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Patel SM, Morrow DA, Bellavia A, Berg DD, Bhatt DL, Jarolim P, Leiter LA, McGuire DK, Raz I, Steg PG, Wilding JPH, Sabatine MS, Wiviott SD, Braunwald E, Scirica BM, Bohula EA. Natriuretic peptides, body mass index and heart failure risk: Pooled analyses of SAVOR-TIMI 53, DECLARE-TIMI 58 and CAMELLIA-TIMI 61. Eur J Heart Fail 2024; 26:260-269. [PMID: 38131261 DOI: 10.1002/ejhf.3118] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/09/2023] [Accepted: 12/19/2023] [Indexed: 12/23/2023] Open
Abstract
AIM N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentrations are lower in patients with obesity. The interaction between body mass index (BMI) and NT-proBNP with respect to heart failure risk remains incompletely defined. METHODS AND RESULTS Data were pooled across three randomized clinical trials enrolling predominantly patients who were overweight or obese with established cardiometabolic disease: SAVOR-TIMI 53, DECLARE-TIMI 58 and CAMELLIA-TIMI 61. Hospitalization for heart failure (HHF) was examined across strata of baseline BMI and NT-proBNP. The effect of dapagliflozin versus placebo was assessed for a treatment interaction across BMI categories in patients with or without an elevated baseline NT-proBNP (≥125 pg/ml). Among 24 455 patients, the median NT-proBNP was 96 (interquartile range [IQR]: 43-225) pg/ml and the median BMI was 33 (IQR 29-37) kg/m2, with 68% of patients having a BMI ≥30 kg/m2. There was a significant inverse association between NT-proBNP and BMI which persisted after adjustment for all clinical variables (p < 0.001). Within any range of NT-proBNP, those at higher BMI had higher risk of HHF at 2 years (comparing BMI <30 vs. ≥40 kg/m2 for NT-proBNP ranges of <125, 125-<450 and ≥450 pg/ml: 0.0% vs. 0.6%, 1.3% vs. 4.0%, and 8.1% vs. 13.8%, respectively), which persisted after multivariable adjustment (adjusted hazard ratio [HRadj] 7.47, 95% confidence interval [CI] 3.16-17.66, HRadj 3.22 [95% CI 2.13-4.86], and HRadj 1.87 [95% CI 1.35-2.60], respectively). In DECLARE-TIMI 58, dapagliflozin versus placebo consistently reduced HHF across BMI categories in those with an elevated NT-proBNP (p-trend for HR across BMI = 0.60), with a pattern of greater absolute risk reduction (ARR) at higher BMI (ARR for BMI <30 to ≥40 kg/m2: 2.2% to 4.7%; p-trend = 0.059). CONCLUSIONS The risk of HHF varies across BMI categories for any given range of circulating NT-proBNP. These findings showcase the importance of considering BMI when applying NT-proBNP for heart failure risk stratification, particularly for patients with low-level elevations in NT-proBNP (125-<450 pg/ml) where there appears to be a clinically meaningful absolute and relative risk gradient.
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Affiliation(s)
- Siddharth M Patel
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrea Bellavia
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - David D Berg
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, NY, USA
| | - Petr Jarolim
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Parkland Health and Hospital System, Dallas, TX, USA
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - P Gabriel Steg
- Université Paris Cité, INSERM U-1148, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France
- FACT (French Alliance for Cardiovascular Trials), Paris, France
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, UK
| | - Marc S Sabatine
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stephen D Wiviott
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eugene Braunwald
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Benjamin M Scirica
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Erin A Bohula
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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2
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Brummel K, Eagle K. An Atherothrombotic Risk Score for Patients With Diabetes: Useful Tool or More of the Same? J Am Coll Cardiol 2023; 81:2403-2405. [PMID: 37344041 DOI: 10.1016/j.jacc.2023.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/17/2023] [Indexed: 06/23/2023]
Affiliation(s)
- Kent Brummel
- Frankel Cardiovascular Center, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA.
| | - Kim Eagle
- Frankel Cardiovascular Center, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA. https://twitter.com/Keaglemd
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3
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Kanie T, Mizuno A, Takaoka Y, Suzuki T, Yoneoka D, Nishikawa Y, Tam WWS, Morze J, Rynkiewicz A, Xin Y, Wu O, Providencia R, Kwong JS. Dipeptidyl peptidase-4 inhibitors, glucagon-like peptide 1 receptor agonists and sodium-glucose co-transporter-2 inhibitors for people with cardiovascular disease: a network meta-analysis. Cochrane Database Syst Rev 2021; 10:CD013650. [PMID: 34693515 PMCID: PMC8812344 DOI: 10.1002/14651858.cd013650.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cardiovascular disease (CVD) is a leading cause of death globally. Recently, dipeptidyl peptidase-4 inhibitors (DPP4i), glucagon-like peptide-1 receptor agonists (GLP-1RA) and sodium-glucose co-transporter-2 inhibitors (SGLT2i) were approved for treating people with type 2 diabetes mellitus. Although metformin remains the first-line pharmacotherapy for people with type 2 diabetes mellitus, a body of evidence has recently emerged indicating that DPP4i, GLP-1RA and SGLT2i may exert positive effects on patients with known CVD. OBJECTIVES To systematically review the available evidence on the benefits and harms of DPP4i, GLP-1RA, and SGLT2i in people with established CVD, using network meta-analysis. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and the Conference Proceedings Citation Index on 16 July 2020. We also searched clinical trials registers on 22 August 2020. We did not restrict by language or publication status. SELECTION CRITERIA We searched for randomised controlled trials (RCTs) investigating DPP4i, GLP-1RA, or SGLT2i that included participants with established CVD. Outcome measures of interest were CVD mortality, fatal and non-fatal myocardial infarction, fatal and non-fatal stroke, all-cause mortality, hospitalisation for heart failure (HF), and safety outcomes. DATA COLLECTION AND ANALYSIS Three review authors independently screened the results of searches to identify eligible studies and extracted study data. We used the GRADE approach to assess the certainty of the evidence. We conducted standard pairwise meta-analyses and network meta-analyses by pooling studies that we assessed to be of substantial homogeneity; subgroup and sensitivity analyses were also pursued to explore how study characteristics and potential effect modifiers could affect the robustness of our review findings. We analysed study data using the odds ratios (ORs) and log odds ratios (LORs) with their respective 95% confidence intervals (CIs) and credible intervals (Crls), where appropriate. We also performed narrative synthesis for included studies that were of substantial heterogeneity and that did not report quantitative data in a usable format, in order to discuss their individual findings and relevance to our review scope. MAIN RESULTS We included 31 studies (287 records), of which we pooled data from 20 studies (129,465 participants) for our meta-analysis. The majority of the included studies were at low risk of bias, using Cochrane's tool for assessing risk of bias. Among the 20 pooled studies, six investigated DPP4i, seven studied GLP-1RA, and the remaining seven trials evaluated SGLT2i. All outcome data described below were reported at the longest follow-up duration. 1. DPP4i versus placebo Our review suggests that DPP4i do not reduce any risk of efficacy outcomes: CVD mortality (OR 1.00, 95% CI 0.91 to 1.09; high-certainty evidence), myocardial infarction (OR 0.97, 95% CI 0.88 to 1.08; high-certainty evidence), stroke (OR 1.00, 95% CI 0.87 to 1.14; high-certainty evidence), and all-cause mortality (OR 1.03, 95% CI 0.96 to 1.11; high-certainty evidence). DPP4i probably do not reduce hospitalisation for HF (OR 0.99, 95% CI 0.80 to 1.23; moderate-certainty evidence). DPP4i may not increase the likelihood of worsening renal function (OR 1.08, 95% CI 0.88 to 1.33; low-certainty evidence) and probably do not increase the risk of bone fracture (OR 1.00, 95% CI 0.83 to 1.19; moderate-certainty evidence) or hypoglycaemia (OR 1.11, 95% CI 0.95 to 1.29; moderate-certainty evidence). They are likely to increase the risk of pancreatitis (OR 1.63, 95% CI 1.12 to 2.37; moderate-certainty evidence). 2. GLP-1RA versus placebo Our findings indicate that GLP-1RA reduce the risk of CV mortality (OR 0.87, 95% CI 0.79 to 0.95; high-certainty evidence), all-cause mortality (OR 0.88, 95% CI 0.82 to 0.95; high-certainty evidence), and stroke (OR 0.87, 95% CI 0.77 to 0.98; high-certainty evidence). GLP-1RA probably do not reduce the risk of myocardial infarction (OR 0.89, 95% CI 0.78 to 1.01; moderate-certainty evidence), and hospitalisation for HF (OR 0.95, 95% CI 0.85 to 1.06; high-certainty evidence). GLP-1RA may reduce the risk of worsening renal function (OR 0.61, 95% CI 0.44 to 0.84; low-certainty evidence), but may have no impact on pancreatitis (OR 0.96, 95% CI 0.68 to 1.35; low-certainty evidence). We are uncertain about the effect of GLP-1RA on hypoglycaemia and bone fractures. 3. SGLT2i versus placebo This review shows that SGLT2i probably reduce the risk of CV mortality (OR 0.82, 95% CI 0.70 to 0.95; moderate-certainty evidence), all-cause mortality (OR 0.84, 95% CI 0.74 to 0.96; moderate-certainty evidence), and reduce the risk of HF hospitalisation (OR 0.65, 95% CI 0.59 to 0.71; high-certainty evidence); they do not reduce the risk of myocardial infarction (OR 0.97, 95% CI 0.84 to 1.12; high-certainty evidence) and probably do not reduce the risk of stroke (OR 1.12, 95% CI 0.92 to 1.36; moderate-certainty evidence). In terms of treatment safety, SGLT2i probably reduce the incidence of worsening renal function (OR 0.59, 95% CI 0.43 to 0.82; moderate-certainty evidence), and probably have no effect on hypoglycaemia (OR 0.90, 95% CI 0.75 to 1.07; moderate-certainty evidence) or bone fracture (OR 1.02, 95% CI 0.88 to 1.18; high-certainty evidence), and may have no impact on pancreatitis (OR 0.85, 95% CI 0.39 to 1.86; low-certainty evidence). 4. Network meta-analysis Because we failed to identify direct comparisons between each class of the agents, findings from our network meta-analysis provided limited novel insights. Almost all findings from our network meta-analysis agree with those from the standard meta-analysis. GLP-1RA may not reduce the risk of stroke compared with placebo (OR 0.87, 95% CrI 0.75 to 1.0; moderate-certainty evidence), which showed similar odds estimates and wider 95% Crl compared with standard pairwise meta-analysis. Indirect estimates also supported comparison across all three classes. SGLT2i was ranked the best for CVD and all-cause mortality. AUTHORS' CONCLUSIONS Findings from both standard and network meta-analyses of moderate- to high-certainty evidence suggest that GLP-1RA and SGLT2i are likely to reduce the risk of CVD mortality and all-cause mortality in people with established CVD; high-certainty evidence demonstrates that treatment with SGLT2i reduce the risk of hospitalisation for HF, while moderate-certainty evidence likely supports the use of GLP-1RA to reduce fatal and non-fatal stroke. Future studies conducted in the non-diabetic CVD population will reveal the mechanisms behind how these agents improve clinical outcomes irrespective of their glucose-lowering effects.
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Affiliation(s)
- Takayoshi Kanie
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
| | - Atsushi Mizuno
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
- Penn Medicine Nudge Unit, University of Pennsylvania Philadelphia, Philadelphia, PA, USA
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Yoshimitsu Takaoka
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
| | - Takahiro Suzuki
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
| | - Daisuke Yoneoka
- Division of Biostatistics and Bioinformatics, Graduate School of Public Health, St. Luke's International University, Tokyo, Japan
| | - Yuri Nishikawa
- Department of Gerontological Nursing and Healthcare Systems Management, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan
- Department of Gerontological Nursing, Kyorin University, Tokyo, Japan
| | - Wilson Wai San Tam
- Alice Lee Center for Nursing Studies, NUS Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Jakub Morze
- Department of Human Nutrition, University of Warmia and Mazury, Olsztyn, Poland
| | - Andrzej Rynkiewicz
- Department of Cardiology and Cardiosurgery, School of Medicine, University of Warmia and Mazury, Olsztyn, Poland
| | - Yiqiao Xin
- Health Economics and Health Technology Assessment (HEHTA), Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Olivia Wu
- Health Economics and Health Technology Assessment (HEHTA), Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Rui Providencia
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Joey Sw Kwong
- Global Health Nursing, Graduate School of Nursing Science, St. Luke's International University, Tokyo, Japan
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Mohseni S, Tabatabaei-Malazy O, Peimani M, Ejtahed HS, Khodaeian M, Nazeri E, Nouhi Z, Khodamoradi K, Aboeerad M, Larijani B. Withdrawal reasons of randomized controlled trials on type 2 diabetes: a systematic review. Daru 2021; 29:39-50. [PMID: 33389690 PMCID: PMC8149490 DOI: 10.1007/s40199-020-00380-7] [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: 08/11/2020] [Accepted: 12/18/2020] [Indexed: 10/22/2022] Open
Abstract
PURPOSE Type 2 diabetes mellitus (T2DM) is the subject of numerous randomized controlled trials (RCTs). The validity of RCTs may be threatened by attrition bias due to the discontinuation of the study. The aim of this systematic review is to evaluate the reasons of patient's withdrawal from these RCTs. METHODS A systematic literature search on PubMed, Cochrane Library, Web of Science, and Scopus databases was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram. The aim was to obtain all relevant blinded RCTs published before January 2017 in which the effectiveness of synthetic drugs, vitamins/minerals were compared to that of placebo or active control in T2DM. The quality of RCTs was assessed using the Jadad score. The frequency of withdrawal reasons was presented based on treatments with placebo/active control, national/international level of the studies, and publication year. Meta-analysis was not performed due to the heterogeneity. RESULTS Overall, 1368 articles comprising of 640,780 subjects were included. In the majority of the RCTs (75.0%), the intervention and the placebo arms were compared. Most of the included studies (96%) were classified in the high-quality category (Jadad score≥3). The highest proportion of reported withdrawal cases was found in international studies, national RCTs conducted in Japan, and RCTs published in 2011. The withdrawal reasons were reported for 91,669 (63.75%) of the total 143,794 participants who had withdrawn from these studies. The main reported reasons were "adverse effects" (24.04%), "withdraw consent" (16.10%), and "missing data" (11.08%). Variations in the reported withdrawal reasons were based on the country or published year. RCTs with triple blinded design as well as those in which anti-hyperlipidemia and anti-obesity medications were applied, showed significantly higher probability of reported the withdrawal. CONCLUSION High proportion of reported discontinuation in blinded RCTs on patients with T2DM was related to drug adverse effects. Overall, the total number and reason of drop out were unsatisfactory.
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Affiliation(s)
- Shahrzad Mohseni
- Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ozra Tabatabaei-Malazy
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Peimani
- Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Hanieh-Sadat Ejtahed
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- Obesity and Eating Habits Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehrnoosh Khodaeian
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Elahe Nazeri
- Genetics Department, Breast Cancer Research Center, Motamed Cancer Institute, ACECR, Tehran, Iran
| | - Zahra Nouhi
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Kajal Khodamoradi
- Department of Urology, Miller School of Medicine, University of Miami, Miami, FL USA
| | - Maryam Aboeerad
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
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5
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Kadowaki T, Yamamoto F, Taneda Y, Naito Y, Clark D, Lund SS, Okamura T, Kaku K. Effects of anti-diabetes medications on cardiovascular and kidney outcomes in Asian patients with type 2 diabetes: a rapid evidence assessment and narrative synthesis. Expert Opin Drug Saf 2021; 20:707-720. [PMID: 33706621 DOI: 10.1080/14740338.2021.1898585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The cardiovascular and kidney safety of glucose-lowering drugs is a key concern in type 2 diabetes (T2D). We evaluated cardiorenal outcomes with glucose-lowering drugs in Asian patients, who comprise over half of T2D cases globally. RESEARCH DESIGN AND METHODS A rapid evidence assessment was conducted for phase III or IV, double-blind, randomized clinical trials of glucose-lowering drugs reporting cardiovascular or kidney outcomes for Asian T2D patients (Embase, Medline, Cochrane Library databases: 1 January 2008-14 June 2020). RESULTS Fifty-four publications reported exploratory data for Asians from 18 trials of dipeptidyl peptidase-4 (DPP-4) inhibitors, sodium-glucose co-transporter-2 (SGLT2) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, and insulin analogs. SGLT2 inhibitors and several GLP-1 receptor agonists were associated with reduced cardiovascular risk in Asian T2D patients, while DPP-4 inhibitors exhibited cardiovascular safety. SGLT2 inhibitors also appeared to reduce renal risk; however, kidney outcomes were lacking for DPP-4 inhibitors other than linagliptin and GLP-1 receptor agonists in Asian patients. Insulin data were inconclusive as the only trial conducted used different types of insulin as both treatment and comparator. CONCLUSIONS Cardiorenal outcomes with glucose-lowering drugs in Asian T2D patients were similar to outcomes in the overall multinational cohorts of these trials. DPP-4 inhibitors appear to demonstrate cardiovascular safety in Asians, while SGLT2 inhibitors and some GLP-1 receptor agonists may reduce cardiorenal and cardiovascular risk, respectively.
