i are associated with lower in-hospital mortality following pneumonia without heart failure than dipeptidyl peptidase-4 inhibitors (DPP-4i).

METHODS

Using the Japanese Diagnosis Procedure Combination database, we retrospectively identified patients with diabetes aged ≥65 years treated with SGLT2i or DPP-4i who were admitted and managed for pneumonia from April 2016 to October 2020. We then compared in-hospital mortality, the need for mechanical ventilation, and discharges to locations (other than home) between the SGLT2i and DPP-4i groups using multivariable logistic regression analyses fitted with generalized estimating equations.

RESULTS

We analyzed the data of 27,334 patients (mean age, 78.8 years; male, 71.2%), including 535 and 26,799 patients regularly treated with SGLT2i and DPP-4i, respectively. No significant differences were observed between the SGLT2i and DPP-4i groups in in-hospital mortality rate (3.4% vs. 5.9%; odds ratio [OR], 0.64; 95% confidence interval [CI], 0.40-1.05), the need for mechanical ventilation (1.5% vs. 1.8%; OR, 0.78; 95%Cl, 0.39-1.59), and discharge to locations other than home (8.1% vs. 14.1%; OR, 0.72; 95%Cl, 0.51-1.02). The association between the diabetic treatment and in-hospital mortality remained insignificant across weight subgroups (underweight: OR, 0.47; 95%Cl, 0.13-1.67; normal weight: OR, 0.66; 95%Cl, 0.34-1.25; and overweight/obesity: OR 1.06; 95%Cl, 0.43-2.65).

CONCLUSIONS

Regular SGLT2i use in patients with diabetes admitted with pneumonia without heart failure may not be associated with improved in-hospital mortality outcomes compared with DPP-4i use.

The role of Sodium-Glucose Transporter-2 Inhibitors (SGLT-2i) in preventing chronic obstructive disease exacerbation in patients with diabetes and COPD: An electronic health database analysis

BACKGROUND

Sodium Glucose Transporter 2 inhibitor (SGLT-2i) medications reduce inflammation, improve glycemic control, and impart weight loss, all of which may play a role in chronic obstructive pulmonary disease (COPD) pathophysiology.

OBJECTIVES

The primary objective of our study was to explore the incidence of COPD exacerbation in patients with diabetes and COPD on SGLT-2i medications. The secondary objective was to assess the impact of SGLT-2i medications on COPD exacerbations needing hospitalization, ICU admission, and mechanical ventilation.

METHODS

This was a retrospective cohort analysis of COPD patients with diabetes enrolled in the COPD registry at a Mid-west Tertiary care teaching hospital from January 1, 2022, to December 31, 2022. We used Slicer-Dicer, a self-service cohort exploration tool embedded in EPIC for data extraction.

RESULTS

We had 31,411 patients registered with the COPD registry during the study period. Of these, 18,713 had diabetes, and 1295 patients were on SGLT-2i medication. The incidence of COPD exacerbation, including severe COPD exacerbation needing hospitalization, was significantly lower in the SGLT-2i medication group (3.16% vs 18.3%, p < 0.05; 1.2% vs 5.04%, p < 0.05). Also, there was a non-significant trend suggesting that the incidence of COPD exacerbation needing intensive care unit admission and intubation was lower in the SGLT-2i medication group (0.07% vs 3.4%; 0 vs 0.04%). SGLT-2i medication use was associated with reduced incidence of COPD exacerbation irrespective of underlying control of diabetes.

CONCLUSIONS

Our study suggests possible role of SGLT-2i in preventing COPD exacerbation. Randomized trials are needed in the future to confirm or refute these findings.

Use of Sodium-glucose cotransporter 2 (SGLT 2) inhibitor is associated with reduced emergency room visits and hospitalizations in patients with Chronic obstructive pulmonary disease (COPD) and type 2 Diabetes Mellitus

BACKGROUND

The Sodium-Glucose Cotransporter 2 inhibitors (SGLT2i) are a class of anti-diabetic medications that confer cardio-renal-metabolic (CRM) benefits. Emerging evidence also suggests that these agents provide better benefits for chronic pulmonary conditions, especially chronic obstructive pulmonary disease (COPD).

RESEARCH QUESTION

We aimed to assess the association between SGLT2i use and outcomes in patients with COPD and concomitant Type 2 Diabetes Mellitus (T2DM).

