Sodium-glucose cotransporter 2 inhibitor-induced euglycaemic diabetic ketoacidosis in heart failure with preserved ejection fraction

Sodium-Glucose Cotransporter-2 Inhibitors and Diabetic-Ketoacidosis in T2DM Patients: An Updated Meta-Analysis and a Mendelian Randomization Analysis

To evaluate the association of sodium-glucose cotransporter 2 inhibitors (SGLT2i) with diabetic ketoacidosis (DKA) in type 2 diabetes mellitus (T2DM) patients across different subgroups, we searched randomized controlled trials (RCTs) comparing SGLT2i with the control groups among T2DM patients and including DKA as a safety outcome. Pooled risk ratios (RRs) were calculated using random or fixed-effects models, as appropriate. An inverse-variance-weighted Mendelian randomization (MR) analysis was performed to estimate the genetic correlation. Twenty-two trials involving 80,235 patients were included. SGLT2i increased the risk of DKA compared to the control groups (RR 2.32, 95% CI 1.64-3.27). The risk was significantly increased in patients with higher HbA1c levels (> 7.9%) (RR 2.24, 95% CI 1.59-3.14), but not in those with lower HbA1c levels (≤ 7.9%) (RR 1.05, 95% CI 0.49-2.26; interaction P = 0.034). SGLT2i increased DKA risk in chronic kidney disease (CKD) (RR 2.70, 95% CI 1.55-4.71) and high atherosclerotic cardiovascular disease (ASCVD) risk trials (RR 2.46, 95% CI 1.47-4.11) but not significantly in heart failure (HF) trials (RR 1.23, 95% CI 0.51-2.96). Moreover, in the HF trials, SGLT2i consistently did not increase the risk of DKA in any clinical subgroups. Nevertheless, MR analysis still confirmed a genetic association between SGLT2i and the risk of DKA among overall T2DM patients. SGLT2i may increase the risk of DKA in T2DM patients, particularly in patients with higher levels of HbA1c and those with comorbid CKD or at high-risk ASCVD. However, the increased risk was not significant in patients with HF.

Metabolomic Profiling of the Effects of Dapagliflozin in Heart Failure With Reduced Ejection Fraction: DEFINE-HF

BACKGROUND

Sodium-glucose cotransporter-2 inhibitors are foundational therapy in patients with heart failure with reduced ejection fraction (HFrEF), but underlying mechanisms of benefit are not well defined. We sought to investigate the relationships between sodium-glucose cotransporter-2 inhibitor treatment, changes in metabolic pathways, and outcomes using targeted metabolomics.

METHODS

DEFINE-HF (Dapagliflozin Effects on Biomarkers, Symptoms and Functional Status in Patients With HF With Reduced Ejection Fraction) was a placebo-controlled trial of dapagliflozin in HFrEF. We performed targeted mass spectrometry profiling of 63 metabolites (45 acylcarnitines [markers of fatty acid oxidation], 15 amino acids, and 3 conventional metabolites) in plasma samples at randomization and 12 weeks. Using mixed models, we identified principal components analysis-defined metabolite clusters that changed differentially with treatment and examined the relationship between change in metabolite clusters and change in Kansas City Cardiomyopathy Questionnaire scores and NT-proBNP (N-terminal probrain natriuretic peptide). Models were adjusted for relevant clinical covariates and nominal P<0.05 with false discovery rate-adjusted P<0.10 was used to determine statistical significance.

RESULTS

Among the 234 DEFINE-HF participants with targeted metabolomic data, the mean age was 62.0±11.1 years, 25% were women, 38% were Black, and mean ejection fraction was 27±8%. Dapagliflozin increased ketone-related and short-chain acylcarnitine as well as medium-chain acylcarnitine principal components analysis-defined metabolite clusters compared with placebo (nominal P=0.01, false discovery rate-adjusted P=0.08 for both clusters). However, ketosis (β-hydroxybutyrate levels >500 μmol/L) was achieved infrequently (3 [2.5%] in dapagliflozin arm versus 1 [0.9%] in placebo arm) and supraphysiologic levels were not observed. Increases in long-chain acylcarnitine, long-chain dicarboxylacylcarnitine, and aromatic amino acid metabolite clusters were associated with decreases in Kansas City Cardiomyopathy Questionnaire scores (ie, worse quality of life) and increases in NT-proBNP levels, without interaction by treatment group.