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Affiliation(s)
| | - Fumiko Yamamoto
- Medicine Division, Nippon Boehringer Ingelheim Co., Ltd, Tokyo, Japan
| | - Yusuke Taneda
- Medicine Division, Nippon Boehringer Ingelheim Co., Ltd, Tokyo, Japan
| | - Yusuke Naito
- Medicine Division, Nippon Boehringer Ingelheim Co., Ltd, Tokyo, Japan
| | - Douglas Clark
- TA CardioMetabolism Respiratory Med, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Søren S Lund
- TA CardioMetabolism Respiratory Med, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Tomoo Okamura
- Medicine Division, Nippon Boehringer Ingelheim Co., Ltd, Tokyo, Japan
| | - Kohei Kaku
- General Internal Medicine, Kawasaki Medical School, Okayama, Japan.,Faculty of Health and Welfare Services Management, Kawasaki University of Medical Welfare, Okayama, Japan
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Bergmark BA, Bhatt DL, McGuire DK, Cahn A, Mosenzon O, Steg PG, Im K, Kanevsky E, Gurmu Y, Raz I, Braunwald E, Scirica BM. Metformin Use and Clinical Outcomes Among Patients With Diabetes Mellitus With or Without Heart Failure or Kidney Dysfunction. Circulation 2019; 140:1004-1014. [DOI: 10.1161/circulationaha.119.040144] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Metformin is first-line therapy for type 2 diabetes mellitus, although its effects on the cardiovascular system are unproved.
Methods:
In this post hoc analysis, patients in SAVOR-TIMI 53 (Saxagliptin and Cardiovascular Outcomes in Patients With Type 2 Diabetes Mellitus) with baseline biomarker samples (n=12 156) were classified as ever versus never taking metformin during the trial period. Associations between metformin exposure and outcomes were estimated with inverse probability of treatment weighting Cox modeling for the composite end point of cardiovascular death, myocardial infarction, or ischemic stroke, as well as cardiovascular death and all-cause mortality, with biomarkers included as covariates. Additional sensitivity analyses included propensity score matching and Cox multivariable models.
Results:
Of the 12 156 patients with baseline biomarker samples, 8971 (74%) had metformin exposure, 1611 (13%) had prior heart failure, and 1332 (11%) had at least moderate chronic kidney disease (estimated glomerular filtration rate ≤45 mL·min
−1
·1.73 m
−2
). Metformin use was associated with no difference in risk for the composite end point (hazard ratio for inverse probability of treatment weighting, 0.92 [95% CI, 0.76–1.11]) but lower risk of all-cause mortality (hazard ratio for inverse probability of treatment weighting, 0.75 [95% CI, 0.59–0.95]). There was no significant relationship between metformin use and these end points in patients with prior heart failure or moderate to severe chronic kidney disease.
Conclusions:
In a cohort of 12 156 patients with type 2 diabetes mellitus and high cardiovascular risk, metformin use was associated with lower rates of all-cause mortality, including after adjustment for clinical variables and biomarkers, but not lower rates of the composite end point of cardiovascular death, myocardial infarction, or ischemic stroke. This association was most apparent in patients without prior heart failure or moderate to severe chronic kidney disease.
Clinical Trial Registration:
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT01107886.
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Affiliation(s)
- Brian A. Bergmark
- Thrombolysis in Myocardial Infarction (TIMI) Study Group (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Cardiovascular Division, Heart and Vascular Center (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Deepak L. Bhatt
- Thrombolysis in Myocardial Infarction (TIMI) Study Group (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Cardiovascular Division, Heart and Vascular Center (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Darren K. McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.)
| | - Avivit Cahn
- Diabetes Unit, Division of Internal Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Israel (A.C., O.M., I.R.)
| | - Ofri Mosenzon
- Diabetes Unit, Division of Internal Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Israel (A.C., O.M., I.R.)
| | - Ph. Gabriel Steg
- FACT (French Alliance for Cardiovascular Clinical Trials), Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation, Remodelling), Université de Paris, Sorbonne Paris-Cité, France (P.G.S.)
- Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (P.G.S.)
- INSERM U-1148, Paris, France (P.G.S.)
- National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London, UK (P.G.S.)
| | - KyungAh Im
- Thrombolysis in Myocardial Infarction (TIMI) Study Group (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Cardiovascular Division, Heart and Vascular Center (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Estella Kanevsky
- Thrombolysis in Myocardial Infarction (TIMI) Study Group (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Cardiovascular Division, Heart and Vascular Center (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Yared Gurmu
- Thrombolysis in Myocardial Infarction (TIMI) Study Group (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Cardiovascular Division, Heart and Vascular Center (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Itamar Raz
- Diabetes Unit, Division of Internal Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Israel (A.C., O.M., I.R.)
| | - Eugene Braunwald
- Thrombolysis in Myocardial Infarction (TIMI) Study Group (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Cardiovascular Division, Heart and Vascular Center (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Benjamin M. Scirica
- Thrombolysis in Myocardial Infarction (TIMI) Study Group (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Cardiovascular Division, Heart and Vascular Center (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
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7
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Hu Y. Advances in reducing cardiovascular risk in the management of patients with type 2 diabetes mellitus. Chronic Dis Transl Med 2019; 5:25-36. [PMID: 30993261 PMCID: PMC6449766 DOI: 10.1016/j.cdtm.2019.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Indexed: 12/25/2022] Open
Abstract
Treatment intended to lower cardiovascular (CV) risk in patients with diabetes has always been a primary goal of diabetes treatment. Due to the subdued effects of reducing hemoglobin A1c (HbA1c) on macrovascular complications, controlling other CV risk factors such as hypertension and hyperlipidemia instead of hyperglycemia has been the mainstay treatment to improve CV outcome in patients with type 2 diabetes mellitus (T2DM) until recent years. This review is intended to summarize and compare the results from the available cardiovascular outcome trials (CVOTs) for the two classes of glucose lowering drug: sodium-glucose co-transporter 2 inhibitor (SGLT2i) and glucagon-like peptide-1 receptor agonist (GLP-1 RA). The results including the EMPA-REG, CANVAS program and DECLARE-TIMI 58 trials for SGLT2i, and the ELIXA, LEADER, SUSTAIN-6, EXSCEL and HARMONY trials for GLP-1 RA were summarized. The potential mechanisms of these CV beneficial effects and the optimal CV risk reduction treatment in patients with T2DM based on patient risk stratification and evidence from these CVOTs in real-world setting were discussed.
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Affiliation(s)
- Ying Hu
- Department of Endocrinology, Lankenau Hospital, Main Line Health System, Wynnewood, PA 19096, USA
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8
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Zelniker TA, Morrow DA, Mosenzon O, Gurmu Y, Im K, Cahn A, Raz I, Steg PG, Leiter LA, Braunwald E, Bhatt DL, Scirica BM. Cardiac and Inflammatory Biomarkers Are Associated with Worsening Renal Outcomes in Patients with Type 2 Diabetes Mellitus: Observations from SAVOR-TIMI 53. Clin Chem 2019; 65:781-790. [PMID: 30988169 DOI: 10.1373/clinchem.2018.298489] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 02/12/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND Cardiac and renal diseases commonly occur with bidirectional interactions. We hypothesized that cardiac and inflammatory biomarkers may assist in identification of patients with type 2 diabetes mellitus (T2DM) at high risk of worsening renal function. METHODS In this exploratory analysis from SAVOR-TIMI 53, concentrations of high-sensitivity cardiac troponin T (hs-TnT), N-terminal pro-B-type natriuretic peptide (NT-proBNP), and high-sensitivity C-reactive protein (hs-CRP) were measured in baseline serum samples of 12310 patients. The primary end point for this analysis was a ≥40% decrease in estimated glomerular filtration rate (eGFR) at end of treatment (EOT) at a median of 2.1 years. The relationships between biomarkers and the end point were modeled using adjusted logistic and Cox regression. RESULTS After multivariable adjustment including baseline renal function, each biomarker was independently associated with an increased risk of ≥40% decrease in eGFR at EOT [Quartile (Q) Q4 vs Q1: hs-TnT adjusted odds ratio (OR), 5.63 (3.49-9.10); NT-proBNP adjusted OR, 3.53 (2.29-5.45); hs-CRP adjusted OR, 1.84 (95% CI, 1.27-2.68); all P values ≤0.001]. Furthermore, each biomarker was independently associated with higher risk of worsening of urinary albumin-to-creatinine ratio (UACR) category (all P values ≤0.002). Sensitivity analyses in patients without heart failure and eGFR >60 mL/min provided similar results. In an adjusted multimarker model, hs-TnT and NT-proBNP remained significantly associated with both renal outcomes (all P values <0.01). CONCLUSIONS hs-TnT, NT-proBNP, and hs-CRP were each associated with worsening of renal function [reduction in eGFR (≥40%) and deterioration in UACR class] in high-risk patients with T2DM. Patients with high cardiac or inflammatory biomarkers should be treated not only for their risk of cardiovascular outcomes but also followed for renal deterioration.
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Affiliation(s)
- Thomas A Zelniker
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - David A Morrow
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Ofri Mosenzon
- Diabetes Unit, Department of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Yared Gurmu
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Kyungah Im
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Avivit Cahn
- Diabetes Unit, Department of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Itamar Raz
- Diabetes Unit, Department of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Philippe Gabriel Steg
- Department of Cardiology, Hôpital Bichat, AP-HP, Paris, France.,FACT, DHU FIRE, Inserm U-1148, LVTS, Université Paris-Diderot, Paris, France.,Imperial College, Royal Brompton Hospital, London, UK
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Eugene Braunwald
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Deepak L Bhatt
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Benjamin M Scirica
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA;
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9
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Davis H, Jones Briscoe V, Dumbadze S, Davis SN. Using DPP-4 inhibitors to modulate beta cell function in type 1 diabetes and in the treatment of diabetic kidney disease. Expert Opin Investig Drugs 2019; 28:377-388. [PMID: 30848158 DOI: 10.1080/13543784.2019.1592156] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION DPP-4 inhibitors have pleomorphic effects that extend beyond the anti-hyperglycemic labeled use of the drug. DPP-4 inhibitors have demonstrated promising renal protective effects in T2DM and T1DM and protective effects against immune destruction of pancreatic beta-cells in T1DM. AREAS COVERED The efficacy of DPP-4 inhibitors in the treatment of diabetic kidney disease and possible adjunct with insulin in the treatment of T1DM to preserve beta-cell function. Pertinent literature was identified through Medline, PubMed and ClinicalTrials.gov (1997-November 2018) using the search terms T1DM, sitagliptin, vildagliptin, linagliptin, beta-cell function, diabetic nephropathy. Only articles are written in the English language, and clinical trials evaluating human subjects were used. EXPERT OPINION DPP-4 inhibitors can be used safely in patients with diabetic kidney disease and do not appear to exacerbate existing diabetic nephropathy. Linagliptin reduces albuminuria and protects renal endothelium from the deleterious effects of hyperglycemia. The effects of DPP-4 inhibitors on preserving beta-cell function in certain subtypes of T1DM [e.g. Latent Autoimmune Diabetes in Adult (LADA) and Slowly Progressive Type 1 Diabetes (SPIDDM)] are encouraging and show promise.
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10
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Gutierrez JA, Scirica BM, Bonaca MP, Steg PG, Mosenzon O, Hirshberg B, Im K, Raz I, Braunwald E, Bhatt DL. Prevalence and Outcomes of Polyvascular (Coronary, Peripheral, or Cerebrovascular) Disease in Patients With Diabetes Mellitus (From the SAVOR-TIMI 53 Trial). Am J Cardiol 2019; 123:145-152. [PMID: 30366601 DOI: 10.1016/j.amjcard.2018.09.014] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 09/21/2018] [Accepted: 09/24/2018] [Indexed: 12/18/2022]
Abstract
We sought to assess the prevalence of polyvascular disease in patients with type 2 diabetes mellitus (T2DM) and its impact on ischemic events. Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with Diabetes Mellitus (SAVOR)-Thrombolysis in Myocardial Infarction (TIMI) 53, a large contemporary, randomized trial, evaluated the effect of saxagliptin versus placebo in 16,492 patients with T2DM and a history of or at risk for cardiovascular (CV) events. Polyvascular disease was defined as a history of clinical events involving 2 or more vascular beds (coronary, peripheral, or cerebrovascular system) at the time of randomization. The primary composite endpoint of CV death, myocardial infarction, or ischemic stroke was compared according to the number of diseased arterial beds. At the time of randomization, 3,667 (22.2%) patients had risk factors for CV events; 11,423 (69.3%) had established 1 arterial bed disease; 1,298 (7.9%) had 2 bed disease; and 104 (0.6%) had 3 bed disease. Compared with diabetic patients with no established atherosclerosis, the adjusted hazard ratio for the composite primary end point in 1, 2, or 3 diseased beds was 1.95, 3.54, and 4.64, respectively (trend p < 0.0001). The adjusted risk for overall mortality increased in a similar stepwise fashion from 1.47 to 2.33 to 3.12, respectively (trend p = 0.0001) with each additional diseased arterial territory. In conclusion, in patients with confirmed atherosclerosis enrolled in SAVOR-TIMI 53, 11% had polyvascular disease; and compared with diabetic patients with single bed disease, the risk of ischemic events and overall mortality was substantially higher in patients with T2DM and polyvascular disease.
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Affiliation(s)
- Jorge Antonio Gutierrez
- Department of Cardiology, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina; Department of Cardiology, Durham Veterans Affairs Health System, Durham, North Carolina
| | - Benjamin M Scirica
- TIMI Study Group, Boston, Massachusetts; Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Marc P Bonaca
- TIMI Study Group, Boston, Massachusetts; Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Ph Gabriel Steg
- FACT (French Alliance for Cardiovascular Trials), Paris, F; INSERM Unité 1148, Université Paris-Diderot, and Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Ofri Mosenzon
- The Diabetes Unit, Department of Internal Medicine, Hadassah University Hospital, Jerusalem, Israel
| | | | - Kyungah Im
- TIMI Study Group, Boston, Massachusetts; Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Itamar Raz
- The Diabetes Unit, Department of Internal Medicine, Hadassah University Hospital, Jerusalem, Israel
| | - Eugene Braunwald
- TIMI Study Group, Boston, Massachusetts; Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Deepak L Bhatt
- TIMI Study Group, Boston, Massachusetts; Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
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11
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Psioda MA, Soukup M, Ibrahim JG. A practical Bayesian adaptive design incorporating data from historical controls. Stat Med 2018. [PMID: 30033617 DOI: 10.1002/sim.7897.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
In this paper, we develop the fixed-borrowing adaptive design, a Bayesian adaptive design which facilitates information borrowing from a historical trial using subject-level control data while assuring a reasonable upper bound on the maximum type I error rate and lower bound on the minimum power. First, one constructs an informative power prior from the historical data to be used for design and analysis of the new trial. At an interim analysis opportunity, one evaluates the degree of prior-data conflict. If there is too much conflict between the new trial data and the historical control data, the prior information is discarded and the study proceeds to the final analysis opportunity at which time a noninformative prior is used for analysis. Otherwise, the trial is stopped early and the informative power prior is used for analysis. Simulation studies are used to calibrate the early stopping rule. The proposed design methodology seamlessly accommodates covariates in the statistical model, which the authors argue is necessary to justify borrowing information from historical controls. Implementation of the proposed methodology is straightforward for many common data models, including linear regression models, generalized linear regression models, and proportional hazards models. We demonstrate the methodology to design a cardiovascular outcomes trial for a hypothetical new therapy for treatment of type 2 diabetes mellitus and borrow information from the SAVOR trial, one of the earliest cardiovascular outcomes trials designed to assess cardiovascular risk in antidiabetic therapies.