STUDY DESIGN AND METHODS

We conducted a retrospective cohort study on adults with T2DM and COPD in a primary care clinic from January 01, 2019 to 01/01//2023. Patients were categorized into two groups based on SGLT2i use. We collected demographic information and outcomes such as emergency room (ER) visits, hospitalizations secondary to COPD exacerbation over the period of four years and time to hospitalization and ER visits. Chi-square analysis was used for categorical variables, whereas an unpaired t-test was used for continuous variables. Cox regression was performed to identify significant prognostic factors of hospitalization and ER visits. A Kaplan-Meir analysis was used to visualize the probability of non-hospitalization and the probability of not visiting the ER. Statistical significance was set at p-value <0.05.

RESULTS

Of the 220 patients screened, 94 met the inclusion criteria, of which 20 patients (21.3 %) had SGLT2i use at admission, and 74 (78.7 %) did not. Baseline demographic information were well-matched between the two groups. SGLT2i use was associated with a significant reduction in ER visits (70 % vs. 97.3 %, p-0.001) and the number of hospitalizations (55 % vs 87.8 %, p-0.001). Further multivariate analysis showed lower hazards of hospitalization (adjusted HR-0.156; CI:0.073 to 0.331) and ER visits (HR)-0.232; CI:0.118 to 0.453) in patients on SGLT2i.

INTERPRETATION

In patients with T2DM with COPD, SGLT2i use was associated with reduced ER visits and hospitalizations related to COPD. This protective effect of SGLT2i could be explained by reduced systemic proinflammatory markers and increased anti-inflammatory markers via inhibition of Node like receptor protein 3(NLRP3) inflammasome activation in multiple tissues, including the lungs.

Association of Sodium-Glucose Cotransporter-2 Inhibitors vs Dipeptidyl Peptidase-4 Inhibitors With Pneumonia, COVID-19, and Other Adverse Respiratory Events in Patients With Type 2 Diabetes Mellitus: A Systematic Review and Meta-analysis

OBJECTIVE

Our aim in this study was to systematically assess the association of sodium-glucose cotransporter-2 inhibitors (SGLT2i) vs dipeptidyl peptidase-4 inhibitors (DPP4i) with pneumonia, COVID-19, and adverse respiratory events in patients with type 2 diabetes mellitus (DM).

METHODS

PubMed, Embase, and Cochrane Library databases were retrieved to include studies on DM patients receiving SGLT2i (exposure group) or DPP4i (control group). Stata version 15.0 statistical software was used for the meta-analysis.

RESULTS

Ten studies were included, all 10 of which were used for the qualitative review and 7 for the meta-analysis. According to the meta-analysis, patients receiving SGLT2i had a lower incidence of pneumonia (odds ratio [OR] 0.62, 95% confidence interval [CI] 0.51 to 0.74) and pneumonia risk (OR 0.63, 95% CI 0.60 to 0.68, p=0.000) compared with those receiving DPP4i. The same situation was seen for mortality for pneumonia (OR 0.49, 95% CI 0.39 to 0.60) and pneumonia mortality risk (OR 0.47, 95% CI 0.42 to 0.51). There was lower mortality due to COVID-19 (OR 0.31, 95% CI 0.28 to 0.34) and a lower hospitalization rate (OR 0.61, 95% CI 0.56 to 0.68, p=0.000) and incidence of mechanical ventilation (OR 0.69, 95% CI 0.58 to 0.83, p=0.000) due to COVID-19 in patients with type 2 DM receiving SGLT2i. Qualitative analysis results show that SGLT2i were associated with a lower incidence of COVID-19, lower risk of obstructive airway disease events, and lower hospitalization rate of health-care-associated pneumonia than DPP4i.

CONCLUSION

In patients with type 2 DM, SGLT2i are associated with a lower risk of pneumonia, COVID-19, and mortality than DPP4i.

SGLT-2 Inhibitor Use and Cause-Specific Hospitalization Rates: An Outcome-Wide Study to Identify Novel Associations of SGLT-2 Inhibitors

