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Shrestha AB, Halder A, Rajak K, Jha SK, Lamichhane R, Oishee AN, Chowdary NT, Pokharel P, Shrestha S, Adhikari L, Adhikari B, Rajak A, Haider Khan J, Mainali N. Cardioprotective effects of sodium glucose cotransporter 2 inhibitor versus dipeptidyl peptidase 4 inhibitor in type 2 diabetes: A meta-analysis of comparative safety and efficacy. SAGE Open Med 2024; 12:20503121241261204. [PMID: 39070014 PMCID: PMC11282519 DOI: 10.1177/20503121241261204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 05/24/2024] [Indexed: 07/30/2024] Open
Abstract
Background Sodium glucose cotransporter 2 inhibitors are recommended for the treatment of heart failure due to their cardioprotective effects, despite primarily being used as antidiabetic medications. However, the comparative profile of two antidiabetic drugs, sodium glucose cotransporter 2 inhibitors with dipeptidyl peptidase 4 inhibitor remains unclear. Study hypothesis This study aims to compare the safety and efficacy profiles of sodium glucose cotransporter 2 inhibitors versus dipeptidyl peptidase 4 inhibitor drugs. Methods A comprehensive search was conducted in PubMed, Scopus, Web of Science, Google Scholar, and ClinicalTrials.gov using appropriate Medical Subject Headings terms from inception until February 23, 2023. The outcomes were pooled using a random-effects model for hazard ratio with a 95% confidence interval. A p-value of <0.05 was considered statistically significant. Results Twelve studies were included after systematic screening, with a sample size of 745,688 for sodium glucose cotransporter 2 inhibitors and 769,386 for dipeptidyl peptidase 4 inhibitor. The mean age in each group was 61.1 (8.52) and 61.28 (9.25) years, respectively. Upon pooling the included articles with sodium glucose cotransporter 2 inhibitors versus dipeptidyl peptidase 4 inhibitor, the primary outcome of all-cause death demonstrated an hazard ratio of 0.64 (0.57, 0.70), I 2: 65.54%, p < 0.001, and major adverse cardiovascular events yielded an hazard ratio of 0.76 (0.65, 0.86), I 2: 87.83%, p < 0.001. The secondary outcomes included myocardial infarction with an hazard ratio of 0.84 (0.78, 0.90), I 2: 47.64%, p < 0.001, stroke with an hazard ratio of 0.81 (0.75, 0.87), I 2: 36.78%, p < 0.001, and hospitalization with an hazard ratio of 0.62 (0.53, 0.70), I 2: 83.32%, p < 0.001. Conclusion Our findings suggest that compared to dipeptidyl peptidase 4 inhibitor, initiating treatment with sodium glucose cotransporter 2 inhibitors provides cardiovascular disease protection and may be considered in patients with type 2 diabetes.
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Affiliation(s)
- Abhigan Babu Shrestha
- Department of Internal Medicine, M Abdur Rahim Medical College, Dinajpur, Bangladesh
| | - Anupam Halder
- Department of Internal Medicine, University of Pittsburgh Medical Centre, Harrisburg, PA, USA
| | - Kripa Rajak
- Department of Internal Medicine, University of Pittsburgh Medical Centre, Harrisburg, PA, USA
| | - Saroj Kumar Jha
- Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Ramesh Lamichhane
- Department of Internal Medicine, Jalalabad Ragib-Rabeya Medical College, Sylhet, Bangladesh
| | - Arefin Naher Oishee
- Department of Internal Medicine, M Abdur Rahim Medical College, Dinajpur, Bangladesh
| | | | - Pashupati Pokharel
- Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | | | | | - Bikash Adhikari
- Kathmandu Medical College, Kathmandu University, Kathmandu, Nepal
| | - Aman Rajak
- Patan Academy of Health Sciences, Patan, Nepal
| | | | - Nischal Mainali
- Nischal Mainali, Kathmandu Medical College, Kathmandu University, Sinamangal, Kathmandu 44600, Nepal.