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Affiliation(s)
- Matthew A Psioda
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina
| | - Mat Soukup
- Division of Biometrics VII, Office of Biostatistics, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Joseph G Ibrahim
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina
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12
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Lo C, Toyama T, Wang Y, Lin J, Hirakawa Y, Jun M, Cass A, Hawley CM, Pilmore H, Badve SV, Perkovic V, Zoungas S. Insulin and glucose-lowering agents for treating people with diabetes and chronic kidney disease. Cochrane Database Syst Rev 2018; 9:CD011798. [PMID: 30246878 PMCID: PMC6513625 DOI: 10.1002/14651858.cd011798.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Diabetes is the commonest cause of chronic kidney disease (CKD). Both conditions commonly co-exist. Glucometabolic changes and concurrent dialysis in diabetes and CKD make glucose-lowering challenging, increasing the risk of hypoglycaemia. Glucose-lowering agents have been mainly studied in people with near-normal kidney function. It is important to characterise existing knowledge of glucose-lowering agents in CKD to guide treatment. OBJECTIVES To examine the efficacy and safety of insulin and other pharmacological interventions for lowering glucose levels in people with diabetes and CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 12 February 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA All randomised controlled trials (RCTs) and quasi-RCTs looking at head-to-head comparisons of active regimens of glucose-lowering therapy or active regimen compared with placebo/standard care in people with diabetes and CKD (estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2) were eligible. DATA COLLECTION AND ANALYSIS Four authors independently assessed study eligibility, risk of bias, and quality of data and performed data extraction. Continuous outcomes were expressed as post-treatment mean differences (MD). Adverse events were expressed as post-treatment absolute risk differences (RD). Dichotomous clinical outcomes were presented as risk ratios (RR) with 95% confidence intervals (CI). MAIN RESULTS Forty-four studies (128 records, 13,036 participants) were included. Nine studies compared sodium glucose co-transporter-2 (SGLT2) inhibitors to placebo; 13 studies compared dipeptidyl peptidase-4 (DPP-4) inhibitors to placebo; 2 studies compared glucagon-like peptide-1 (GLP-1) agonists to placebo; 8 studies compared glitazones to no glitazone treatment; 1 study compared glinide to no glinide treatment; and 4 studies compared different types, doses or modes of administration of insulin. In addition, 2 studies compared sitagliptin to glipizide; and 1 study compared each of sitagliptin to insulin, glitazars to pioglitazone, vildagliptin to sitagliptin, linagliptin to voglibose, and albiglutide to sitagliptin. Most studies had a high risk of bias due to funding and attrition bias, and an unclear risk of detection bias.Compared to placebo, SGLT2 inhibitors probably reduce HbA1c (7 studies, 1092 participants: MD -0.29%, -0.38 to -0.19 (-3.2 mmol/mol, -4.2 to -2.2); I2 = 0%), fasting blood glucose (FBG) (5 studies, 855 participants: MD -0.48 mmol/L, -0.78 to -0.19; I2 = 0%), systolic blood pressure (BP) (7 studies, 1198 participants: MD -4.68 mmHg, -6.69 to -2.68; I2 = 40%), diastolic BP (6 studies, 1142 participants: MD -1.72 mmHg, -2.77 to -0.66; I2 = 0%), heart failure (3 studies, 2519 participants: RR 0.59, 0.41 to 0.87; I2 = 0%), and hyperkalaemia (4 studies, 2788 participants: RR 0.58, 0.42 to 0.81; I2 = 0%); but probably increase genital infections (7 studies, 3086 participants: RR 2.50, 1.52 to 4.11; I2 = 0%), and creatinine (4 studies, 848 participants: MD 3.82 μmol/L, 1.45 to 6.19; I2 = 16%) (all effects of moderate certainty evidence). SGLT2 inhibitors may reduce weight (5 studies, 1029 participants: MD -1.41 kg, -1.8 to -1.02; I2 = 28%) and albuminuria (MD -8.14 mg/mmol creatinine, -14.51 to -1.77; I2 = 11%; low certainty evidence). SGLT2 inhibitors may have little or no effect on the risk of cardiovascular death, hypoglycaemia, acute kidney injury (AKI), and urinary tract infection (low certainty evidence). It is uncertain whether SGLT2 inhibitors have any effect on death, end-stage kidney disease (ESKD), hypovolaemia, fractures, diabetic ketoacidosis, or discontinuation due to adverse effects (very low certainty evidence).Compared to placebo, DPP-4 inhibitors may reduce HbA1c (7 studies, 867 participants: MD -0.62%, -0.85 to -0.39 (-6.8 mmol/mol, -9.3 to -4.3); I2 = 59%) but may have little or no effect on FBG (low certainty evidence). DPP-4 inhibitors probably have little or no effect on cardiovascular death (2 studies, 5897 participants: RR 0.93, 0.77 to 1.11; I2 = 0%) and weight (2 studies, 210 participants: MD 0.16 kg, -0.58 to 0.90; I2 = 29%; moderate certainty evidence). Compared to placebo, DPP-4 inhibitors may have little or no effect on heart failure, upper respiratory tract infections, and liver impairment (low certainty evidence). Compared to placebo, it is uncertain whether DPP-4 inhibitors have any effect on eGFR, hypoglycaemia, pancreatitis, pancreatic cancer, or discontinuation due to adverse effects (very low certainty evidence).Compared to placebo, GLP-1 agonists probably reduce HbA1c (7 studies, 867 participants: MD -0.53%, -1.01 to -0.06 (-5.8 mmol/mol, -11.0 to -0.7); I2 = 41%; moderate certainty evidence) and may reduce weight (low certainty evidence). GLP-1 agonists may have little or no effect on eGFR, hypoglycaemia, or discontinuation due to adverse effects (low certainty evidence). It is uncertain whether GLP-1 agonists reduce FBG, increase gastrointestinal symptoms, or affect the risk of pancreatitis (very low certainty evidence).Compared to placebo, it is uncertain whether glitazones have any effect on HbA1c, FBG, death, weight, and risk of hypoglycaemia (very low certainty evidence).Compared to glipizide, sitagliptin probably reduces hypoglycaemia (2 studies, 551 participants: RR 0.40, 0.23 to 0.69; I2 = 0%; moderate certainty evidence). Compared to glipizide, sitagliptin may have had little or no effect on HbA1c, FBG, weight, and eGFR (low certainty evidence). Compared to glipizide, it is uncertain if sitagliptin has any effect on death or discontinuation due to adverse effects (very low certainty).For types, dosages or modes of administration of insulin and other head-to-head comparisons only individual studies were available so no conclusions could be made. AUTHORS' CONCLUSIONS Evidence concerning the efficacy and safety of glucose-lowering agents in diabetes and CKD is limited. SGLT2 inhibitors and GLP-1 agonists are probably efficacious for glucose-lowering and DPP-4 inhibitors may be efficacious for glucose-lowering. Additionally, SGLT2 inhibitors probably reduce BP, heart failure, and hyperkalaemia but increase genital infections, and slightly increase creatinine. The safety profile for GLP-1 agonists is uncertain. No further conclusions could be made for the other classes of glucose-lowering agents including insulin. More high quality studies are required to help guide therapeutic choice for glucose-lowering in diabetes and CKD.
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Affiliation(s)
- Clement Lo
- Monash UniversityMonash Centre for Health Research and Implementation, School of Public Health and Preventive MedicineClaytonVICAustralia
- Monash HealthDiabetes and Vascular Medicine UnitClaytonVICAustralia
- Monash UniversityDivision of Metabolism, Ageing and Genomics, School of Public Health and Preventive MedicinePrahanVICAustralia
| | - Tadashi Toyama
- The George Institute for Global Health, UNSW SydneyRenal and Metabolic DivisionNewtownNSWAustralia2050
- Kanazawa University HospitalDivision of NephrologyKanazawaJapan
| | - Ying Wang
- The George Institute for Global Health, UNSW SydneyRenal and Metabolic DivisionNewtownNSWAustralia2050
| | - Jin Lin
- Beijing Friendship Hospital, Capital Medical UniversityDepartment of Critical Care Medicine95 Yong‐An Road, Xuan Wu DistrictBeijingChina100050
| | - Yoichiro Hirakawa
- The George Institute for Global Health, UNSW SydneyProfessorial UnitNewtownNSWAustralia
| | - Min Jun
- The George Institute for Global Health, UNSW SydneyRenal and Metabolic DivisionNewtownNSWAustralia2050
| | - Alan Cass
- Menzies School of Health ResearchPO Box 41096CasuarinaNTAustralia0811
| | - Carmel M Hawley
- Princess Alexandra HospitalDepartment of NephrologyIpswich RoadWoolloongabbaQLDAustralia4102
| | - Helen Pilmore
- Auckland HospitalDepartment of Renal MedicinePark RoadGraftonAucklandNew Zealand
- University of AucklandDepartment of MedicineGraftonNew Zealand
| | - Sunil V Badve
- St George HospitalDepartment of Renal MedicineKogarahNSWAustralia
| | - Vlado Perkovic
- The George Institute for Global Health, UNSW SydneyRenal and Metabolic DivisionNewtownNSWAustralia2050
| | - Sophia Zoungas
- Monash HealthDiabetes and Vascular Medicine UnitClaytonVICAustralia
- Monash UniversityDivision of Metabolism, Ageing and Genomics, School of Public Health and Preventive MedicinePrahanVICAustralia
- The George Institute for Global Health, UNSW SydneyProfessorial UnitNewtownNSWAustralia
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13
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Psioda MA, Soukup M, Ibrahim JG. A practical Bayesian adaptive design incorporating data from historical controls. Stat Med 2018; 37:4054-4070. [PMID: 30033617 DOI: 10.1002/sim.7897] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 05/24/2018] [Accepted: 06/13/2018] [Indexed: 12/12/2022]
Abstract
In this paper, we develop the fixed-borrowing adaptive design, a Bayesian adaptive design which facilitates information borrowing from a historical trial using subject-level control data while assuring a reasonable upper bound on the maximum type I error rate and lower bound on the minimum power. First, one constructs an informative power prior from the historical data to be used for design and analysis of the new trial. At an interim analysis opportunity, one evaluates the degree of prior-data conflict. If there is too much conflict between the new trial data and the historical control data, the prior information is discarded and the study proceeds to the final analysis opportunity at which time a noninformative prior is used for analysis. Otherwise, the trial is stopped early and the informative power prior is used for analysis. Simulation studies are used to calibrate the early stopping rule. The proposed design methodology seamlessly accommodates covariates in the statistical model, which the authors argue is necessary to justify borrowing information from historical controls. Implementation of the proposed methodology is straightforward for many common data models, including linear regression models, generalized linear regression models, and proportional hazards models. We demonstrate the methodology to design a cardiovascular outcomes trial for a hypothetical new therapy for treatment of type 2 diabetes mellitus and borrow information from the SAVOR trial, one of the earliest cardiovascular outcomes trials designed to assess cardiovascular risk in antidiabetic therapies.
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Affiliation(s)
- Matthew A Psioda
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina
| | - Mat Soukup
- Division of Biometrics VII, Office of Biostatistics, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Joseph G Ibrahim
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina
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14
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Bergmark BA, Scirica BM, Steg PG, Fanola CL, Gurmu Y, Mosenzon O, Cahn A, Raz I, Bhatt DL. Blood pressure and cardiovascular outcomes in patients with diabetes and high cardiovascular risk. Eur Heart J 2018; 39:2255-2262. [PMID: 29394350 PMCID: PMC6012971 DOI: 10.1093/eurheartj/ehx809] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 11/10/2017] [Accepted: 12/26/2017] [Indexed: 12/11/2022] Open
Abstract
Aims Optimal blood pressure for prevention of cardiovascular (CV) events in patients with Type 2 diabetes mellitus (T2DM) remains uncertain and there is concern for increased risk with low diastolic blood pressure (DBP). This study analysed the association between blood pressure and CV outcomes in high-risk patients with T2DM. Methods and results Patients with T2DM and elevated CV risk were enrolled in the Saxagliptin Assessment of Vascular Outcomes Recorded in patients with diabetes mellitus-Thrombolysis in Myocardial Infarction 53 trial. Cardiovascular outcomes were compared in the biomarker subgroup (n = 12 175) after stratification by baseline systolic blood pressure (SBP) and DBP. Adjusted risk was calculated by blood pressure stratum using clinical covariates plus N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity troponin-T (hsTnT). Trends were tested using linear and quadratic models. Adjusted risk of the composite endpoint of CV death, myocardial infarction (MI), or ischaemic stroke showed U-shaped relationships with baseline SBP and DBP (Pquadratic ≤ 0.01) with nadirs at SBP 130-140 or DBP 80-90 mmHg. Diastolic blood pressure <60 mmHg was associated with increased risk of MI (adjusted hazard ratio 2.30; 95% confidence interval 1.50-3.53) relative to DBP 80-90 mmHg. Adjusted odds of hsTnT concentration ≥14 ng/L showed U-shaped relationships with SBP and DBP (Pquadratic ≤ 0.01). The relationships between low DBP, elevated hsTnT, and increased MI remained after exclusion of patients with prior heart failure or NT-proBNP >median, suggesting that the relationship was not due to confounding from diagnosed or undiagnosed heart failure. Conclusions In patients with diabetes and elevated CV risk, even after extensive adjustment for underlying disease burden, there was a persistent association for low DBP with subclinical myocardial injury and risk of MI.
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Affiliation(s)
- Brian A Bergmark
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA, USA
| | - Benjamin M Scirica
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA, USA
| | - Ph Gabriel Steg
- FACT (French Alliance for Cardiovascular clinical Trials), Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation, Remodelling), Université Paris-Diderot, Sorbonne Paris-Cité, Paris, France
- Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France; INSERM, Paris, France
- National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London, UK
| | - Christina L Fanola
- Cardiovascular Division, Department of Medicine, University of Minnesota, 401 East River Road, Minneapolis, Minnesota, USA
| | - Yared Gurmu
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA, USA
| | - Ofri Mosenzon
- The Diabetes Unit, Internal Medicine Section, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Avivit Cahn
- The Diabetes Unit, Internal Medicine Section, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Itamar Raz
- The Diabetes Unit, Internal Medicine Section, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Deepak L Bhatt
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA, USA
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15
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Bergmark BA, Bhatt DL, Braunwald E, Morrow DA, Steg PG, Gurmu Y, Cahn A, Mosenzon O, Raz I, Bohula E, Scirica BM. Risk Assessment in Patients With Diabetes With the TIMI Risk Score for Atherothrombotic Disease. Diabetes Care 2018; 41:577-585. [PMID: 29196298 PMCID: PMC5829964 DOI: 10.2337/dc17-1736] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 11/07/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Improved risk assessment for patients with type 2 diabetes and elevated cardiovascular (CV) risk is needed. The Thrombolysis in Myocardial Infarction (TIMI) Risk Score for Secondary Prevention (TRS 2°P) predicts a gradient of risk in patients with prior myocardial infarction (MI) but has not been evaluated in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS CV event rates were compared by baseline TRS 2°P in 16,488 patients enrolled in SAVOR-TIMI 53 (Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with Diabetes Mellitus-Thrombolysis in Myocardial Infarction 53) with type 2 diabetes and high CV risk or established CV disease. Calibration was tested in the diabetes cohort from the REACH (REduction of Atherothrombosis for Continued Health) Registry. RESULTS TRS 2°P revealed a robust risk gradient for the composite of CV death, MI, and ischemic stroke in the full trial population, with 2-year event rates of 0.9% in the lowest- and 19.8% in the highest-risk groups (Ptrend < 0.001). A clear risk gradient was present within the subgroups of all coronary artery disease (CAD), CAD without prior MI, CAD with prior MI, peripheral artery disease, and prior stroke (Ptrend < 0.001 for each), with consistent risk relationships across subgroups. The C-statistic (0.71 for CV death and 0.66 for the composite end point) was consistent in each subgroup. There was close calibration with the type 2 diabetes cohort from the REACH Registry (goodness-of-fit P = 0.78). CONCLUSIONS The expanded TRS 2°P provides a practical and well-calibrated risk prediction tool for patients with type 2 diabetes.
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Affiliation(s)
- Brian A Bergmark
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Deepak L Bhatt
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Eugene Braunwald
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - David A Morrow
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Ph Gabriel Steg
- French Alliance for Cardiovascular Clinical Trials, Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation, Remodeling), Université Paris-Diderot, Sorbonne Paris-Cité, Paris, France.,Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France.,INSERM U-1148, Paris, France.,National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, London, U.K
| | - Yared Gurmu
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Avivit Cahn
- Diabetes Unit, Division of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Ofri Mosenzon
- Diabetes Unit, Division of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Itamar Raz
- Diabetes Unit, Division of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Erin Bohula
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Benjamin M Scirica
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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Scirica BM, Mosenzon O, Bhatt DL, Udell JA, Steg PG, McGuire DK, Im K, Kanevsky E, Stahre C, Sjöstrand M, Raz I, Braunwald E. Cardiovascular Outcomes According to Urinary Albumin and Kidney Disease in Patients With Type 2 Diabetes at High Cardiovascular Risk: Observations From the SAVOR-TIMI 53 Trial. JAMA Cardiol 2018; 3:155-163. [PMID: 29214305 PMCID: PMC6594440 DOI: 10.1001/jamacardio.2017.4228] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 09/21/2017] [Indexed: 12/22/2022]
Abstract
Importance An elevated level of urinary albumin to creatinine ratio (UACR) is a marker of renal dysfunction and predictor of kidney failure/death in patients with type 2 diabetes. The prognostic use of UACR in established cardiac biomarkers is not well described. Objective To evaluate whether UACR offers incremental prognostic benefit beyond risk factors and established plasma cardiovascular biomarkers. Design, Setting, and Participants The Saxagliptin Assessment of Vascular Outcomes Recorded in Patients With Diabetes Mellitus-Thrombolysis in Myocardial Infarction (SAVOR-TIMI) 53 study was performed from May 2010 to May 2013 and evaluated the safety of saxagliptin vs placebo in patients with type 2 diabetes with overt cardiovascular disease or multiple risk factors. Median follow-up was 2.1 years (interquartile range, 1.8-2.3 years). Interventions Patients were randomized to saxagliptin vs placebo plus standard care. Main Outcomes and Measures Baseline UACR was measured in 15 760 patients (95.6% of the trial population) and categorized into thresholds. Results Of 15 760 patients, 5205 were female (33.0%). The distribution of UARC categories were: 5805 patients (36.8%) less than 10 mg/g, 3891 patients (24.7%) at 10 to 30 mg/g, 4426 patients (28.1%) at 30 to 300 mg/g, and 1638 patients (10.4%) at more than 300 mg/g. When evaluated without cardiac biomarkers, there was a stepwise increase with each higher UACR category in the incidence of the primary composite end point (cardiovascular death, myocardial infarction, or ischemic stroke) (3.9%, 6.9%, 9.2%, and 14.3%); cardiovascular death (1.4%, 2.6%, 4.1%, and 6.9%); and hospitalization for heart failure (1.5%, 2.5%, 4.0%, and 8.3%) (adjusted P < .001 for trend). The net reclassification improvement at the event rate for each end point was 0.081 (95% CI, 0.025 to 0.161), 0.129 (95% CI, 0.029 to 0.202), and 0.056 (95% CI, -0.005 to 0.141), respectively. The stepwise increased cardiovascular risk associated with a UACR of more than 10 mg/g was also present within each chronic kidney disease category. The UACR was associated with outcomes after including cardiac biomarkers. However, the improvement in discrimination and reclassification was attenuated; net reclassification improvement at the event rate was 0.022 (95% CI, -0.022 to 0.067), -0.008 (-0.034 to 0.053), and 0.043 (-0.030 to 0.052) for the primary end point, cardiovascular death, and hospitalization for heart failure, respectively. Conclusions and Relevance In patients with type 2 diabetes, UACR was independently associated with increased risk for a spectrum of adverse cardiovascular outcomes. However, the incremental cardiovascular prognostic value of UACR was minimal when evaluated together with contemporary cardiac biomarkers. Trial Registration clinicaltrials.gov Identifier: NCT01107886.