Sodium-glucose co-transporter 2 inhibitors (SGLT2is) have demonstrated multifaceted pharmacological effects. In addition to type 2 diabetes, they are now indicated for heart failure and chronic kidney disease. This study aimed to identify novel associations between SGLT2i use and health outcomes using real-world data. Using linked data from a nationwide diabetes registry in Australia, we compared hospitalization rates in people living with type 2 diabetes commencing treatment with SGLT2i and dipeptidyl peptidase-4 inhibitor (DPP4i) between December 1, 2013, and June 30, 2019. Cause-specific hospitalizations were categorized across three hierarchies of diagnoses (first, first three, and first four digits of International Classification of Diseases, Tenth Version, Australian Modification codes). Incidence rate ratio (IRR) and 95% confidence interval (95% CI) for each cause-specific hospitalization were estimated using negative binomial regression. In the first hierarchy, hospitalization rates were lower across most diagnosis groups among SGLT2i initiators (n = 99,569) compared with DPP4i initiators (n = 186,353). In the second and third hierarchies, there were lower hospitalization rates relating to infections, anemias, and obstructive airway diseases among SGLT2i initiators compared with DPP4i initiators. These included sepsis (IRR: 0.60, 95% CI: 0.51-0.72) anemia (IRR: 0.55, 95% CI: 0.46-0.66), and chronic obstructive pulmonary diseases (IRR: 0.52, 95% CI: 0.40-0.68), as well as for previously known associations (e.g., heart failure (IRR: 0.63, 95% CI: 0.56-0.70)). SGLT2is have previously uncharacterized associations on a range of important clinical outcomes; validation of these associations requires further study, some of which may suggest novel benefits or new indications for SGLT2is.

Genetic variations in anti-diabetic drug targets and COPD risk: evidence from mendelian randomization

BACKGROUND

Previous research has emphasized the potential benefits of anti-diabetic medications in inhibiting the exacerbation of Chronic Obstructive Pulmonary Disease (COPD), yet the role of anti-diabetic drugs on COPD risk remains uncertain.

METHODS

This study employed a Mendelian randomization (MR) approach to evaluate the causal association of genetic variations related to six classes of anti-diabetic drug targets with COPD. The primary outcome for COPD was obtained from the Global Biobank Meta-analysis Initiative (GBMI) consortium, encompassing a meta-analysis of 12 cohorts with 81,568 cases and 1,310,798 controls. Summary-level data for HbA1c was derived from the UK Biobank, involving 344,182 individuals. Positive control analysis was conducted for Type 2 Diabetes Mellitus (T2DM) to validate the choice of instrumental variables. The study applied Summary-data-based MR (SMR) and two-sample MR for effect estimation and further adopted colocalization analysis to verify evidence of genetic variations.

RESULTS

SMR analysis revealed that elevated KCNJ11 gene expression levels in blood correlated with reduced COPD risk (OR = 0.87, 95% CI = 0.79-0.95; p = 0.002), whereas an increase in DPP4 expression corresponded with an increased COPD incidence (OR = 1.18, 95% CI = 1.03-1.35; p = 0.022). Additionally, the primary method within MR analysis demonstrated a positive correlation between PPARG-mediated HbA1c and both FEV1 (OR = 1.07, 95% CI = 1.02-1.13; P = 0.013) and FEV1/FVC (OR = 1.08, 95% CI = 1.01-1.14; P = 0.007), and a negative association between SLC5A2-mediated HbA1c and FEV1/FVC (OR = 0.86, 95% CI = 0.74-1.00; P = 0.045). No colocalization evidence with outcome phenotypes was detected (all PP.H4 < 0.7).

CONCLUSION

This study provides suggestive evidence for anti-diabetic medications' role in improving COPD and lung function. Further updated MR analyses are warranted in the future, following the acquisition of more extensive and comprehensive data, to validate our results.

Preventing CXCL12 elevation helps to reduce acute exacerbation of COPD in individuals co-existing type-2 diabetes: A bioinformatics and clinical pharmacology study

AIMS

To investigate the immunology shared mechanisms underlying chronic obstructive pulmonary disease (COPD) and type 2 diabetes mellitus (T2DM) and examine the impact of anti-diabetic drugs on acute exacerbation of COPD (AECOPD).

METHODS

We analyzed GSE76925, GSE76894, GSE37768, and GSE25724 to identify differentially expressed genes. Hub-genes were identified through protein-protein interaction network analysis and evaluated by the receiver operating characteristic curve. CXCL12 emerged as a robust biomarker, and its correlation with lung function and CD8+ T cells were further quantified and validated. The activated signaling pathways were inferred through Gene set enrichment analysis (GSEA). The retrospective clinical analysis was executed to identify the influence of dipeptidyl peptidase-4 inhibitors (DPP-4i) on CXCL12 and evaluate the drug's efficacy in AECOPD.