CONCLUSIONS

In this study of targeted metabolomics in a placebo-controlled trial of sodium-glucose cotransporter-2 inhibitors in HFrEF, we observed effects of dapagliflozin on key metabolic pathways, supporting a role for altered ketone and fatty acid biology with sodium-glucose cotransporter-2 inhibitors in patients with HFrEF. Only physiologic levels of ketosis were observed. In addition, we identified several metabolic biomarkers associated with adverse HFrEF outcomes.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT02653482.

Socio-economic status and 1 year mortality among patients hospitalized for heart failure in China

AIMS

This study explored the association between socio-economic status (SES) and mortality among patients hospitalized for heart failure (HF) in China.

METHODS AND RESULTS

We used data from the China Patient-centred Evaluative Assessment of Cardiac Events-Prospective Heart Failure Study (China PEACE 5p-HF Study), which enrolled patients hospitalized primarily for HF from 52 hospitals between 2016 and 2018. SES was measured using the income, employment status, educational attainment, and partner status. Individual socio-economic risk factor (SERF) scores were assigned based on the number of coexisting SERFs, including low income, unemployed status, low education, and unpartnered status. We assessed the effects of SES on 1 year all-cause mortality using Cox models. We used the Harrell c statistic to investigate whether SES added incremental prognostic information for mortality prediction. A total of 4725 patients were included in the analysis. The median (interquartile range) age was 67 (57-76) years; 37.6% were women. In risk-adjusted analyses, patients with low/middle income [low income: hazard ratio (HR) 1.61, 95% confidence interval (CI) 1.21-2.14; middle income: HR 1.32, 95% CI 1.00-1.74], unemployment status (HR 1.43, 95% CI 1.10-1.86), low education (HR 1.25, 95% CI 1.03-1.53), and unpartnered status (HR 1.22, 95% CI 1.03-1.46) had a higher risk of death than patients with high income, who were employed, who had a high education level, and who had a partner, respectively. Compared with the patients without SERFs, those with 1, 2, 3, and 4 SERFs had 1.52-, 2.01-, 2.45-, and 3.20-fold increased risk of death, respectively. The addition of SES to fully adjusted model improved the mortality prediction, with increments in c statistic of 0.01 (P < 0.01).

CONCLUSIONS

In a national Chinese cohort of patients hospitalized for HF, low income, unemployment status, low education, and unpartnered status were all associated with a higher risk of death 1 year following discharge. In addition, incorporating SES into a clinical-based model could better identify patients at risk for death. Tailored clinical interventions are needed to mitigate the excess risk experienced by those socio-economic deprived HF patients.

Sodium-glucose cotransporter 2 inhibitor-induced euglycaemic diabetic ketoacidosis in heart failure with preserved ejection fraction

The number of patients receiving sodium-glucose cotransporter 2 inhibitors (SGLT2is), especially those with heart failure, is increasing worldwide. SGLT2is control glycaemia by triggering glycosuria with simultaneous facilitation of a more ketogenic metabolic profile. Patients therefore are more prone to develop euglycaemic diabetic ketoacidosis (euDKA), an entity largely unknown beyond diabetes care professionals. We present a heart failure with preserved ejection fraction (HFpEF) patient with known Type 2 diabetes. He was treated with dapagliflozin and presented acutely with dyspnoea, hyperglycaemia, and ketoacidosis. After standard treatment for diabetic ketoacidosis, hyperglycaemia was corrected, while metabolic ketoacidosis persisted, and thus, euDKA was suspected. With adequate therapy, the patient recovered completely and was discharged without any sequelae. To the best of our knowledge, our case is the first to describe SGLT2i-induced euDKA in HFpEF patients. Regarding no previous reports of euDKA in heart failure with reduced ejection fraction, our report is highly relevant for ongoing SGLT2i trials in HFpEF and clinical practice in general.