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Affiliation(s)
- Benjamin M Scirica
- Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ofri Mosenzon
- Diabetes Unit, Division of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Deepak L Bhatt
- Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jacob A Udell
- Women's College Research Institute and Cardiovascular Division, Department of Medicine, Women's College Hospital, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Ph Gabriel Steg
- Département Hospitalo-Universitaire Fibrosis, Inflammation and REmodeling, INSERM U-1148, Université Paris-Diderot, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France
- National Heart and Lung Institute, Imperial College, Institute of Cardiovascular Medicine and Sciences, Royal Brompton Hospital, London, United Kingdom
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - KyungAh Im
- Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Estella Kanevsky
- Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | - Itamar Raz
- Diabetes Unit, Division of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Eugene Braunwald
- Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Wise RA, Chapman KR, Scirica BM, Schoenfeld DA, Bhatt DL, Daoud SZ, Seoane B, Reisner C, Garcia Gil E. Long-Term Evaluation of the Effects of Aclidinium Bromide on Major Adverse Cardiovascular Events and COPD Exacerbations in Patients with Moderate to Very Severe COPD: Rationale and Design of the ASCENT COPD Study. CHRONIC OBSTRUCTIVE PULMONARY DISEASES (MIAMI, FLA.) 2018; 5:5-15. [PMID: 29629400 PMCID: PMC5870740 DOI: 10.15326/jcopdf.5.1.2017.0149] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/25/2017] [Indexed: 01/21/2023]
Abstract
Introduction: Chronic obstructive pulmonary disease (COPD) is a heterogeneous illness characterized by persistent airflow obstruction and exacerbations. Patients typically experience a decline in lung function, increasingly impaired health-related quality of life, and high mortality. Poor lung function and exacerbations are associated with an increased risk of cardiovascular (CV) and cerebrovascular events, and approximately 30% of patients with COPD die from CV‑related disease. Treatment with inhaled long-acting bronchodilators, such as long-acting muscarinic antagonists (LAMAs), is recommended; however, some studies have suggested that LAMAs may increase the risk of CV events. As patients with CV and cerebrovascular conditions are often excluded from clinical trials, an evaluation of the safety of COPD treatments in an at-risk population is vital. Aclidinium bromide is a LAMA approved for the long-term maintenance treatment of COPD. Methods and Objectives: The Phase 4, multicenter, double-blind, randomized, placebo-controlled, parallel-group Aclidinium Bromide on Long-Term Cardiovascular Safety and COPD Exacerbations in PatieNTs with Moderate to Very Severe COPD (ASCENT COPD) study (NCT01966107) is being conducted at 500 sites in the United States and Canada. The primary objectives are to evaluate the long-term effects of twice-daily aclidinium bromide 400 µg on CV safety and exacerbations in patients with moderate to very severe COPD with a history of cerebrovascular, coronary, or peripheral artery disease, or the presence of ≥2 atherothrombotic risk factors. The primary safety and efficacy variables are time to first major adverse CV event (MACE) (on-study analysis) and rate of moderate to severe COPD exacerbations during the first year of treatment (on-treatment analysis), respectively. The study will be terminated after approximately 122 MACE have occurred.
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Affiliation(s)
- Robert A. Wise
- 1-Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Benjamin M. Scirica
- 3-Brigham and Women’s Hospital, Boston, Massachusetts
- 4-Harvard Medical School, Boston, Massachusetts
| | | | - Deepak L. Bhatt
- 3-Brigham and Women’s Hospital, Boston, Massachusetts
- 4-Harvard Medical School, Boston, Massachusetts
| | - Sami Z. Daoud
- 5-AstraZeneca Research &Development Center, Gaithersburg, Maryland
| | - Beatriz Seoane
- 6-AstraZeneca Research & Development Centre, Barcelona, Spain
| | - Colin Reisner
- 5-AstraZeneca Research &Development Center, Gaithersburg, Maryland
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Nauck MA, Meier JJ, Cavender MA, Abd El Aziz M, Drucker DJ. Cardiovascular Actions and Clinical Outcomes With Glucagon-Like Peptide-1 Receptor Agonists and Dipeptidyl Peptidase-4 Inhibitors. Circulation 2017; 136:849-870. [PMID: 28847797 DOI: 10.1161/circulationaha.117.028136] [Citation(s) in RCA: 354] [Impact Index Per Article: 50.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Potentiation of glucagon-like peptide-1 (GLP-1) action through selective GLP-1 receptor (GLP-1R) agonism or by prevention of enzymatic degradation by inhibition of dipeptidyl peptidase-4 (DPP-4) promotes glycemic reduction for the treatment of type 2 diabetes mellitus by glucose-dependent control of insulin and glucagon secretion. GLP-1R agonists also decelerate gastric emptying, reduce body weight by reduction of food intake and lower circulating lipoproteins, inflammation, and systolic blood pressure. Preclinical studies demonstrate that both GLP-1R agonists and DPP-4 inhibitors exhibit cardioprotective actions in animal models of myocardial ischemia and ventricular dysfunction through incompletely characterized mechanisms. The results of cardiovascular outcome trials in human subjects with type 2 diabetes mellitus and increased cardiovascular risk have demonstrated a cardiovascular benefit (significant reduction in time to first major adverse cardiovascular event) with the GLP-1R agonists liraglutide (LEADER trial [Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Ourcome Results], -13%) and semaglutide (SUSTAIN-6 trial [Trial to Evaluate Cardiovascular and Other Long-term Outcomes with Semaglutide], -24%). In contrast, cardiovascular outcome trials examining the safety of the shorter-acting GLP-1R agonist lixisenatide (ELIXA trial [Evaluation of Lixisenatide in Acute Coronary Syndrom]) and the DPP-4 inhibitors saxagliptin (SAVOR-TIMI 53 trial [Saxagliptin Assessment of Vascular Outcomes Recorded in Patients With Diabetes Mellitus-Thrombolysis in Myocardial Infarction 53]), alogliptin (EXAMINE trial [Examination of Cardiovascular Outcomes With Alogliptin Versus Standard of Care in Patients With Type 2 Diabetes Mellitus and Acute Coronary Syndrome]), and sitagliptin (TECOS [Trial Evaluating Cardiovascular Outcomes With Sitagliptin]) found that these agents neither increased nor decreased cardiovascular events. Here we review the cardiovascular actions of GLP-1R agonists and DPP-4 inhibitors, with a focus on the translation of mechanisms derived from preclinical studies to complementary findings in clinical studies. We highlight areas of uncertainty requiring more careful scrutiny in ongoing basic science and clinical studies. As newer more potent GLP-1R agonists and coagonists are being developed for the treatment of type 2 diabetes mellitus, obesity, and nonalcoholic steatohepatitis, the delineation of the potential mechanisms that underlie the cardiovascular benefit and safety of these agents have immediate relevance for the prevention and treatment of cardiovascular disease.
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Affiliation(s)
- Michael A Nauck
- From Diabetes Center Bochum-Hattingen, St Josef-Hospital, Ruhr-University Bochum, Germany (M.A.N., J.J.M., M.A.E.A.); Department of Medicine, University of North Carolina, Chapel Hill (M.A.C.); and Department of Medicine, Lunenfeld-Tanenbaum Research Institute, Mt Sinai Hospital, University of Toronto, Ontario, Canada (D.J.D.).
| | - Juris J Meier
- From Diabetes Center Bochum-Hattingen, St Josef-Hospital, Ruhr-University Bochum, Germany (M.A.N., J.J.M., M.A.E.A.); Department of Medicine, University of North Carolina, Chapel Hill (M.A.C.); and Department of Medicine, Lunenfeld-Tanenbaum Research Institute, Mt Sinai Hospital, University of Toronto, Ontario, Canada (D.J.D.)
| | - Matthew A Cavender
- From Diabetes Center Bochum-Hattingen, St Josef-Hospital, Ruhr-University Bochum, Germany (M.A.N., J.J.M., M.A.E.A.); Department of Medicine, University of North Carolina, Chapel Hill (M.A.C.); and Department of Medicine, Lunenfeld-Tanenbaum Research Institute, Mt Sinai Hospital, University of Toronto, Ontario, Canada (D.J.D.)
| | - Mirna Abd El Aziz
- From Diabetes Center Bochum-Hattingen, St Josef-Hospital, Ruhr-University Bochum, Germany (M.A.N., J.J.M., M.A.E.A.); Department of Medicine, University of North Carolina, Chapel Hill (M.A.C.); and Department of Medicine, Lunenfeld-Tanenbaum Research Institute, Mt Sinai Hospital, University of Toronto, Ontario, Canada (D.J.D.)
| | - Daniel J Drucker
- From Diabetes Center Bochum-Hattingen, St Josef-Hospital, Ruhr-University Bochum, Germany (M.A.N., J.J.M., M.A.E.A.); Department of Medicine, University of North Carolina, Chapel Hill (M.A.C.); and Department of Medicine, Lunenfeld-Tanenbaum Research Institute, Mt Sinai Hospital, University of Toronto, Ontario, Canada (D.J.D.)
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Briggs AH, Bhatt DL, Scirica BM, Raz I, Johnston KM, Szabo SM, Bergenheim K, Mukherjee J, Hirshberg B, Mosenzon O. Health-related quality-of-life implications of cardiovascular events in individuals with type 2 diabetes mellitus: A subanalysis from the Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with Diabetes Mellitus (SAVOR)-TIMI 53 trial. Diabetes Res Clin Pract 2017; 130:24-33. [PMID: 28554140 DOI: 10.1016/j.diabres.2016.12.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 12/10/2016] [Accepted: 12/29/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND The impact of cardiovascular complications on health-related quality-of-life (HRQoL) in type 2 diabetes mellitus has not been clearly established. Using EQ5D utility data from SAVOR-TIMI 53, a large phase IV trial of saxagliptin versus placebo, we quantified the impact of cardiovascular and other major events on HRQoL. METHODS EQ5D utilities were recorded annually and following myocardial infarction (MI) or stroke. Utilities among patients experiencing major cardiovascular events were analyzed using linear mixed-effects regression, adjusting for baseline characteristics (including EQ5D utility), and compared to those not experiencing major cardiovascular events. Mean utility decrements with standard errors (SE) were estimated as the difference in utility before and after the event. FINDINGS The mean EQ5D utility of the sample was 0.776 at all time points, and did not differ by treatment. However, mean baseline and month 12 utilities among those with a major cardiovascular event were 0.751 and 0.714. Mean utilities were 0.691 within 3months of, 0.691 3-6months after, and 0.714 6-12months after, a major cardiovascular event. Cardiovascular event-specific utility decrements were 0.05 (0.007) for major cardiovascular events over the same time periods. Decrements of 0.051 (0.012; myocardial infarction), 0.111 (0.022; stroke), 0.065 (0.014; hospitalization for heart failure) 0.019 (0.024; hospitalization for hypoglycemia) were estimated; all coefficients were statistically significant. INTERPRETATION Consistent with clinical outcomes reported elsewhere, saxagliptin did not improve HRQoL. Cardiovascular complications were associated with significantly decreased HRQoL, most substantial earlier after the event. FUNDING BMS/AZ.
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Affiliation(s)
- Andrew H Briggs
- Health Economics & Health Technology Assessment, Institute of Health & Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow G12 8RZ, United Kingdom.
| | - Deepak L Bhatt
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Benjamin M Scirica
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Itamar Raz
- Diabetes Unit, Hadassah Hebrew University Hospital, PO Box 12000, Jerusalem 91120, Israel
| | - Karissa M Johnston
- Broad Street Health Economics & Outcomes Research, 4016 Glen Dr, Vancouver V5V 4T3, Canada
| | - Shelagh M Szabo
- Broad Street Health Economics & Outcomes Research, 4016 Glen Dr, Vancouver V5V 4T3, Canada
| | | | - Jayanti Mukherjee
- Bristol-Myers Squibb, 5 Research Parkway, Wallingford, CT 06492, USA
| | - Boaz Hirshberg
- MedImmune, One Medimmune Way, Gaithersburg, MD, 20878, USA
| | - Ofri Mosenzon
- Diabetes Unit, Hadassah Hebrew University Hospital, PO Box 12000, Jerusalem 91120, Israel
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Zhang Z, Chen X, Lu P, Zhang J, Xu Y, He W, Li M, Zhang S, Jia J, Shao S, Xie J, Yang Y, Yu X. Incretin-based agents in type 2 diabetic patients at cardiovascular risk: compare the effect of GLP-1 agonists and DPP-4 inhibitors on cardiovascular and pancreatic outcomes. Cardiovasc Diabetol 2017; 16:31. [PMID: 28249585 PMCID: PMC5333444 DOI: 10.1186/s12933-017-0512-z] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 02/21/2017] [Indexed: 02/06/2023] Open
Abstract
Background Incretin-based agents, including dipeptidyl peptidase-4 inhibitors (DPP-4Is) and glucagon-like peptide-1 agonists (GLP-1As), work via GLP-1 receptor for hyperglycemic control directly or indirectly, but have different effect on cardiovascular (CV) outcomes. The present study is to evaluate and compare effects of incretin-based agents on CV and pancreatic outcomes in patients with type 2 diabetes mellitus (T2DM) and high CV risk. Methods Six prospective randomized controlled trials (EXMAINE, SAVOR-TIMI53, TECOS, ELIXA, LEADER and SUSTAIN-6), which included three trials for DPP-4Is and three trials for GLP-1As, with 55,248 participants were selected to assess the effect of different categories of incretin-based agents on death, CV outcomes (CV mortality, major adverse CV events, nonfatal myocardial infarction, nonfatal stroke, heart failure hospitalization), pancreatic events (acute pancreatitis and pancreatic cancer) as well as on hypoglycemia. Results When we evaluated the combined effect of six trials, the results suggested that incretin-based treatment had no significant effect on overall risks of CV and pancreatic outcomes compared with placebo. However, GLP-1As reduced all-cause death (RR = 0.90, 95% CI 0.82–0.98) and CV mortality (RR = 0.84, 95% CI 0.73–0.97), whereas DPP-4Is had no significant effect on CV outcomes but elevated the risk for acute pancreatitis (OR = 1.76, 95% CI 1.14–2.72) and hypoglycemia (both any and severe hypoglycemia), while GLP-1As lowered the risk of severe hypoglycemia. Conclusions GLP-1As decreased risks of all-cause and CV mortality and severe hypoglycemia, whereas DPP-4Is had no effect on CV outcomes but increased risks in acute pancreatitis and hypoglycemia. Electronic supplementary material The online version of this article (doi:10.1186/s12933-017-0512-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Zeqing Zhang
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, People's Republic of China
| | - Xi Chen
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, People's Republic of China
| | - Puhan Lu
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, People's Republic of China
| | - Jianhua Zhang
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, People's Republic of China
| | - Yongping Xu
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, People's Republic of China
| | - Wentao He
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, People's Republic of China
| | - Mengni Li
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, People's Republic of China
| | - Shujun Zhang
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, People's Republic of China
| | - Jing Jia
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, People's Republic of China
| | - Shiying Shao
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, People's Republic of China
| | - Junhui Xie
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, People's Republic of China
| | - Yan Yang
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, People's Republic of China
| | - Xuefeng Yu
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, People's Republic of China.
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Secrest MH, Udell JA, Filion KB. The cardiovascular safety trials of DPP-4 inhibitors, GLP-1 agonists, and SGLT2 inhibitors. Trends Cardiovasc Med 2017; 27:194-202. [PMID: 28291655 DOI: 10.1016/j.tcm.2017.01.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 01/26/2017] [Accepted: 01/27/2017] [Indexed: 01/22/2023]
Abstract
In this paper, we review the results of large, double-blind, placebo-controlled randomized trials mandated by the US Food and Drug Administration to examine the cardiovascular safety of newly-approved antihyperglycemic agents in patients with type 2 diabetes. The cardiovascular effects of dipeptidyl peptidase-4 (DPP-4) inhibitors remain controversial: while these drugs did not reduce or increase the risk of primary, pre-specified composite cardiovascular outcomes, one DPP-4 inhibitor (saxagliptin) increased the risk of hospitalization for heart failure in the overall population; another (alogliptin) demonstrated inconsistent effects on heart failure hospitalization across subgroups of patients, and a third (sitagliptin) demonstrated no effect on heart failure. Evidence for cardiovascular benefits of glucagon-like peptide-1 (GLP-1) agonists has been similarly heterogeneous, with liraglutide and semaglutide reducing the risk of composite cardiovascular outcomes, but lixisenatide having no reduction or increase in cardiovascular risk. The effect of GLP-1 agonists on retinopathy remains a potential concern. In the only completed trial to date to assess a sodium-glucose cotransporter-2 (SGLT2) inhibitor, empagliflozin reduced the risk of composite cardiovascular endpoints, predominantly through its impact on cardiovascular mortality and heart failure hospitalization.
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Affiliation(s)
- Matthew H Secrest
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
| | - Jacob A Udell
- Women's College Research Institute, Department of Medicine, Women's College Hospital, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kristian B Filion
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada; Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada; Division of Clinical Epidemiology, Department of Medicine, McGill University, Montreal, Quebec, Canada.