RESULTS

The significant up-regulation of CXCL12 expression in patients with two diseases were revealed. CXCL12 exhibited a negative correlation with pulmonary function (r = -0.551, p < 0.05). Consistent with analysis in GSE76925 and GSE76894, the positive correlation between the proportion of CD8+ T cells was demonstrated(r=0.469, p<0.05). GSEA identified "cytokines interaction" as an activated signaling pathway, and the clinical study revealed the correlation between CXCL12 and IL-6 (r=0.668, p<0.05). In patients with COPD and T2DM, DDP-4i treatment exhibited significantly higher serum CXCL12, compared to GLP-1RA. Analysis of 187 COPD patients with T2DM indicated that the DPP-4i group had a higher frequency of AECOPD compared to the GLP-1RA group (OR 1.287, 95%CI [1.018-2.136]).

CONCLUSIONS

CXCL12 may represent a therapeutic target for COPD and T2DM. GLP-1RA treatment may be associated with lower CXCL12 levels and a lower risk of AECOPD compared to DPP-4i treatment.

CLINICAL TRIAL REGISTRATION

China Clinical Trial Registration Center（ChiCTR2200055611）.

Extrapulmonary Comorbidities Associated with Chronic Obstructive Pulmonary Disease: A Review

Most patients with chronic obstructive pulmonary disease (COPD) suffer from at least one additional, clinically relevant chronic disease. To a degree, the high global prevalence and mortality rate of COPD is closely related to its extrapulmonary effects. Moreover, the various of comorbidities of COPD and itself interact with each other, resulting in diverse clinical manifestations and individual differences, and thus further influencing the prognosis as well as healthcare burden of COPD patients. This is closely related to the common risk factors of chronic diseases (aging, smoking, inactivity, etc.). Additionally, some pathophysiological mechanisms caused by COPD, including the systemic inflammatory response, hypoxia, oxidative stress, and others, also have an impact on other systems. But comprehensive management and medical interventions have not yet been established. The clinicians should improve their knowledge and skills in diagnosing as well as treating the comorbidities of COPD, and then aim to develop more individualized, efficient diagnostic and therapeutic strategies for different patients to achieve greater clinical benefits. In this article, we will review the risk factors, mechanisms, and treatment strategies for extrapulmonary comorbidities in chronic obstructive pulmonary disease, including cardiovascular diseases, diabetes, anemia, osteoporosis, emotional disorders, and gastroesophageal reflux disease.

Association of GLP-1 Receptor Agonists with Chronic Obstructive Pulmonary Disease Exacerbations among Patients with Type 2 Diabetes

Rationale: Patients with chronic obstructive pulmonary disease (COPD) and type 2 diabetes (T2D) have worse clinical outcomes compared with patients without metabolic dysregulation. GLP-1 (glucagon-like peptide 1) receptor agonists (GLP-1RAs) reduce asthma exacerbation risk and improve FVC in patients with COPD. Objectives: To determine whether GLP-1RA use is associated with reduced COPD exacerbation rates, and severe and moderate exacerbation risk, compared with other T2D therapies. Methods: A retrospective, observational, electronic health records-based study was conducted using an active comparator, new-user design of 1,642 patients with COPD in a U.S. health system from 2012 to 2022. The COPD cohort was identified using a previously validated machine learning algorithm that includes a natural language processing tool. Exposures were defined as prescriptions for GLP-1RAs (reference group), DPP-4 (dipeptidyl peptidase 4) inhibitors (DPP-4is), SGLT2 (sodium-glucose cotransporter 2) inhibitors, or sulfonylureas. Measurements and Main Results: Unadjusted COPD exacerbation counts were lower in GLP-1RA users. Adjusted exacerbation rates were significantly higher in DPP-4i (incidence rate ratio, 1.48 [95% confidence interval, 1.08-2.04]; P = 0.02) and sulfonylurea (incidence rate ratio, 2.09 [95% confidence interval, 1.62-2.69]; P < 0.0001) users compared with GLP-1RA users. GLP-1RA use was also associated with significantly reduced risk of severe exacerbations compared with DPP-4i and sulfonylurea use, and of moderate exacerbations compared with sulfonylurea use. After adjustment for clinical covariates, moderate exacerbation risk was also lower in GLP-1RA users compared with DPP-4i users. No statistically significant difference in exacerbation outcomes was seen between GLP-1RA and SGLT2 inhibitor users. Conclusions: Prospective studies of COPD exacerbations in patients with comorbid T2D are warranted. Additional research may elucidate the mechanisms underlying these observed associations with T2D medications.