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Deng S, Zhao H, Chai S, Sun Y, Shen P, Lin H, Zhan S. Influence of early use of sodium-glucose transport protein 2 inhibitors, glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors on the legacy effect of hyperglycemia. Front Endocrinol (Lausanne) 2024; 15:1369908. [PMID: 38803473 PMCID: PMC11128627 DOI: 10.3389/fendo.2024.1369908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 04/29/2024] [Indexed: 05/29/2024] Open
Abstract
Background A phenomenon known as legacy effect was observed that poor glycemic control at early stage of patients with newly-diagnosed type 2 diabetes (T2D) increases the risk of subsequent cardiovascular diseases (CVD). Early use of some novel anti-hyperglycemic agents, such as sodium-glucose transport protein 2 inhibitors (SGLT-2i), may attenuate this effect, but the evidence is limited. Methods Two retrospective cohorts of newly diagnosed T2D patients from 2010-2023 were assembled using the Yinzhou Regional Health Care Database (YRHCD) with different definitions of the early exposure period - the 1-year exposure cohort and 2-year exposure cohort, which were comprised of subjects who had HbA1c measurement data within 1 year and 2 years after their T2D diagnosis, respectively. Using Cox proportional hazards models, we examined the association between high HbA1c level (HbA1c>7%) during the early exposure period and the risk of subsequent CVD. This analysis was performed in the overall cohort and three subpopulations with different treatments during the early exposure period, including patients initiating SGLT-2i or glucagon-like peptide-1 receptor agonists (GLP-1RA), patients using dipeptidyl peptidase-4 inhibitors (DPP-4i), and patients without using SGLT-2i, GLP-1RA, and DPP-4i. Besides, subgroup analyses were performed by stratifying patients into age <55 and ≥55 years. Results A total of 21,477 and 22,493 patients with newly diagnosed T2D were included in the two final cohorts. Compared with patients with mean HbA1c ≤ 7% during the early exposure period, those with HbA1c>7% had higher risks of incident CVD, with a HR of 1.165 (95%CI, 1.056-1.285) and 1.143 (95%CI, 1.044-1.252) in 1-year and 2-year exposure period cohort. Compared to non-users, in patients initiating SGLT-2i/GLP-1RA within 1 or 2 years after T2D diagnosis, higher HbA1c level at baseline was not associated with CVD in both two cohorts. In subgroup analyses, results were generally consistent with the main analysis. Conclusions Poor glycemic control in the early stage of T2D increased later CVD risk in Chinese adults with newly diagnosed T2D. Compared to non-users, this association was smaller and non-significant in patients receiving SGLT-2i/GLP-1RA during the early stage of T2D, indicating early use of these drugs may have the potential to mitigate legacy effects of hyperglycemia.
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Affiliation(s)
- Siwei Deng
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
- Center for Intelligent Public Health, Institute for Artificial Intelligence, Peking University, Beijing, China
- Key Laboratory of Epidemiology of Major Diseases (Peking University), Ministry of Education, Beijing, China
| | - Houyu Zhao
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
- School of Medicine, Chongqing University, Chongqing, China
| | - Sanbao Chai
- Department of Endocrinology, Peking University International Hospital, Beijing, China
| | - Yexiang Sun
- Big Data Center, Yinzhou District Center for Disease Control and Prevention, Ningbo, China
| | - Peng Shen
- Big Data Center, Yinzhou District Center for Disease Control and Prevention, Ningbo, China
| | - Hongbo Lin
- Big Data Center, Yinzhou District Center for Disease Control and Prevention, Ningbo, China
| | - Siyan Zhan
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
- Center for Intelligent Public Health, Institute for Artificial Intelligence, Peking University, Beijing, China
- Key Laboratory of Epidemiology of Major Diseases (Peking University), Ministry of Education, Beijing, China
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