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Cebrián-Cuenca AM, Orozco-Beltrán D, Navarro-Pérez J, Franch-Nadal J, Núñez-Villota J, Consuegra-Sánchez L. Saxagliptin and risk of heart failure hospitalization: Concern or miscalculation? Int J Cardiol 2016; 220:573-4. [DOI: 10.1016/j.ijcard.2016.06.269] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 06/27/2016] [Indexed: 10/21/2022]
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Cahn A, Raz I, Mosenzon O, Leibowitz G, Yanuv I, Rozenberg A, Iqbal N, Hirshberg B, Sjostrand M, Stahre C, Im K, Kanevsky E, Scirica BM, Bhatt DL, Braunwald E. Predisposing Factors for Any and Major Hypoglycemia With Saxagliptin Versus Placebo and Overall: Analysis From the SAVOR-TIMI 53 Trial. Diabetes Care 2016; 39:1329-37. [PMID: 27222508 DOI: 10.2337/dc15-2763] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 04/29/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To analyze the impact of adding saxagliptin versus placebo on the risk for hypoglycemia and to identify predictors of any and major hypoglycemia in patients with type 2 diabetes included in the Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with Diabetes Mellitus-Thrombolysis in Myocardial Infarction 53 (SAVOR-TIMI 53) study. RESEARCH DESIGN AND METHODS Patients with type 2 diabetes (n = 16,492) were randomized to saxagliptin or placebo and followed for a median of 2.1 years. Associations between any hypoglycemia (symptomatic or glucose measurement <54 mg/dL) or major hypoglycemia (requiring extended assistance) and patient characteristics overall and by treatment allocation were studied. RESULTS At least one hypoglycemic event was reported in 16.6% of patients, and 1.9% reported at least one major event. Patients allocated to saxagliptin versus placebo experienced higher rates of any (hazard ratio [HR] 1.16 [95% CI 1.08, 1.25]; P < 0.001) or major (HR 1.26 [1.01, 1.58]; P = 0.038) hypoglycemia. Hypoglycemia rates (any or major) were increased with saxagliptin in patients taking sulfonylureas (SURs) but not in those taking insulin. Rates were increased with saxagliptin in those with baseline HbA1c ≤7.0% and not in those with baseline HbA1c >7.0%. Multivariate analysis of the overall population revealed that independent predictors of any hypoglycemia were as follows: allocation to saxagliptin, long duration of diabetes, increased updated HbA1c, macroalbuminuria, moderate renal failure, SUR use, and insulin use. Predictors of major hypoglycemia were allocation to saxagliptin, advanced age, black race, reduced BMI, long duration of diabetes, declining renal function, microalbuminuria, and use of short-acting insulin. Among SURs, glibenclamide was associated with increased risk of major but not any hypoglycemia. CONCLUSIONS The identification of patients at risk for hypoglycemia can guide physicians to better tailor antidiabetic therapy.
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Affiliation(s)
- Avivit Cahn
- Diabetes Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel Endocrinology and Metabolism Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Itamar Raz
- Diabetes Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Ofri Mosenzon
- Diabetes Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Gil Leibowitz
- Diabetes Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel Endocrinology and Metabolism Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Ilan Yanuv
- Diabetes Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Aliza Rozenberg
- Diabetes Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Nayyar Iqbal
- AstraZeneca Research and Development, Gaithersburg, MD
| | | | | | | | - KyungAh Im
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Estella Kanevsky
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Benjamin M Scirica
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Deepak L Bhatt
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Eugene Braunwald
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Hoogwerf BJ, Manner DH, Fu H, Moscarelli E, Gaydos BL, Heine RJ. Perspectives on Some Controversies in Cardiovascular Disease Risk Assessment in the Pharmaceutical Development of Glucose-Lowering Medications. Diabetes Care 2016; 39 Suppl 2:S219-27. [PMID: 27440836 DOI: 10.2337/dcs15-3025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The U.S. Food and Drug Administration (FDA) issued guidance on requirements to assess cardiovascular disease (CVD) risk with drugs being developed for approval for clinical use. The guidance was triggered by a meta-analysis published by Nissen and Wolski that suggested an increased risk for myocardial infarction with the use of rosiglitazone. This article discusses controversies around CVD trials in diabetes beginning with the University Group Diabetes Program. This is followed by a brief description of the FDA guidance for evaluating CVD risk with glucose-lowering medications. Limitations of meta-analyses of data from phase 2 and 3 (phase 2/3) trials to inform CVD risk are highlighted. These include the differences between patient characteristics in phase 2/3 trials and those in cardiovascular outcome trials (CVOTs) and the relatively short exposure time in phase 2/3 trials. The differences may partly explain the observed disparity between phase 2/3 meta-analyses and the results of completed CVOTs. Approaches to understanding CVD risk with a new medication should get to the answer about risk as efficiently as possible to minimize any potential harm to patients. In that context, we discuss options for clinical trial design and an alternative approach for statistical analyses.
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Affiliation(s)
| | | | - Haoda Fu
- Eli Lilly and Company, Indianapolis, IN
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John M, Gopalakrishnan Unnikrishnan A, Kalra S, Nair T. Cardiovascular outcome trials for anti-diabetes medication: A holy grail of drug development? Indian Heart J 2016; 68:564-71. [PMID: 27543483 PMCID: PMC4990725 DOI: 10.1016/j.ihj.2016.02.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 01/28/2016] [Accepted: 02/15/2016] [Indexed: 01/21/2023] Open
Abstract
Since the time questions arose on cardiovascular safety of Rosiglitazone, FDA has suggested guidelines on conduct of studies on anti-diabetic drugs so as to prove that the cardiovascular risk is acceptable. Based on the cardiovascular risks of pre-approval clinical trials, guidelines have been made to conduct cardiovascular safety outcome trials (CVSOTs) prior to the drug approval or after the drug has been approved. Unlike the trials comparing the efficacy of antidiabetic agents, the CVSOTs examine the cardiovascular safety of a drug in comparison to standard of care. These trials are expensive aspects of drug development and are associated with various technical and operational challenges. More cost effective models of assessing cardiovascular safety like use of biomarkers, electronic medical records, pragmatic and factorial designs can be adopted. This article critically looks at the antidiabetic drug approval from a cardiovascular perspective by asking a few questions and arriving at answers.
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Affiliation(s)
- Mathew John
- Consultant Endocrinologist, Department of Endocrinology and Diabetes, Providence Endocrine and Diabetes Specialty Centre, TC 1/2138, Murinjapalam, Trivandrum 695011, India.
| | | | - Sanjay Kalra
- Endocrinologist, Bharti Hospital and B.R.I.D.E., Karnal, Haryana 132001, India.
| | - Tiny Nair
- Head, Department of Cardiology, PRS Hospital, Trivandrum, Kerala 695012, India.
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Sharma A, Bhatt DL, Calvo G, Brown NJ, Zannad F, Mentz RJ. Heart failure event definitions in drug trials in patients with type 2 diabetes. Lancet Diabetes Endocrinol 2016; 4:294-6. [PMID: 27016320 PMCID: PMC5221765 DOI: 10.1016/s2213-8587(16)00049-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 02/04/2016] [Accepted: 02/04/2016] [Indexed: 01/06/2023]
Affiliation(s)
- Abhinav Sharma
- Duke Clinical Research Institute, Duke University, Durham, NC, USA; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada.
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Gonzalo Calvo
- Hospital Clinic de Barcelona, Institut D'Investigacion Agusti Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Nancy J Brown
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Faiez Zannad
- Hypertension and Preventive Cardiology Division, Department of Cardiovascular Disease, Centre d'Investigations Cliniques, Hopital Jeanne d'Arc, Nancy, France
| | - Robert J Mentz
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
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Abstract
INTRODUCTION The safety of agents used to treat type 2 diabetes (T2D), a chronic disease requiring life-long intervention, is of particular interest. Saxagliptin is a potent and selective DPP-4 inhibitor that has emerged as a therapeutic option for T2D. AREAS COVERED Its safety was assessed in a development program of 20 phase 2/3 randomized clinical trials and in SAVOR-TIMI 53 trial that evaluated the cardiovascular outcomes. In order to capture any further safety signals, mainly in the long-term, a post-marketing safety surveillance is ongoing. This paper discusses the tolerability and safety profile of the agent, including cardiovascular, renal, pancreatic, hepatic and bone adverse events. EXPERT OPINION Saxagliptin is a safe therapeutic option for patients with T2D, with low risk of hypoglycemia and good tolerability. It demonstrated cardiovascular safety (including in patients with pre-existing cardiovascular disease and/or HF) and safety with respect to all-cause mortality and adverse events of special interest. In SAVOR-TIMI53, saxagliptin was associated with an unexpected increased risk of HF hospitalization, mainly in the first 12 months; a mechanistic explanation for this has not been found. Further research needs to elucidate the effect of antidiabetic drugs on the heart, by including biomarkers and echocardiographic sub-studies within large outcome trials.
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Affiliation(s)
- Simona Cernea
- a Department M3/Internal Medicine IV , University of Medicine and Pharmacy , Târgu Mureş , Romania.,b Diabetes, Nutrition and Metabolic Diseases , Emergency County Clinical Hospital , Târgu Mureş , Romania
| | - Avivit Cahn
- c Diabetes Unit, Department of Internal Medicine , Hadassah Hebrew University Hospital , Jerusalem , Israel
| | - Itamar Raz
- c Diabetes Unit, Department of Internal Medicine , Hadassah Hebrew University Hospital , Jerusalem , Israel
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Cavender MA, Scirica BM, Raz I, Steg PG, McGuire DK, Leiter LA, Hirshberg B, Davidson J, Cahn A, Mosenzon O, Im K, Braunwald E, Bhatt DL. Cardiovascular Outcomes of Patients in SAVOR-TIMI 53 by Baseline Hemoglobin A1c. Am J Med 2016; 129:340.e1-8. [PMID: 26524706 DOI: 10.1016/j.amjmed.2015.09.022] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Revised: 09/26/2015] [Accepted: 09/28/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND The effect of saxagliptin on cardiovascular outcomes according to different hemoglobin A1c (HbA1c) levels has not been described. Thus, we analyzed the SAVOR-TIMI 53 trial to compare the cardiovascular effects of saxagliptin vs placebo according to baseline HbA1c. METHODS A total of 16,492 patients with type 2 diabetes (HbA1c 6.5%-12.0% in the 6 months before randomization) and either a history of established cardiovascular disease or multiple risk factors for atherosclerosis were randomized to saxagliptin or placebo in addition to usual care. Patients were followed for a median of 2.1 years. The primary endpoint was cardiovascular death, myocardial infarction, or ischemic stroke. RESULTS Patients were stratified by HbA1c at randomization into the following prespecified groups: <7%, 7%-<8%, 8%-<9%, and ≥9%. Baseline HbA1c ≥7% was associated with increased risk of cardiovascular death, myocardial infarction, or ischemic stroke (adjusted hazard ratio [HR(adj)] 1.35; 95% confidence interval [CI], 1.17-1.58) but not hospitalization for heart failure (HR(adj) 1.09; 95% CI, 0.88-1.36). Saxagliptin neither increased nor decreased the risk of cardiovascular death, myocardial infarction, or ischemic stroke in patients with HbA1c <7% (HR 1.01; 95% CI, 0.78-1.31), 7%-<8% (HR 0.98; 95% CI, 0.80-1.20), 8%-<9% (HR 1.09; 95% CI, 0.85-1.39), ≥9% (HR 0.95; 95% CI, 0.77-1.18) (P-interaction = .89). CONCLUSIONS Baseline HbA1c is associated with increased risk of macrovascular events but not hospitalization for heart failure. There was no heterogeneity in the effect of saxagliptin on cardiovascular events by baseline HbA1c, with cardiovascular death, myocardial infarction, or ischemic stroke neither increased nor decreased across the spectrum of baseline HbA1c values.
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Affiliation(s)
- Matthew A Cavender
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Heart and Vascular Center, Brigham and Women's Hospital, and Harvard Medical School, Boston, Mass
| | - Benjamin M Scirica
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Heart and Vascular Center, Brigham and Women's Hospital, and Harvard Medical School, Boston, Mass
| | - Itamar Raz
- Diabetes Unit, Department of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Ph Gabriel Steg
- FACT, DHU FIRE, Université Paris-Diderot, Sorbonne Paris-Cité, LVTS INSERM U-1148, Hôpital Bichat, HUPNVS, AP-HP, Paris, France; NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Lawrence A Leiter
- Division of Endocrinology and Metabolism, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, ON, Canada
| | | | - Jaime Davidson
- Touchstone Diabetes Center, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Avivit Cahn
- Diabetes Unit, Department of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Ofri Mosenzon
- Diabetes Unit, Department of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - KyungAh Im
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Heart and Vascular Center, Brigham and Women's Hospital, and Harvard Medical School, Boston, Mass
| | - Eugene Braunwald
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Heart and Vascular Center, Brigham and Women's Hospital, and Harvard Medical School, Boston, Mass
| | - Deepak L Bhatt
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Heart and Vascular Center, Brigham and Women's Hospital, and Harvard Medical School, Boston, Mass.
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Ghosal S, Sinha B. Gliptins and Cardiovascular Outcomes: A Comparative and Critical Analysis after TECOS. J Diabetes Res 2016; 2016:1643496. [PMID: 26649315 PMCID: PMC4663001 DOI: 10.1155/2016/1643496] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Accepted: 08/19/2015] [Indexed: 12/30/2022] Open
Abstract
The issue related to macrovascular outcomes and intensive glycemic control was hotly debated after the publication of landmark trials like ACCORD, ADVANCE, and VADT. The only benefits seem to come from intervening early on in the disease process as indicated by the 10-year UKPDS follow-up. To complicate matters USFDA made it mandatory for modern drugs to conduct cardiovascular safety trials in high-risk populations after the 2008 rosiglitazone scare. This led to all the modern group of drugs designing cardiovascular safety trials (gliptins, GLP-1 agonists, and SGLT-2 inhibitors) to meet USFDA regulatory requirements. We saw publication of the first 2 randomized trials with gliptins published a year and a half back. On the face value SAVOR TIMI and EXAMINE satisfied the primary composite CV end-points. However, issues related to significant increase in heart failure and all-cause 7-day on-treatment mortality created a lot of confusion. FDA reanalysis of these data (especially SAVOR) raises a lot of doubts as far as CV safety of these groups of drugs was concerned. Hence, all eyes were on TECOS, which was published this year. We take a microscopic look at these trials trying to understand where we stand as from now on this issue.
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Affiliation(s)
- Samit Ghosal
- Nightingale Hospital, 11 Shakespeare Sarani, Kolkata, India
- *Samit Ghosal:
| | - Binayak Sinha
- AMRI Hospitals, JC-16/17, Salt Lake City, Kolkata 700091, India
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Li D, Xu X, Zhang Y, Zhu J, Ye L, Lee KO, Ma J. Liraglutide treatment causes upregulation of adiponectin and downregulation of resistin in Chinese type 2 diabetes. Diabetes Res Clin Pract 2015; 110:224-8. [PMID: 26376464 DOI: 10.1016/j.diabres.2015.05.051] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 05/13/2015] [Accepted: 05/28/2015] [Indexed: 01/02/2023]
Abstract
AIMS To assess the effect of 16 weeks of liraglutide administration on the plasma levels of adiponectin and resistin in Chinese patients diagnosed with type 2 diabetes mellitus (T2DM). METHODS Forty-four subjects were recruited and randomly assigned to once-a-day dosage of either liraglutide, or glimepiride (4 mg) in a double-blinded double-dummy active-controlled study. All treatments were administered in combination with metformin (1 g, twice daily). The efficacy of liraglutide was estimated by measuring and comparing the levels of HbA1c, adiponectin and resistin in the plasma before and after the 16-week treatment. RESULTS The plasma level of adiponectin was significantly increased (0.74±0.19 ng/ml, p<0.05) and resistin was significantly lowered (-1.34±0.34 pg/ml, p<0.05) in a dose-dependent manner in the liraglutide group when compared with the glimepiride group (-0.44±0.09 ng/ml of adiponectin and 0.14±0.41 pg/ml of resistin). In contrast, we found no differences in the decrease in HbA1c between the two groups (8.3±1.2% to 7.2±1.1% in NGSP units vs. 8.3±1.0% to 7.3±1.2% in NGSP units; 67±13 mmol/mol to 55±12 mmol/mol vs. 67±11 mmol/mol to 56±13 mmol/mol in IFCC units). CONCLUSIONS In Chinese T2DM patients, liraglutide treatment led to increased adiponectin and decreased resistin levels compared to glimepiride-treated subjects, while inducing similar glycemic changes.
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Affiliation(s)
- Dongmei Li
- Department of Endocrinology, Nanjing Medical University Affiliated Nanjing First Hospital, No. 68 Changle Road, Nanjing, China
| | - Xiaohua Xu
- Department of Endocrinology, Nanjing Medical University Affiliated Nanjing First Hospital, No. 68 Changle Road, Nanjing, China
| | - Ying Zhang
- Department of Endocrinology, Nanjing Medical University Affiliated Nanjing First Hospital, No. 68 Changle Road, Nanjing, China
| | - Jian Zhu
- Department of Endocrinology, Nanjing Medical University Affiliated Nanjing First Hospital, No. 68 Changle Road, Nanjing, China
| | - Lei Ye
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Kok Onn Lee
- Department of Medicine, National University of Singapore, Singapore, Singapore
| | - Jianhua Ma
- Department of Endocrinology, Nanjing Medical University Affiliated Nanjing First Hospital, No. 68 Changle Road, Nanjing, China.