Hyperglycaemia and Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) may coexist with type 2 diabetes mellitus (T2DM). Patients with COPD have an increased risk of developing T2DM compared with a control but, on the other side, hyperglycaemia and DM have been associated with reduced predicted levels of lung function. The mechanistic relationships between these two diseases are complicated, multifaceted, and little understood, yet they can impact treatment strategy. The potential risks and benefits for patients with T2DM treated with pulmonary drugs and the potential pulmonary risks and benefits for patients with COPD when taking antidiabetic drugs should always be considered. The interaction between the presence and/or treatment of COPD, risk of infection, presence and/or treatment of T2DM and risk of acute exacerbations of COPD (AECOPDs) can be represented as a vicious circle; however, several strategies may help to break this circle. The most effective approach to simultaneously treating T2DM and COPD is to interfere with the shared inflammatory substrate, thus targeting both lung inflammation (COPD) and vascular inflammation (DM). In any case, it is always crucial to establish glycaemic management since the reduction in lung function found in people with diabetes might decrease the threshold for clinical manifestations of COPD. In this article, we examine possible connections between COPD and T2DM as well as pharmacological strategies that could focus on these connections.

Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitors: Harms or Unexpected Benefits?

There is a need for innovative pharmaceutical intervention in light of the increasing prevalence of metabolic disease and cardiovascular disease. The kidneys' sodium-glucose cotransporter 2 inhibitors (SGLT2) receptors are targeted to reduce glucose reabsorption by SGLT2. Patients with type 2 diabetes mellitus (T2DM) benefit the most from reduced blood glucose levels, although this is just one of the numerous physiological consequences. To establish existing understanding and possible advantages and risks for SGLT2 inhibitors in clinical practice, this article will explore the influence of SGLT2 inhibitors on six major organ systems. In addition, this literature review will discuss the benefits and potential drawbacks of SGLT2 inhibitors on various organ systems and their potential application in therapeutic settings.

Validation of Diagnostic Coding for Asthma in an Electronic Health Record System in Hong Kong

Background

Electronic health record (EHR) databases can facilitate epidemiology research into various diseases including asthma. Given the diagnostic challenges of asthma, the validity of the coding in EHR requires clarification. We aimed to assess the validity of International Classification of Diseases, 9th Revision (ICD-9) code algorithms for identifying asthma in the territory-wide electronic medical health record system of the Clinical Data Analysis and Reporting System (CDARS) in Hong Kong.

Methods

Adult patients who had the diagnosis of asthma input from all public hospitals in Hong Kong and those from Queen Mary Hospital in 2011-2020 were identified using the ICD-9 code of 493 (493.0, 493.1, 493.2, and 493.9) by CDARS. Patients' clinical record and spirometry were reviewed by two respiratory specialists to confirm the presence of asthma in the randomly selected cases.

Results

There were 43,454 patients who had the diagnostic code of asthma among all public hospitals in Hong Kong and 1852 in Queen Mary Hospital in the same period. A total of 200 cases were randomly selected and validated using medical record and spirometry review by a respiratory specialist. The overall positive predictive value (PPV) was 85.0% (95% CI 80.1-89.9%).

Conclusion

This was the first ICD-9 code validation for CDARS (EHR) in Hong Kong on asthma. Our study demonstrated that using ICD-9 code (493.0, 493.1, 493.2 and 493.9) to identify asthma can result in a PPV that was reliable to support the utility of the CDARS database for further research on asthma among the Hong Kong population.

Population-Based Clinical Studies Using Routinely Collected Data in Hong Kong, China: A Systematic Review of Trends and Established Local Practices

Background: Routinely collected health data are increasingly used in clinical research. No study has systematically reviewed the temporal trends in the number of publications and analyzed different aspects of local research practices and their variations in Hong Kong, China, with a specific focus on research ethics governance and approval.

Methods: PubMed was systematically searched from its inception to March 28, 2023, for studies using routinely collected healthcare data from Hong Kong.

Results: A total of 454 studies were included. Between 2000 and 2009, 32 studies were identified. The number of publications increased from 5 to 120 between 2010 and 2022. Of the investigator-led studies using the Hospital Authority (HA)’s cross-cluster data (n = 393), 327 (83.2%) reported receiving ethics approval from a single cluster/university-based REC, whereas 50 studies (12.7%) did not report approval from a REC. For use of the HA Data Collaboration Lab, approval by a single hospital-based or University-based REC is accepted. Repeated submission of identical ethics applications to different RECs is estimated to cost HK$4.2 million yearly.

Conclusions: Most studies reported gaining approval from a single cluster REC before retrieval of cross-cluster HA data. Substantial cost savings would result if repeated review of identical ethics applications were not required.