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Al-Hindi B, Mohammed MA, Mangantig E, Martini ND. Prevalence of sodium-glucose transporter 2 inhibitor-associated diabetic ketoacidosis in real-world data: A systematic review and meta-analysis. J Am Pharm Assoc (2003) 2024; 64:9-26.e6. [PMID: 37844733 DOI: 10.1016/j.japh.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/30/2023] [Accepted: 10/09/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND The U.S. Food and Drug Administration (FDA) revised the labels of sodium-glucose transporter 2 (SGLT2) inhibitors in December 2015 to inform users regarding the risk of diabetic ketoacidosis (DKA). As more drugs of this class are approved and their indications are expanded, this serious adverse effect has been increasingly reported. OBJECTIVE This review evaluated observational studies to inform the prevalence of SGLT2-inhibitor-associated DKA compared with other antihyperglycemic agents. METHODS A systematic review was conducted in PubMed and EMBASE until 19 July 2022 (PROSPERO: CRD42022385425). We included published retrospective cohort active comparator/new user (ACNU) and prevalent new user studies assessing SGLT2-inhibitor-associated DKA prevalence in adult patients with type 2 diabetes mellitus (T2DM) against active comparators. We excluded studies which lacked 1:1 propensity score matching. The JBI Checklist for Cohort Studies guided the risk-of-bias assessments. Meta-analysis was conducted based on the inverse variance method in R software. RESULTS Sixteen studies with a sample of 2,956,100 nonunique patients met the inclusion criteria. Most studies were conducted in North America (n = 9) and adopted the ACNU design (n = 15). Meta-analysis of 14 studies identified 33% higher DKA risk associated with SGLT2 inhibitors (HR = 1.33, 95% CI: 1.14-1.55, P < 0.01). Meta-regression analysis identified the study location (P = 0.02), analysis principle (P < 0.001), exclusion of chronic comorbidities (P = 0.007), and canagliflozin (P = 0.04) as significant moderator variables. CONCLUSIONS Despite limitations related to heterogeneity, generalizability, and misclassification, the results of this study show that SGLT2 inhibitors increase the prevalence of DKA among adult T2DM patients in the real world. The findings supplement evidence from randomized controlled trials (RCTs) and call for continued vigilance.
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Hinton W, Ansari AS, Whyte MB, McGovern AP, Feher MD, Munro N, de Lusignan S. Sodium-glucose co-transporter-2 inhibitors in type 2 diabetes: Are clinical trial benefits for heart failure reflected in real-world clinical practice? A systematic review and meta-analysis of observational studies. Diabetes Obes Metab 2023; 25:501-515. [PMID: 36239122 DOI: 10.1111/dom.14893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 10/11/2022] [Accepted: 10/12/2022] [Indexed: 02/02/2023]
Abstract
AIM To determine the absolute risk reduction (ARR) of heart failure events in people treated with sodium-glucose co-transporter-2 (SGLT2) inhibitors. MATERIALS AND METHODS We searched PubMed, EMBASE, CINAHL and ISI Web of Science for observational studies published to 9 May 2022 that explored the association between SGLT2 inhibitors and any indication for heart failure (including new diagnosis or hospitalization for heart failure) in type 2 diabetes. Identified studies were independently screened by two reviewers and assessed for bias using the Newcastle-Ottawa scale. Eligible studies with comparable outcome data were pooled for meta-analysis using random-effects models, reporting hazard ratios (HRs) with 95% confidence intervals (CIs). The ARR per 100 person-years was determined overall, and in subgroups with and without baseline cardiovascular disease (CVD). RESULTS From 43 eligible studies, with a total of 4 818 242 participants from 17 countries, 21 were included for meta-analysis. SGLT2 inhibitors were associated with a reduced risk of hospitalization for heart failure (HR 0.65, 95% CI 0.59-0.72) overall and both in those with CVD (HR 0.78, 95% CI 0.68-0.89) and without CVD (HR 0.53, 95% CI 0.39-0.71). Risk reduction for hospitalization for heart failure in people with a history of CVD (ARR 1.17, 95% CI 0.78-1.55) was significantly greater than for those without CVD (ARR 0.39, 95% CI 0.32-0.47). The number-needed-to-treat to prevent one event of hospitalization for heart failure was 86 (95% CI 65-128) person-years of treatment for the CVD group and 256 (95% CI 215-316) person-years for those without CVD. CONCLUSIONS Real-world SGLT2 inhibitor use supports randomized trial data for the size effect of reduced hospitalization for heart failure in type 2 diabetes, although with a much lower ARR in people without CVD.