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Ryan G. Dipeptidyl peptidase-4 inhibitor use in patients with type 2 diabetes and cardiovascular disease or risk factors. Postgrad Med 2015; 127:842-54. [PMID: 26436470 DOI: 10.1080/00325481.2015.1095616] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Management of cardiovascular (CV) risk is an essential aspect of diabetes care, and acceptable CV risk is a requirement for antidiabetes medications. Dipeptidyl peptidase-4 (DPP-4) inhibitors effectively reduce glycated hemoglobin, with a low risk of hypoglycemia and weight gain. The purpose of this review is to discuss the use of DPP-4 inhibitors in patients with type 2 diabetes mellitus (T2DM) and CV disease or risk factors. METHODS A PubMed search (January 2013-June 2015) was conducted to identify prospective trials, meta-analyses, pooled analyses and cohort studies evaluating CV outcomes with DPP-4 inhibitors. RESULTS Meta-analyses, pooled analyses and retrospective cohort studies in patients with T2DM suggest no increased CV risk and possible CV benefit compared with some antidiabetes medications. The three published, long-term, prospective, randomized, double-blind CV outcomes trials in patients with CV disease or risk factors found no increased rate of major CV events in patients treated with alogliptin, saxagliptin or sitagliptin versus placebo as add-on to standard-of-care. However, the analysis of the components of the secondary end point of the saxagliptin study showed an increased number of hospitalizations for heart failure (HF) in treated patients versus placebo. A post hoc analysis of the alogliptin study showed no increase in HF hospitalization in treated patients with a history of HF versus placebo, but did show an increase in alogliptin-treated patients with no baseline HF history. Sitagliptin showed no increased risk for HF hospitalization versus placebo in the overall cohort. Two CV outcomes trials for linagliptin are ongoing. CONCLUSION The majority of available data from CV outcomes trials suggest a neutral effect of DPP-4 inhibitors on major CV events.
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Affiliation(s)
- Gina Ryan
- a Mercer University, College of Pharmacy , Atlanta, GA 30341, USA
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Son JW, Kim S. Dipeptidyl Peptidase 4 Inhibitors and the Risk of Cardiovascular Disease in Patients with Type 2 Diabetes: A Tale of Three Studies. Diabetes Metab J 2015; 39:373-83. [PMID: 26566494 PMCID: PMC4641966 DOI: 10.4093/dmj.2015.39.5.373] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Dipeptidyl peptidase 4 (DPP4) inhibitors have been touted as promising antihyperglycemic agents due to their beneficial effects on glycemia without inducing hypoglycemia or body weight gain and their good tolerability. Beyond their glucose-lowering effects, numerous clinical trials and experimental studies have suggested that DPP4 inhibitors may exert cardioprotective effects through their pleiotropic actions via glucagon-like peptide 1-dependent mechanisms or involving other substrates. Since 2008, regulatory agencies have required an assessment of cardiovascular disease (CVD) safety for the approval of all new anti-hyperglycemic agents, including incretin-based therapies. Three large prospective DPP4 inhibitor trials with cardiovascular (CV) outcomes have recently been published. According to the Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with Diabetes Mellitus (SAVOR-TIMI 53) and EXamination of cArdiovascular outcoMes with alogliptIN versus standard of carE in patients with type 2 diabetes mellitus and acute coronary syndrome (EXAMINE) trials, DPP4 inhibitors, including saxagliptin and alogliptin, did not appear to increase the risk of CV events in patients with type 2 diabetes and established CVD or high risk factors. Unexpectedly, saxagliptin significantly increased the risk of hospitalization for heart failure by 27%, a finding that has not been explained and that requires further exploration. More recently, the Trial Evaluating Cardiovascular Outcomes with Sitagliptin (TECOS) trial demonstrated the CV safety of sitagliptin, including assessments of the primary composite CV endpoint and hospitalization for heart failure in patients with type 2 diabetes and established CVD. The CV outcomes of an ongoing linagliptin trial are expected to provide new evidence about the CV effects of a DPP4-inhibitor in patients with type 2 diabetes.
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Affiliation(s)
- Jang Won Son
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
| | - Sungrae Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
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Schuetz CA, Ong SH, Blüher M. Clinical trial simulation methods for estimating the impact of DPP-4 inhibitors on cardiovascular disease. CLINICOECONOMICS AND OUTCOMES RESEARCH 2015; 7:313-23. [PMID: 26089691 PMCID: PMC4462855 DOI: 10.2147/ceor.s75935] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Introduction Dipeptidyl peptidase-4 (DPP-4) inhibitors are a class of oral antidiabetic agents for the treatment of type 2 diabetes mellitus, which lower blood glucose without causing severe hypoglycemia. However, the first cardiovascular (CV) safety trials have only recently reported their results, and our understanding of these therapies remains incomplete. Using clinical trial simulations, we estimated the effectiveness of DPP-4 inhibitors in preventing major adverse cardiovascular events (MACE) in a population like that enrolled in the SAVOR-TIMI (the Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with Diabetes Mellitus – Thrombolysis in Myocardial Infarction) 53 trial. Methods We used the Archimedes Model to simulate a clinical trial of individuals (N=11,000) with diagnosed type 2 diabetes and elevated CV risk, based on established disease or multiple risk factors. The DPP-4 class was modeled with a meta-analysis of HbA1c and weight change, pooling results from published trials of alogliptin, linagliptin, saxagliptin, sitagliptin, and vildagliptin. The study treatments were added-on to standard care, and outcomes were tracked for 20 years. Results The DPP-4 class was associated with an HbA1c drop of 0.66% (0.71%, 0.62%) and a weight drop of 0.14 (−0.07, 0.36) kg. These biomarker improvements produced a relative risk (RR) for MACE at 5 years of 0.977 (0.968, 0.986). The number needed to treat to prevent one occurrence of MACE at 5 years was 327 (233, 550) in the elevated CV risk population. Conclusion Consistent with recent trial publications, our analysis indicates that DPP-4 inhibitors do not increase the risk of MACE relative to the standard of care. This study provides insights about the long-term benefits of DPP-4 inhibitors and supports the interpretation of the published CV safety trial results.
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Affiliation(s)
| | | | - Matthias Blüher
- Department of Medicine, University of Leipzig, Leipzig, Germany
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35
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Leibowitz G, Cahn A, Bhatt DL, Hirshberg B, Mosenzon O, Wei C, Jermendy G, Sheu WHH, Sendon JL, Im K, Braunwald E, Scirica BM, Raz I. Impact of treatment with saxagliptin on glycaemic stability and β-cell function in the SAVOR-TIMI 53 study. Diabetes Obes Metab 2015; 17:487-94. [PMID: 25656169 DOI: 10.1111/dom.12445] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 01/18/2015] [Accepted: 01/31/2015] [Indexed: 12/20/2022]
Abstract
AIMS To study the effects of saxagliptin, a dipeptidyl peptidase-4 inhibitor, on glycaemic stability and β-cell function in the SAVOR-TIMI 53 trial. METHODS We randomized 16,492 patients with type 2 diabetes (T2D) to saxagliptin or placebo, added to current antidiabetic medications, and followed them for a median of 2.1 years. Glycaemic instability was defined by: (i) a glycated haemoglobin (HbA1c) increase of ≥ 0.5% post-randomization; (ii) the initiation of new antidiabetic medications for ≥ 3 months; or (iii) an increase in dose of oral antidiabetic medication or ≥ 25% increase in insulin dose for ≥ 3 months. β-cell function was assessed according to fasting homeostatic model 2 assessment of β-cell function (HOMA-2β) values at baseline and at year 2 in patients not treated with insulin. RESULTS Compared with placebo, participants treated with saxagliptin had a reduction in the development of glycaemic instability (hazard ratio 0.71; 95% confidence interval 0.68-0.74; p < 0.0001). In participants treated with saxagliptin compared with placebo, the occurrence of an HbA1c increase of ≥ 0.5% was reduced by 35.2%; initiation of insulin was decreased by 31.7% and the increases in doses of an oral antidiabetic drug or insulin were reduced by 19.5 and 23.5%, respectively (all p < 0.0001). At 2 years, HOMA-2β values decreased by 4.9% in participants treated with placebo, compared with an increase of 1.1% in those treated with saxagliptin (p < 0.0001). CONCLUSIONS Saxagliptin improved glycaemia and prevented the reduction in HOMA-2β values. Saxagliptin may reduce the usual decline in β-cell function in T2D, thereby slowing diabetes progression.
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Affiliation(s)
- G Leibowitz
- The Diabetes Unit, Hadassah University Hospital, Jerusalem, Israel; The Endocrine Service, Hadassah University Hospital, Jerusalem, Israel
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Rotz ME, Ganetsky VS, Sen S, Thomas TF. Implications of incretin-based therapies on cardiovascular disease. Int J Clin Pract 2015; 69:531-49. [PMID: 25363540 DOI: 10.1111/ijcp.12572] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 09/08/2014] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Incretin-based therapies offer another treatment option for patients with type 2 diabetes. Agents that provide glycaemic control in addition to attenuating cardiovascular disease (CVD) risk factors are important for diabetes management. This review will focus on the off-target effects of incretin-based therapies on CVD risk factors [body weight, blood pressure (BP), lipid profile and albuminuria], major adverse cardiovascular events (MACE), heart failure (HF) and beta-cell preservation. METHODS A literature search was conducted to identify English-language publications for incretin-based therapies evaluating the following off-target end-points: body weight, BP, lipid profile, albuminuria, MACE, HF and beta-cell function. Randomised controlled trials (RCTs) were prioritised as the primary source of information. RESULTS Overall, incretin-based therapies have shown beneficial effects on CVD risk factors, and glucagon-like peptide 1 (GLP-1) receptor agonists appear to have a more pronounced effect compared with dipeptidyl peptidase-4 inhibitors. RCTs are being conducted to determine if these positive effects on CVD risk factors translate to a reduction in MACE. To date, these studies have not shown an increase in MACE. A signal of increased hospitalisations for HF was observed with saxagliptin, warranting continued evaluation and vigilance in high-risk patients. In addition, incretin-based therapies have shown positive effects on measures of beta-cell function supporting their durability in the management of diabetes. CONCLUSIONS Incretin-based therapies are an important treatment option for patients with type 2 diabetes, offering beneficial effects on CVD risk factors without increasing MACE.
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Affiliation(s)
- M E Rotz
- Temple University School of Pharmacy, Philadelphia, PA, USA
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Udell JA, Bhatt DL, Braunwald E, Cavender MA, Mosenzon O, Steg PG, Davidson JA, Nicolau JC, Corbalan R, Hirshberg B, Frederich R, Im K, Umez-Eronini AA, He P, McGuire DK, Leiter LA, Raz I, Scirica BM. Saxagliptin and cardiovascular outcomes in patients with type 2 diabetes and moderate or severe renal impairment: observations from the SAVOR-TIMI 53 Trial. Diabetes Care 2015; 38:696-705. [PMID: 25552421 DOI: 10.2337/dc14-1850] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The glycemic management of patients with type 2 diabetes mellitus (T2DM) and renal impairment is challenging, with few treatment options. We investigated the effect of saxagliptin in the Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with Diabetes Mellitus (SAVOR)-Thrombolysis in Myocardial Infarction (TIMI) 53 trial according to baseline renal function. RESEARCH DESIGN AND METHODS Patients with T2DM at risk for cardiovascular events were stratified as having normal or mildly impaired renal function (estimated glomerular filtration rate [eGFR] >50 mL/min/1.73 m(2); n = 13,916), moderate renal impairment (eGFR 30-50 mL/min/1.73 m(2); n = 2,240), or severe renal impairment (eGFR <30 mL/min/1.73 m(2); n = 336) and randomized to receive saxagliptin or placebo. The primary end point was cardiovascular death, myocardial infarction, or ischemic stroke. RESULTS After a median duration of 2 years, saxagliptin neither increased nor decreased the risk of the primary and secondary composite end points compared with placebo, irrespective of renal function (all P for interactions ≥ 0.19). Overall, the risk of hospitalization for heart failure among the three eGFR groups of patients was 2.2% (referent), 7.4% (adjusted hazard ratio [HR] 2.38 [95% CI 1.95-2.91], P < 0.001), and 13.0% (adjusted HR 4.59 [95% CI 3.28-6.28], P < 0.001), respectively. The relative risk of hospitalization for heart failure with saxagliptin was similar (P for interaction = 0.43) in patients with eGFR >50 mL/min/1.73 m(2) (HR 1.23 [95% CI 0.99-1.55]), eGFR 30-50 mL/min/1.73 m(2) (HR 1.46 [95% CI 1.07-2.00]), and in patients with eGFR <30 (HR 0.94 [95% CI 0.52-1.71]). Patients with renal impairment achieved reductions in microalbuminuria with saxagliptin (P = 0.041) that were similar to those of the overall trial population. CONCLUSIONS Saxagliptin did not affect the risk of ischemic cardiovascular events, increased the risk of heart failure hospitalization, and reduced progressive albuminuria, irrespective of baseline renal function.
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Affiliation(s)
- Jacob A Udell
- Cardiovascular Division, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Deepak L Bhatt
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Eugene Braunwald
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Matthew A Cavender
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Ofri Mosenzon
- Diabetes Unit, Division of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Ph Gabriel Steg
- Département Hospitalo-Universitaire-Fibrosis Inflammation Remodelling, INSERM U-1148, Université Paris-Diderot, and Hôpital Bichat, AP-HP, Paris, France Imperial College, Royal Brompton Hospital, London, U.K
| | - Jaime A Davidson
- Division of Endocrinology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jose C Nicolau
- Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Ramon Corbalan
- Cardiovascular Division, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | | | - KyungAh Im
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Amarachi A Umez-Eronini
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Ping He
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Darren K McGuire
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Lawrence A Leiter
- Division of Endocrinology and Metabolism, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Itamar Raz
- Diabetes Unit, Division of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Benjamin M Scirica
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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Kalra S, Gupta Y, Baruah M. Can cardiac autonomic neuropathy be a predictor of cardiovascular outcomes in diabetes? Indian J Endocrinol Metab 2015; 19:196-7. [PMID: 25729680 PMCID: PMC4319258 DOI: 10.4103/2230-8210.145795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Sanjay Kalra
- Department of Endocrinology, Bharti Hospital and B.R.I.D.E., Karnal, Haryana, India
| | - Yashdeep Gupta
- Department of Medicine, Government Medical College, Chandigarh, India
| | - Manash Baruah
- Department of Endocrinology, Excel Hospitals, Guwahati, Assam, India
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Yang F, Stewart M, Ye J, DeMets D. Type 2 diabetes mellitus development programs in the new regulatory environment with cardiovascular safety requirements. Diabetes Metab Syndr Obes 2015; 8:315-25. [PMID: 26229496 PMCID: PMC4516202 DOI: 10.2147/dmso.s84005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
For type 2 diabetes mellitus treatment and clinical development, proper evaluation of cardiovascular risk has been required by regulatory agencies (eg, the US Food and Drug Administration) since cardiovascular safety is very important in this patient population. The US Food and Drug Administration issued general guidelines for cardiovascular safety evaluation that outlined the requirements considered adequate for cardiovascular safety evaluation. However, there are multiple options to obtain the data and fulfill these requirements. In this paper, we outline the potential pathways and challenges in various aspects of cardiovascular safety evaluation in type 2 diabetes clinical development, including study design, populations, and endpoints. Specifically, we discuss some challenges in statistical analysis which have implications for the design, implementation, and interpretation of these outcome studies.
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Affiliation(s)
- Fred Yang
- AstraZeneca, Gaithersburg, MD, USA
- Correspondence: Fred Yang, AstraZeneca, One Medimmune Way, Building 200, Gaithersburg, MD 20878, USA, Tel +1 267 980 9451, Email
| | | | - June Ye
- GlaxoSmithKline, Upper Merion, PA, USA
| | - David DeMets
- Department of Biostatistics and Medical Informatics, University of Wisconsin–Madison, Madison, WI, USA
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Genuth S. Should sulfonylureas remain an acceptable first-line add-on to metformin therapy in patients with type 2 diabetes? No, it's time to move on! Diabetes Care 2015; 38:170-5. [PMID: 25538314 DOI: 10.2337/dc14-0565] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Since their introduction to clinical practice in the 1950s, sulfonylureas have been widely prescribed for use in patients with type 2 diabetes. Of all the other medications currently available for clinical use, only metformin has been used more frequently. However, several new drug classes have emerged that are reported to have equal glucose-lowering efficacy and greater safety when added to treatment of patients in whom metformin monotherapy is no longer sufficient. Moreover, current arguments also suggest that the alternative drugs may be superior to sulfonylureas with regard to the risk of cardiovascular complications. Thus, while there is universal agreement that metformin should remain the first-line pharmacologic therapy for those in whom lifestyle modification is insufficient to control hyperglycemia, there is no consensus as to which drug should be added to metformin. Therefore, given the current controversy, we provide a Point-Counterpoint on this issue. In the preceding point narrative, Dr. Abrahamson provides his argument suggesting that avoiding use of sulfonylureas as a class of medication as an add-on to metformin is not appropriate as there are many patients whose glycemic control would improve with use of these drugs with minimal risk of adverse events. In the counterpoint narrative below, Dr. Genuth suggests there is no longer a need for sulfonylureas to remain a first-line addition to metformin for those patients whose clinical characteristics are appropriate and whose health insurance and/or financial resources make an alternative drug affordable.
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Affiliation(s)
- Saul Genuth
- Case Western Reserve University, Cleveland, OH
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Jayawardene D, Ward GM, O’Neal DN, Theverkalam G, MacIsaac AI, MacIsaac RJ. New Treatments for Type 2 Diabetes: Cardiovascular Protection Beyond Glucose Lowering? Heart Lung Circ 2014; 23:997-1008. [DOI: 10.1016/j.hlc.2014.05.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 05/17/2014] [Indexed: 01/29/2023]
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Hirshberg B, Parker A, Edelberg H, Donovan M, Iqbal N. Safety of saxagliptin: events of special interest in 9156 patients with type 2 diabetes mellitus. Diabetes Metab Res Rev 2014; 30:556-69. [PMID: 24376173 DOI: 10.1002/dmrr.2502] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 11/18/2013] [Accepted: 11/26/2013] [Indexed: 12/15/2022]
Abstract
BACKGROUND A post hoc pooled analysis was undertaken to evaluate the safety of saxagliptin in patients with type 2 diabetes mellitus, with attention to events of special interest for dipeptidyl peptidase-4 inhibitors. METHODS Pooled analyses were performed for 20 randomized controlled studies (N = 9156) of saxagliptin as monotherapy or add-on therapy, and a subset of 11 saxagliptin + metformin studies. Adverse events and events of special interest (gastrointestinal adverse events, infections, hypersensitivity, pancreatitis, skin lesions, lymphopenia, thrombocytopenia, hypoglycaemia, bone fracture, severe cutaneous adverse reactions, opportunistic infection, angioedema, malignancy, worsening renal function, and specific laboratory events) were assessed; incidence rates (events/100 person-years) and incidence rates ratios (saxagliptin/control) were calculated (Mantel-Haenszel method). RESULTS In both pooled datasets, the incidence rates for deaths, serious adverse events, discontinuations due to adverse events, pancreatitis, malignancy, and most other events of special interest, excepting bone fractures and hypersensitivity, were similar between treatments, with 95% confidence intervals (CIs) for incidence rates ratios including 1. In the 20-study pool, the incidence rates per 100 person-years was higher with saxagliptin versus control for bone fractures [1.1 vs 0.6; incidence rates ratio (95% CI), 1.81 (1.04-3.28)] and hypersensitivity adverse events [1.3 vs 0.8; 1.67 (1.01-2.87)]. CONCLUSIONS Pooled data from 20 studies confirm that saxagliptin has a favourable safety and benefit-risk profile.
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Scirica BM, Braunwald E, Raz I, Cavender MA, Morrow DA, Jarolim P, Udell JA, Mosenzon O, Im K, Umez-Eronini AA, Pollack PS, Hirshberg B, Frederich R, Lewis BS, McGuire DK, Davidson J, Steg PG, Bhatt DL. Heart failure, saxagliptin, and diabetes mellitus: observations from the SAVOR-TIMI 53 randomized trial. Circulation 2014; 130:1579-88. [PMID: 25189213 DOI: 10.1161/circulationaha.114.010389] [Citation(s) in RCA: 473] [Impact Index Per Article: 47.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Diabetes mellitus and heart failure frequently coexist. However, few diabetes mellitus trials have prospectively evaluated and adjudicated heart failure as an end point. METHODS AND RESULTS A total of 16 492 patients with type 2 diabetes mellitus and a history of, or at risk of, cardiovascular events were randomized to saxagliptin or placebo (mean follow-up, 2.1 years). The primary end point was the composite of cardiovascular death, myocardial infarction, or ischemic stroke. Hospitalization for heart failure was a predefined component of the secondary end point. Baseline N-terminal pro B-type natriuretic peptide was measured in 12 301 patients. More patients treated with saxagliptin (289, 3.5%) were hospitalized for heart failure compared with placebo (228, 2.8%; hazard ratio, 1.27; 95% confidence intercal, 1.07-1.51; P=0.007). Corresponding rates at 12 months were 1.9% versus 1.3% (hazard ratio, 1.46; 95% confidence interval, 1.15-1.88; P=0.002), with no significant difference thereafter (time-varying interaction, P=0.017). Subjects at greatest risk of hospitalization for heart failure had previous heart failure, an estimated glomerular filtration rate ≤60 mL/min, or elevated baseline levels of N-terminal pro B-type natriuretic peptide. There was no evidence of heterogeneity between N-terminal pro B-type natriuretic peptide and saxagliptin (P for interaction=0.46), although the absolute risk excess for heart failure with saxagliptin was greatest in the highest N-terminal pro B-type natriuretic peptide quartile (2.1%). Even in patients at high risk of hospitalization for heart failure, the risk of the primary and secondary end points were similar between treatment groups. CONCLUSIONS In the context of balanced primary and secondary end points, saxagliptin treatment was associated with an increased risk or hospitalization for heart failure. This increase in risk was highest among patients with elevated levels of natriuretic peptides, previous heart failure, or chronic kidney disease. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT01107886.
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Affiliation(s)
- Benjamin M Scirica
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division (B.M.S., E.B., M.A.C., D.A.M., K.I., A.A.U.-E., D.L.B.) and Department of Pathology (P.J.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Diabetes Unit (I.R., O.M.), Division of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel; Cardiovascular Division (J.A.U.), Women's College Hospital and Toronto General Hospital, University of Toronto, Toronto, Canada; AstraZeneca Research and Development (P.S.P., B.H.), Gaithersburg, MD; Bristol-Myers Squibb (R.F.), Princeton, NJ; Cardiovascular Research Institute (B.S.L.), Lady Davis Carmel Medical Center and Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; Cardiovascular Medicine (D.K.M.) and Division of Endocrinology, Department of Internal Medicine (J.D.), University of Texas Southwestern Medical Center, Dallas, TX; University Hospital Department (G.S.), Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation, Remodelling), Institut National de la Santé et de la Recherche Médicale (INSERM) Unit 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France (P.G.S.), Imperial College, Institute of Cardiovascular Medicine and Science, Royal Brompton Hospital, London, UK.
| | - Eugene Braunwald
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division (B.M.S., E.B., M.A.C., D.A.M., K.I., A.A.U.-E., D.L.B.) and Department of Pathology (P.J.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Diabetes Unit (I.R., O.M.), Division of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel; Cardiovascular Division (J.A.U.), Women's College Hospital and Toronto General Hospital, University of Toronto, Toronto, Canada; AstraZeneca Research and Development (P.S.P., B.H.), Gaithersburg, MD; Bristol-Myers Squibb (R.F.), Princeton, NJ; Cardiovascular Research Institute (B.S.L.), Lady Davis Carmel Medical Center and Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; Cardiovascular Medicine (D.K.M.) and Division of Endocrinology, Department of Internal Medicine (J.D.), University of Texas Southwestern Medical Center, Dallas, TX; University Hospital Department (G.S.), Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation, Remodelling), Institut National de la Santé et de la Recherche Médicale (INSERM) Unit 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France (P.G.S.), Imperial College, Institute of Cardiovascular Medicine and Science, Royal Brompton Hospital, London, UK
| | - Itamar Raz
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division (B.M.S., E.B., M.A.C., D.A.M., K.I., A.A.U.-E., D.L.B.) and Department of Pathology (P.J.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Diabetes Unit (I.R., O.M.), Division of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel; Cardiovascular Division (J.A.U.), Women's College Hospital and Toronto General Hospital, University of Toronto, Toronto, Canada; AstraZeneca Research and Development (P.S.P., B.H.), Gaithersburg, MD; Bristol-Myers Squibb (R.F.), Princeton, NJ; Cardiovascular Research Institute (B.S.L.), Lady Davis Carmel Medical Center and Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; Cardiovascular Medicine (D.K.M.) and Division of Endocrinology, Department of Internal Medicine (J.D.), University of Texas Southwestern Medical Center, Dallas, TX; University Hospital Department (G.S.), Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation, Remodelling), Institut National de la Santé et de la Recherche Médicale (INSERM) Unit 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France (P.G.S.), Imperial College, Institute of Cardiovascular Medicine and Science, Royal Brompton Hospital, London, UK
| | - Matthew A Cavender
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division (B.M.S., E.B., M.A.C., D.A.M., K.I., A.A.U.-E., D.L.B.) and Department of Pathology (P.J.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Diabetes Unit (I.R., O.M.), Division of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel; Cardiovascular Division (J.A.U.), Women's College Hospital and Toronto General Hospital, University of Toronto, Toronto, Canada; AstraZeneca Research and Development (P.S.P., B.H.), Gaithersburg, MD; Bristol-Myers Squibb (R.F.), Princeton, NJ; Cardiovascular Research Institute (B.S.L.), Lady Davis Carmel Medical Center and Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; Cardiovascular Medicine (D.K.M.) and Division of Endocrinology, Department of Internal Medicine (J.D.), University of Texas Southwestern Medical Center, Dallas, TX; University Hospital Department (G.S.), Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation, Remodelling), Institut National de la Santé et de la Recherche Médicale (INSERM) Unit 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France (P.G.S.), Imperial College, Institute of Cardiovascular Medicine and Science, Royal Brompton Hospital, London, UK
| | - David A Morrow
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division (B.M.S., E.B., M.A.C., D.A.M., K.I., A.A.U.-E., D.L.B.) and Department of Pathology (P.J.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Diabetes Unit (I.R., O.M.), Division of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel; Cardiovascular Division (J.A.U.), Women's College Hospital and Toronto General Hospital, University of Toronto, Toronto, Canada; AstraZeneca Research and Development (P.S.P., B.H.), Gaithersburg, MD; Bristol-Myers Squibb (R.F.), Princeton, NJ; Cardiovascular Research Institute (B.S.L.), Lady Davis Carmel Medical Center and Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; Cardiovascular Medicine (D.K.M.) and Division of Endocrinology, Department of Internal Medicine (J.D.), University of Texas Southwestern Medical Center, Dallas, TX; University Hospital Department (G.S.), Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation, Remodelling), Institut National de la Santé et de la Recherche Médicale (INSERM) Unit 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France (P.G.S.), Imperial College, Institute of Cardiovascular Medicine and Science, Royal Brompton Hospital, London, UK
| | - Petr Jarolim
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division (B.M.S., E.B., M.A.C., D.A.M., K.I., A.A.U.-E., D.L.B.) and Department of Pathology (P.J.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Diabetes Unit (I.R., O.M.), Division of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel; Cardiovascular Division (J.A.U.), Women's College Hospital and Toronto General Hospital, University of Toronto, Toronto, Canada; AstraZeneca Research and Development (P.S.P., B.H.), Gaithersburg, MD; Bristol-Myers Squibb (R.F.), Princeton, NJ; Cardiovascular Research Institute (B.S.L.), Lady Davis Carmel Medical Center and Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; Cardiovascular Medicine (D.K.M.) and Division of Endocrinology, Department of Internal Medicine (J.D.), University of Texas Southwestern Medical Center, Dallas, TX; University Hospital Department (G.S.), Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation, Remodelling), Institut National de la Santé et de la Recherche Médicale (INSERM) Unit 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France (P.G.S.), Imperial College, Institute of Cardiovascular Medicine and Science, Royal Brompton Hospital, London, UK
| | - Jacob A Udell
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division (B.M.S., E.B., M.A.C., D.A.M., K.I., A.A.U.-E., D.L.B.) and Department of Pathology (P.J.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Diabetes Unit (I.R., O.M.), Division of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel; Cardiovascular Division (J.A.U.), Women's College Hospital and Toronto General Hospital, University of Toronto, Toronto, Canada; AstraZeneca Research and Development (P.S.P., B.H.), Gaithersburg, MD; Bristol-Myers Squibb (R.F.), Princeton, NJ; Cardiovascular Research Institute (B.S.L.), Lady Davis Carmel Medical Center and Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; Cardiovascular Medicine (D.K.M.) and Division of Endocrinology, Department of Internal Medicine (J.D.), University of Texas Southwestern Medical Center, Dallas, TX; University Hospital Department (G.S.), Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation, Remodelling), Institut National de la Santé et de la Recherche Médicale (INSERM) Unit 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France (P.G.S.), Imperial College, Institute of Cardiovascular Medicine and Science, Royal Brompton Hospital, London, UK
| | - Ofri Mosenzon
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division (B.M.S., E.B., M.A.C., D.A.M., K.I., A.A.U.-E., D.L.B.) and Department of Pathology (P.J.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Diabetes Unit (I.R., O.M.), Division of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel; Cardiovascular Division (J.A.U.), Women's College Hospital and Toronto General Hospital, University of Toronto, Toronto, Canada; AstraZeneca Research and Development (P.S.P., B.H.), Gaithersburg, MD; Bristol-Myers Squibb (R.F.), Princeton, NJ; Cardiovascular Research Institute (B.S.L.), Lady Davis Carmel Medical Center and Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; Cardiovascular Medicine (D.K.M.) and Division of Endocrinology, Department of Internal Medicine (J.D.), University of Texas Southwestern Medical Center, Dallas, TX; University Hospital Department (G.S.), Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation, Remodelling), Institut National de la Santé et de la Recherche Médicale (INSERM) Unit 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France (P.G.S.), Imperial College, Institute of Cardiovascular Medicine and Science, Royal Brompton Hospital, London, UK
| | - KyungAh Im
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division (B.M.S., E.B., M.A.C., D.A.M., K.I., A.A.U.-E., D.L.B.) and Department of Pathology (P.J.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Diabetes Unit (I.R., O.M.), Division of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel; Cardiovascular Division (J.A.U.), Women's College Hospital and Toronto General Hospital, University of Toronto, Toronto, Canada; AstraZeneca Research and Development (P.S.P., B.H.), Gaithersburg, MD; Bristol-Myers Squibb (R.F.), Princeton, NJ; Cardiovascular Research Institute (B.S.L.), Lady Davis Carmel Medical Center and Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; Cardiovascular Medicine (D.K.M.) and Division of Endocrinology, Department of Internal Medicine (J.D.), University of Texas Southwestern Medical Center, Dallas, TX; University Hospital Department (G.S.), Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation, Remodelling), Institut National de la Santé et de la Recherche Médicale (INSERM) Unit 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France (P.G.S.), Imperial College, Institute of Cardiovascular Medicine and Science, Royal Brompton Hospital, London, UK
| | - Amarachi A Umez-Eronini
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division (B.M.S., E.B., M.A.C., D.A.M., K.I., A.A.U.-E., D.L.B.) and Department of Pathology (P.J.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Diabetes Unit (I.R., O.M.), Division of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel; Cardiovascular Division (J.A.U.), Women's College Hospital and Toronto General Hospital, University of Toronto, Toronto, Canada; AstraZeneca Research and Development (P.S.P., B.H.), Gaithersburg, MD; Bristol-Myers Squibb (R.F.), Princeton, NJ; Cardiovascular Research Institute (B.S.L.), Lady Davis Carmel Medical Center and Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; Cardiovascular Medicine (D.K.M.) and Division of Endocrinology, Department of Internal Medicine (J.D.), University of Texas Southwestern Medical Center, Dallas, TX; University Hospital Department (G.S.), Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation, Remodelling), Institut National de la Santé et de la Recherche Médicale (INSERM) Unit 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France (P.G.S.), Imperial College, Institute of Cardiovascular Medicine and Science, Royal Brompton Hospital, London, UK
| | - Pia S Pollack
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division (B.M.S., E.B., M.A.C., D.A.M., K.I., A.A.U.-E., D.L.B.) and Department of Pathology (P.J.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Diabetes Unit (I.R., O.M.), Division of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel; Cardiovascular Division (J.A.U.), Women's College Hospital and Toronto General Hospital, University of Toronto, Toronto, Canada; AstraZeneca Research and Development (P.S.P., B.H.), Gaithersburg, MD; Bristol-Myers Squibb (R.F.), Princeton, NJ; Cardiovascular Research Institute (B.S.L.), Lady Davis Carmel Medical Center and Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; Cardiovascular Medicine (D.K.M.) and Division of Endocrinology, Department of Internal Medicine (J.D.), University of Texas Southwestern Medical Center, Dallas, TX; University Hospital Department (G.S.), Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation, Remodelling), Institut National de la Santé et de la Recherche Médicale (INSERM) Unit 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France (P.G.S.), Imperial College, Institute of Cardiovascular Medicine and Science, Royal Brompton Hospital, London, UK
| | - Boaz Hirshberg
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division (B.M.S., E.B., M.A.C., D.A.M., K.I., A.A.U.-E., D.L.B.) and Department of Pathology (P.J.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Diabetes Unit (I.R., O.M.), Division of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel; Cardiovascular Division (J.A.U.), Women's College Hospital and Toronto General Hospital, University of Toronto, Toronto, Canada; AstraZeneca Research and Development (P.S.P., B.H.), Gaithersburg, MD; Bristol-Myers Squibb (R.F.), Princeton, NJ; Cardiovascular Research Institute (B.S.L.), Lady Davis Carmel Medical Center and Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; Cardiovascular Medicine (D.K.M.) and Division of Endocrinology, Department of Internal Medicine (J.D.), University of Texas Southwestern Medical Center, Dallas, TX; University Hospital Department (G.S.), Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation, Remodelling), Institut National de la Santé et de la Recherche Médicale (INSERM) Unit 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France (P.G.S.), Imperial College, Institute of Cardiovascular Medicine and Science, Royal Brompton Hospital, London, UK
| | - Robert Frederich