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Affiliation(s)
- William Hinton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Abdus Samad Ansari
- Department of Twin Research and Genetic Epidemiology, King's College London, London, UK
| | - Martin B Whyte
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Andrew P McGovern
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Michael D Feher
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Neil Munro
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC), London, UK
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Longato E, Di Camillo B, Sparacino G, Avogaro A, Fadini GP. Time-resolved trajectory of glucose lowering medications and cardiovascular outcomes in type 2 diabetes: a recurrent neural network analysis. Cardiovasc Diabetol 2022; 21:159. [PMID: 35996111 PMCID: PMC9396779 DOI: 10.1186/s12933-022-01600-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 08/09/2022] [Indexed: 11/25/2022] Open
Abstract
Aim Treatment algorithms define lines of glucose lowering medications (GLM) for the management of type 2 diabetes (T2D), but whether therapeutic trajectories are associated with major adverse cardiovascular events (MACE) is unclear. We explored whether the temporal resolution of GLM usage discriminates patients who experienced a 4P-MACE (heart failure, myocardial infarction, stroke, death for all causes). Methods We used an administrative database (Veneto region, North-East Italy, 2011–2018) and implemented recurrent neural networks (RNN) with outcome-specific attention maps. The model input included age, sex, diabetes duration, and a matrix of GLM pattern before the 4P-MACE or censoring. Model output was discrimination, reported as area under receiver characteristic curve (AUROC). Attention maps were produced to show medications whose time-resolved trajectories were the most important for discrimination. Results The analysis was conducted on 147,135 patients for training and model selection and on 10,000 patients for validation. Collected data spanned a period of ~ 6 years. The RNN model efficiently discriminated temporal patterns of GLM ending in a 4P-MACE vs. those ending in an event-free censoring with an AUROC of 0.911 (95% C.I. 0.904–0.919). This excellent performance was significantly better than that of other models not incorporating time-resolved GLM trajectories: (i) a logistic regression on the bag-of-words encoding all GLM ever taken by the patient (AUROC 0.754; 95% C.I. 0.743–0.765); (ii) a model including the sequence of GLM without temporal relationships (AUROC 0.749; 95% C.I. 0.737–0.761); (iii) a RNN model with the same construction rules but including a time-inverted or randomised order of GLM. Attention maps identified the time-resolved pattern of most common first-line (metformin), second-line (sulphonylureas) GLM, and insulin (glargine) as those determining discrimination capacity. Conclusions The time-resolved pattern of GLM use identified patients with subsequent cardiovascular events better than the mere list or sequence of prescribed GLM. Thus, a patient’s therapeutic trajectory could determine disease outcomes.
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Affiliation(s)
- Enrico Longato
- Department of Information Engineering, University of Padova, 35100, Padua, Italy
| | - Barbara Di Camillo
- Department of Information Engineering, University of Padova, 35100, Padua, Italy.,Department of Comparative Biomedicine and Food Science, University of Padova, 35020, Legnaro, Italy
| | - Giovanni Sparacino
- Department of Information Engineering, University of Padova, 35100, Padua, Italy
| | - Angelo Avogaro
- Department of Medicine DIMED, University of Padova, Via Giustiniani 2, 35100, Padua, Italy
| | - Gian Paolo Fadini
- Department of Medicine DIMED, University of Padova, Via Giustiniani 2, 35100, Padua, Italy.
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Wilding JPH, Evans M, Fernando K, Gorriz JL, Cebrian A, Diggle J, Hicks D, James J, Newland-Jones P, Ali A, Bain S, Da Porto A, Patel D, Viljoen A, Wheeler DC, Del Prato S. The Place and Value of Sodium-Glucose Cotransporter 2 Inhibitors in the Evolving Treatment Paradigm for Type 2 Diabetes Mellitus: A Narrative Review. Diabetes Ther 2022; 13:847-872. [PMID: 35307801 PMCID: PMC8934539 DOI: 10.1007/s13300-022-01228-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 02/08/2022] [Indexed: 02/07/2023] Open
Abstract
Over recent years, the expanding evidence base for sodium-glucose cotransporter-2 inhibitor (SGLT2i) therapies has revealed benefits beyond their glucose-lowering efficacy in the treatment of Type 2 diabetes mellitus (T2DM), resulting in their recognition as cardiorenal medicines. While SGLT2is continue to be recommended among the second-line therapies for the treatment of hyperglycaemia, their true value now extends to the prevention of debilitating and costly cardiovascular and renal events for high-risk individuals, with particular benefit shown in reducing major adverse cardiac events and heart failure (HF) and slowing the progression of chronic kidney disease. However, SGLT2i usage is still suboptimal among groups considered to be at greatest risk of cardiorenal complications. The ongoing coronavirus disease 2019 (COVID-19) pandemic has intensified financial pressures on healthcare systems, which may hamper further investment in newer effective medicines. Emerging evidence indicates that glycaemic control should be prioritised for people with T2DM in the era of COVID-19 and practical advice on the use of T2DM medications during periods of acute illness remains important, particularly for healthcare professionals working in primary care who face multiple competing priorities. This article provides the latest update from the Improving Diabetes Steering Committee, including perspectives on the value of SGLT2is as cost-effective therapies within the T2DM treatment paradigm, with particular focus on the latest published evidence relating to the prevention or slowing of cardiorenal complications. The implications for ongoing and future approaches to diabetes care are considered in the light of the continuing coronavirus pandemic, and relevant aspects of international treatment guidelines are highlighted with practical advice on the appropriate use of SGLT2is in commonly occurring T2DM clinical scenarios. The 'SGLT2i Prescribing Tool for T2DM Management', previously published by the Steering Committee, has been updated to reflect the latest evidence and is provided in the Supplementary Materials to help support clinicians delivering T2DM care.
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Affiliation(s)
- John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, Clinical Sciences Centre, University Hospital Aintree, Liverpool, UK.
| | - Marc Evans
- University Hospital Llandough, Cardiff, UK
| | | | - Jose Luis Gorriz
- University Hospital Clinic, University of Valencia, Valencia, Spain
| | - Ana Cebrian
- Spanish Diabetes Association, Catholic University of Murcia, Service Murciano de Salud, Cartagena, Murcia, Spain
- Centro de Salud Casco Antiguo Cartagena, Murcia, Spain
- Primary Care Research Group, Biomedical Research Institute of Murcia (IMIB), 30120, Murcia, Spain
| | - Jane Diggle
- College Lane Surgery, Ackworth, West Yorkshire, UK
| | | | - June James
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Amar Ali
- Royal Blackburn Hospital, Lancashire, UK
| | - Stephen Bain
- Swansea University and Diabetes Research Unit, Swansea, UK
| | | | | | - Adie Viljoen
- Cambridge University Hospitals NHS Foundation Trust, Stevenage, UK
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Qiu M, Zhou X, Zhang M. Cardiorenal benefits of sodium-glucose co-transporter-2 inhibitors versus dipeptidyl peptidase-4 inhibitors in type 2 diabetes without cardiovascular and renal diseases. Diabetes Obes Metab 2022; 24:575-577. [PMID: 34729884 DOI: 10.1111/dom.14588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 10/26/2021] [Accepted: 10/31/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Mei Qiu
- Department of General Medicine, Shenzhen Longhua District Central Hospital, Shenzhen, China
| | - Xian Zhou
- Department of General Medicine, Yan'an Hospital Affiliated to Kunming Medical University, Kunming, China
| | - Miao Zhang
- Department of Nephrology, Shenzhen Hospital of Beijing University of Chinese Medicine, Shenzhen, China
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