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division (B.M.S., E.B., M.A.C., D.A.M., K.I., A.A.U.-E., D.L.B.) and Department of Pathology (P.J.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Diabetes Unit (I.R., O.M.), Division of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel; Cardiovascular Division (J.A.U.), Women's College Hospital and Toronto General Hospital, University of Toronto, Toronto, Canada; AstraZeneca Research and Development (P.S.P., B.H.), Gaithersburg, MD; Bristol-Myers Squibb (R.F.), Princeton, NJ; Cardiovascular Research Institute (B.S.L.), Lady Davis Carmel Medical Center and Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; Cardiovascular Medicine (D.K.M.) and Division of Endocrinology, Department of Internal Medicine (J.D.), University of Texas Southwestern Medical Center, Dallas, TX; University Hospital Department (G.S.), Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation, Remodelling), Institut National de la Santé et de la Recherche Médicale (INSERM) Unit 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France (P.G.S.), Imperial College, Institute of Cardiovascular Medicine and Science, Royal Brompton Hospital, London, UK
| | - Basil S Lewis
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division (B.M.S., E.B., M.A.C., D.A.M., K.I., A.A.U.-E., D.L.B.) and Department of Pathology (P.J.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Diabetes Unit (I.R., O.M.), Division of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel; Cardiovascular Division (J.A.U.), Women's College Hospital and Toronto General Hospital, University of Toronto, Toronto, Canada; AstraZeneca Research and Development (P.S.P., B.H.), Gaithersburg, MD; Bristol-Myers Squibb (R.F.), Princeton, NJ; Cardiovascular Research Institute (B.S.L.), Lady Davis Carmel Medical Center and Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; Cardiovascular Medicine (D.K.M.) and Division of Endocrinology, Department of Internal Medicine (J.D.), University of Texas Southwestern Medical Center, Dallas, TX; University Hospital Department (G.S.), Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation, Remodelling), Institut National de la Santé et de la Recherche Médicale (INSERM) Unit 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France (P.G.S.), Imperial College, Institute of Cardiovascular Medicine and Science, Royal Brompton Hospital, London, UK
| | - Darren K McGuire
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division (B.M.S., E.B., M.A.C., D.A.M., K.I., A.A.U.-E., D.L.B.) and Department of Pathology (P.J.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Diabetes Unit (I.R., O.M.), Division of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel; Cardiovascular Division (J.A.U.), Women's College Hospital and Toronto General Hospital, University of Toronto, Toronto, Canada; AstraZeneca Research and Development (P.S.P., B.H.), Gaithersburg, MD; Bristol-Myers Squibb (R.F.), Princeton, NJ; Cardiovascular Research Institute (B.S.L.), Lady Davis Carmel Medical Center and Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; Cardiovascular Medicine (D.K.M.) and Division of Endocrinology, Department of Internal Medicine (J.D.), University of Texas Southwestern Medical Center, Dallas, TX; University Hospital Department (G.S.), Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation, Remodelling), Institut National de la Santé et de la Recherche Médicale (INSERM) Unit 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France (P.G.S.), Imperial College, Institute of Cardiovascular Medicine and Science, Royal Brompton Hospital, London, UK
| | - Jaime Davidson
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division (B.M.S., E.B., M.A.C., D.A.M., K.I., A.A.U.-E., D.L.B.) and Department of Pathology (P.J.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Diabetes Unit (I.R., O.M.), Division of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel; Cardiovascular Division (J.A.U.), Women's College Hospital and Toronto General Hospital, University of Toronto, Toronto, Canada; AstraZeneca Research and Development (P.S.P., B.H.), Gaithersburg, MD; Bristol-Myers Squibb (R.F.), Princeton, NJ; Cardiovascular Research Institute (B.S.L.), Lady Davis Carmel Medical Center and Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; Cardiovascular Medicine (D.K.M.) and Division of Endocrinology, Department of Internal Medicine (J.D.), University of Texas Southwestern Medical Center, Dallas, TX; University Hospital Department (G.S.), Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation, Remodelling), Institut National de la Santé et de la Recherche Médicale (INSERM) Unit 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France (P.G.S.), Imperial College, Institute of Cardiovascular Medicine and Science, Royal Brompton Hospital, London, UK
| | - Ph Gabriel Steg
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division (B.M.S., E.B., M.A.C., D.A.M., K.I., A.A.U.-E., D.L.B.) and Department of Pathology (P.J.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Diabetes Unit (I.R., O.M.), Division of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel; Cardiovascular Division (J.A.U.), Women's College Hospital and Toronto General Hospital, University of Toronto, Toronto, Canada; AstraZeneca Research and Development (P.S.P., B.H.), Gaithersburg, MD; Bristol-Myers Squibb (R.F.), Princeton, NJ; Cardiovascular Research Institute (B.S.L.), Lady Davis Carmel Medical Center and Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; Cardiovascular Medicine (D.K.M.) and Division of Endocrinology, Department of Internal Medicine (J.D.), University of Texas Southwestern Medical Center, Dallas, TX; University Hospital Department (G.S.), Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation, Remodelling), Institut National de la Santé et de la Recherche Médicale (INSERM) Unit 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France (P.G.S.), Imperial College, Institute of Cardiovascular Medicine and Science, Royal Brompton Hospital, London, UK
| | - Deepak L Bhatt
- From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division (B.M.S., E.B., M.A.C., D.A.M., K.I., A.A.U.-E., D.L.B.) and Department of Pathology (P.J.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Diabetes Unit (I.R., O.M.), Division of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel; Cardiovascular Division (J.A.U.), Women's College Hospital and Toronto General Hospital, University of Toronto, Toronto, Canada; AstraZeneca Research and Development (P.S.P., B.H.), Gaithersburg, MD; Bristol-Myers Squibb (R.F.), Princeton, NJ; Cardiovascular Research Institute (B.S.L.), Lady Davis Carmel Medical Center and Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; Cardiovascular Medicine (D.K.M.) and Division of Endocrinology, Department of Internal Medicine (J.D.), University of Texas Southwestern Medical Center, Dallas, TX; University Hospital Department (G.S.), Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation, Remodelling), Institut National de la Santé et de la Recherche Médicale (INSERM) Unit 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France (P.G.S.), Imperial College, Institute of Cardiovascular Medicine and Science, Royal Brompton Hospital, London, UK
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Raz I, Bhatt DL, Hirshberg B, Mosenzon O, Scirica BM, Umez-Eronini A, Im K, Stahre C, Buskila A, Iqbal N, Greenberger N, Lerch MM. Incidence of pancreatitis and pancreatic cancer in a randomized controlled multicenter trial (SAVOR-TIMI 53) of the dipeptidyl peptidase-4 inhibitor saxagliptin. Diabetes Care 2014; 37:2435-41. [PMID: 24914244 DOI: 10.2337/dc13-2546] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine the incidence of pancreatitis and pancreatic cancer in the SAVOR-TIMI 53 trial. RESEARCH DESIGN AND METHODS A total of 16,492 type 2 diabetic patients ≥40 years old with established cardiovascular (CV) disease or CV risk factors were randomized to saxagliptin or placebo and followed for 2.1 years. Outcome measures were investigator reported with blinded expert adjudication of total pancreatitis (acute and chronic) and reported cases of pancreatic cancer. RESULTS Trial investigators reported 35 events of pancreatitis in each treatment arm in 63 patients (33 [0.40%] in the saxagliptin arm and 30 [0.37%] in control arm), with a hazard ratio (HR) of 1.09 (95% CI 0.66-1.79, P = 0.80). Adjudication confirmed pancreatitis in 24 patients (26 events) in the saxagliptin arm (0.29%) and 21 patients (25 events) in placebo arm (0.26%), with an HR of 1.13 (0.63-2.06, P = 0.77). Cases of definite acute pancreatitis were confirmed in 17 (0.2%) vs. 9 (0.1%) (HR 1.88 [0.86-4.41], P = 0.17), definite plus possible pancreatitis in 22 vs. 16 (HR 1.36 [0.72-2.64], P = 0.42), and chronic pancreatitis in 2 vs. 6 (HR 0.33 [0.05-1.44], P = 0.18) in the saxagliptin and placebo arms, respectively. No differences in time to event onset, concomitant risk factors for pancreatitis, investigator-reported causality from study medication or disease severity, and outcome were found between treatment arms. The investigators reported 5 and 12 cases of pancreatic cancer in the saxagliptin and placebo arms, respectively (HR 0.42 [0.13-1.12], P = 0.09). CONCLUSIONS In the SAVOR-TIMI 53 trial, within 2.1 years of follow-up, risk for pancreatitis in type 2 diabetic patients treated with saxagliptin was low and apparently similar to placebo, with no sign of increased risk for pancreatic cancer. Further studies are needed to completely resolve the pancreatic safety issues with incretin-based therapy.
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Affiliation(s)
- Itamar Raz
- Diabetes Unit, Department of Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Deepak L Bhatt
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | | | - Ofri Mosenzon
- Diabetes Unit, Department of Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Benjamin M Scirica
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Amarachi Umez-Eronini
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - KyungAh Im
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | | | - Alona Buskila
- Diabetes Unit, Department of Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | | | - Norton Greenberger
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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Moses RG, Kalra S, Brook D, Sockler J, Monyak J, Visvanathan J, Montanaro M, Fisher SA. A randomized controlled trial of the efficacy and safety of saxagliptin as add-on therapy in patients with type 2 diabetes and inadequate glycaemic control on metformin plus a sulphonylurea. Diabetes Obes Metab 2014; 16:443-50. [PMID: 24205943 DOI: 10.1111/dom.12234] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Revised: 10/20/2013] [Accepted: 11/06/2013] [Indexed: 11/28/2022]
Abstract
AIMS To evaluate the efficacy and safety of saxagliptin as add-on therapy in adults with type 2 diabetes with inadequate glycaemic control on metformin plus a sulphonylurea. METHODS In this 24-week, multicentre, randomized, parallel-group, double-blind study, outpatients aged ≥18 years with type 2 diabetes, body mass index ≤40 kg/m(2) and inadequate glycaemic control, received saxagliptin 5 mg or placebo once-daily added to background medication consisting of a stable maximum tolerated dose of metformin plus a sulphonylurea. The primary end point was change in glycated haemoglobin (HbA1c) from baseline to week 24. Safety and tolerability assessments included adverse events (AEs), hypoglycaemia and body weight. RESULTS A total of 257 patients were randomized, treated and included in the safety analysis (saxagliptin, n = 129; placebo, n = 128); 255 were included in the efficacy analysis (saxagliptin, n = 127; placebo, n = 128). HbA1c reduction was greater with saxagliptin versus placebo [between-group difference in adjusted mean change from baseline, -0.66%; 95% confidence interval (CI), -0.86 to -0.47 (7 mmol/mol, -9.4 to -5.1); p < 0.0001]. The proportion of patients with ≥1 AE was 62.8% with saxagliptin and 71.7% with placebo. In the saxagliptin and placebo groups, rates of reported hypoglycaemia were 10.1 and 6.3%, respectively, and rates of confirmed hypoglycaemia (symptoms + glucose < 2.8 mmol/l) were 1.6 and 0%. Mean change in body weight was 0.2 kg for saxagliptin and -0.6 kg for placebo (p = 0.0272). CONCLUSION Addition of saxagliptin 5 mg/day in patients inadequately controlled on metformin and sulphonylurea effectively improved glycaemic control and was well tolerated.
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Affiliation(s)
- R G Moses
- Wollongong Diabetes Service, Illawarra Shoalhaven Local Health District, Wollongong, Australia
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Abstract
Glucagon-like (GLP-1) is a peptide hormone secreted from the small intestine in response to nutrient ingestion. GLP-1 stimulates insulin secretion in a glucose-dependent manner, inhibits glucagon secretion and gastric emptying, and reduces appetite. Because of the short circulating half-life of the native GLP-1, novel GLP-1 receptor (GLP-1R) agonists and analogs and dipeptidyl peptidase 4 (DPP-4) inhibitors have been developed to facilitate clinical use. Emerging evidence indicates that GLP-1-based therapies are safe and may provide cardiovascular (CV) benefits beyond glycemic control. Preclinical and clinical studies are providing increasing evidence that GLP-1 therapies may positively affect CV function and metabolism by salutary effects on CV risk factors as well as via direct cardioprotective actions. However, the mechanisms whereby the various classes of incretin-based therapies exert CV effects may be mechanistically distinct and may not necessarily lead to similar CV outcomes. In this review, we will discuss the potential mechanisms and current understanding of CV benefits of native GLP-1, GLP-1R agonists and analogs, and of DPP-4 inhibitor therapies as a means to compare their putative CV benefits.
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Affiliation(s)
- Franca S Angeli
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce Street, Centrex 100, Philadelphia, Pennsylvania 19104, USA
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Abstract
It is well known that patients with type 2 diabetes mellitus (T2DM) are at increased risk of cardiovascular (CV) disease. Elevated plasma glucose levels that independently lead to increased cardiovascular risk, combined with associated co-morbidities such as obesity, hypertension, and dyslipidemia, further contribute to the development of CV complications. Dipeptidyl peptidase 4 inhibitors (DPP-4 inhibitors) are a relatively new class of drugs used for the treatment of diabetes and recently have been widely used in clinical practice. They exert their actions through degradation inhibition of endogenous glucagon-like peptides (GLP-1) and glucose-dependent insulinotropic peptides (GIP), with a resulting increase in glucose mediated insulin secretion and a suppression of glucagon secretion. Since GLP-1 is known to have an impact not only on plasma glucose levels but also to have cardiovascular protective effects there is increased speculation of whether DPP-4 inhibitors will have similar effects. Though many short-term studies have been encouraging, ongoing long-term clinical trials on humans are needed to provide further clarity to the complete safety profiles of these agents in terms of cardiovascular risk, and whether they may exert potential cardiovascular benefit. This review includes available data on the cardiovascular effects of DPP-4 inhibitors as well as their overall safety profile.
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The emerging role of dipeptidyl peptidase-4 inhibitors in cardiovascular protection: current position and perspectives. Cardiovasc Drugs Ther 2014; 27:297-307. [PMID: 23645229 DOI: 10.1007/s10557-013-6459-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Dipeptidyl peptidase-4 (DPP-4 or CD26) inhibitors, a new class of oral anti-hyperglycemic agents that prolong the bioavailability of the endogenously secreted incretin hormone glucagon-like peptide-1 (GLP-1) and the glucose-dependent insulinotropic polypeptide (GIP), are effective in the treatment of diabetes. Accumulating data have indicated that DPP-4 inhibitors play important protective roles in the cardiovascular system. DPP-4 inhibitors act to decrease myocardial infarct size, stabilize the cardiac electrophysiological state during myocardial ischemia, reduce ischemia/reperfusion injury, and prevent left ventricular remodeling after myocardial infarction. Moreover, DPP-4 inhibitors can mobilize stem/progenitor cells to move to sites of cardiovascular injury, thus further promoting tissue repair. In addition, DPP-4 inhibitors not only improve myocardial metabolism but also regulate cardioactive peptides. DPP-4 inhibitors can also protect the vasculature through their anti-inflammatory and anti-atherosclerotic effects and through the ability of the inhibitors to promote vascular relaxation. Finally, the potential effects of DPP-4 inhibitors on blood pressure and lipid metabolism have also been investigated. However, some reports on the cardioprotective activities of DPP-4 inhibitors are controversial. Herein, we summarize the available data on cardiovascular protection by DPP-4 inhibitors that have emerged in recent years and discuss current position and future perspectives concerning the use of DPP-4 inhibitors in cardiovascular medicine.
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Ott C, Raff U, Schmidt S, Kistner I, Friedrich S, Bramlage P, Harazny JM, Schmieder RE. Effects of saxagliptin on early microvascular changes in patients with type 2 diabetes. Cardiovasc Diabetol 2014; 13:19. [PMID: 24423149 PMCID: PMC3897922 DOI: 10.1186/1475-2840-13-19] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 01/11/2014] [Indexed: 01/21/2023] Open
Abstract
Background Patients with diabetes mellitus are at increased risk for microvascular complications. Early changes in microcirculation are characterized by hyperperfusion (e.g. in the retina and kidney) and increased pulse wave reflection leading to increased aortic pressure. We investigated the effects of the DPP-4-inhibitor saxagliptin on early retinal microvascular changes. Methods In this double-blind, controlled, cross-over trial 50 patients (without clinical signs of microvascular alterations) with type-2 diabetes (mean duration of 4 years) were randomized to receive placebo or 5 mg saxagliptin for 6 weeks. Retinal arteriolar structure and retinal capillary flow (RCF) at baseline and during flicker-light exposure was assessed by scanning laser Doppler flowmetry. Central hemodynamics were assessed by pulse wave analysis. Results Postprandial blood glucose (9.27 ± 0.4 versus 10.1 ± 0.4 mmol/L; p = 0.001) and HbA1c (6.84 ± 0.15 (51 ± 1.6) versus 7.10 ± 0.17% (54 ± 1.9 mmol/mol); p < 0.001) were significantly reduced with saxagliptin treatment compared to placebo. RCF was significantly reduced after treatment with saxagliptin (288 ± 13.2 versus 314 ± 14.1 AU; p = 0.033). This was most pronounced in a subgroup of patients (n = 32) with a fall in postprandial blood glucose (280 ± 12.1 versus 314 ± 16.6 AU; p = 0.011). No significant changes in RCF were seen during flicker-light exposure between placebo and saxagliptin, but the vasodilatory capacity increased two-fold with saxagliptin treatment. Central augmentation pressure tended to be lower after treatment with saxagliptin (p = 0.094), and central systolic blood pressure was significantly reduced (119 ± 2.3 versus 124 ± 2.3 mmHg; p = 0.038). Conclusions Our data suggest that treatment with saxagliptin for 6 weeks normalizes retinal capillary flow and improves central hemodynamics in type-2 diabetes. Trial registration The study was registered at (ID: NCT01319357).
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Affiliation(s)
| | | | | | | | | | | | | | - Roland E Schmieder
- Department of Nephrology and Hypertension, University of Erlangen-Nuremberg, Ulmenweg 18, Erlangen, Germany.
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Deacon CF, Marx N. Potential cardiovascular effects of incretin-based therapies. Expert Rev Cardiovasc Ther 2014; 10:337-51. [DOI: 10.1586/erc.12.5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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