Sodium glucose cotransporter-2 inhibitors and heart disease: Current perspectives

Sodium-glucose cotransporter 2 inhibitors in the treatment of heart failure patients: A systematic review and meta-analysis of cost-utility studies

AIMS

Sodium-glucose cotransporter-2 inhibitors (SGLT-2i) have shown promise in reducing cardiovascular mortality and hospitalization due to heart failure (HF), a significant global health issue. This study aims to evaluate the incremental net benefit (INB) of SGLT-2i in HF patients through a systematic review and meta-analysis of cost-utility studies.

METHODS

We searched five databases from their inception until Aug 30, 2024, economic evolution studies reporting cost-effectiveness and cost-utility analyses comparing SGLT-2i combined with standard triple-therapy versus standard triple-therapy alone in HF patients were selected. INB as the primary outcome was calculated in monetary units adjusted for purchasing power parity in 2022 US dollars.

RESULTS

This review included 46 studies, with 41 studies (55 comparisons) pooled into meta-analysis. Adding SGLT2is was cost-effective compared to standard triple-therapy alone, from both healthcare system perspective (INB, $4042.08; 95 % CI, $1758.70-$6325.46) and payer perspective (INB, $12,972.84; 95 % CI, $4711.5-$21,234.22). However, subgroup analyses showed non-significant economic benefit in HF patients with preserved ejection fraction (HFpEF) both from the healthcare system perspective (INB, -$639.32; 95 % CI, -$1850.09-$571.44) and the payer perspective (INB, $3611.07; 95 % CI, -$208.49-$7430.64). Additionally, HF patients from low- and middle-income countries did not show significant economic benefit from the payer perspective (INB, $55,645.70; 95 % CI, -$51,000.00-$160,000.00).

CONCLUSIONS

The findings suggest that adding SGLT-2i is cost-effective compared to conventional standard triple-therapy alone, from both healthcare system and payer perspectives. Nevertheless, the economic benefits are limited in HFpEF and those from low- and middle-income countries. Further research is needed to explore the cost-effectiveness from a broader societal perspective.

Anti-Inflammatory Effects of SGLT2 Inhibitors: Focus on Macrophages

A growing body of evidence indicates that nonglycemic effects of sodium-glucose cotransporter 2 (SGLT2) inhibitors play an important role in the protective effects of these drugs in diabetes, chronic kidney disease, and heart failure. In recent years, the anti-inflammatory potential of SGLT2 inhibitors has been actively studied. This review summarizes results of clinical and experimental studies on the anti-inflammatory activity of SGLT2 inhibitors, with a special focus on their effects on macrophages, key drivers of metabolic inflammation. In patients with type 2 diabetes, therapy with SGLT2 inhibitors reduces levels of inflammatory mediators. In diabetic and non-diabetic animal models, SGLT2 inhibitors control low-grade inflammation by suppressing inflammatory activation of tissue macrophages, recruitment of monocytes from the bloodstream, and macrophage polarization towards the M1 phenotype. The molecular mechanisms of the effects of SGLT2 inhibitors on macrophages include an attenuation of inflammasome activity and inhibition of the TLR4/NF-κB pathway, as well as modulation of other signaling pathways (AMPK, PI3K/Akt, ERK 1/2-MAPK, and JAKs/STAT). The review discusses the state-of-the-art concepts and prospects of further investigations that are needed to obtain a deeper insight into the mechanisms underlying the effects of SGLT2 inhibitors on the molecular, cellular, and physiological levels.

Trends in drug repurposing: Advancing cardiovascular disease management in geriatric populations

Drug repurposing is a promising strategy for managing cardiovascular disease (CVD) in geriatric populations, offering efficient and cost-effective solutions. CVDs are prevalent across all age groups, with a significant increase in prevalence among geriatric populations. The middle-age period (40-65 years) is critical due to factors like obesity, sedentary lifestyle, and psychosocial stress. In individuals aged 65 and older, the incidence of CVDs is highest due to age-related physiological changes and prolonged exposure to risk factors. In this review we find that certain drugs, such as non-cardiovascular drugs like anakinra, probenecid, N-acetyl cysteine, quercetin, resveratrol, rapamycin, colchicine, bisphosphonates, hydroxychloroquine, SGLT-2i drugs, GLP-1Ras drugs and sildenafil are recommended for drug repurposing to achieve cardiovascular benefits in geriatric patients. However, agents such as canakinumab, methotrexate, ivermectin, erythromycin, capecitabine, carglumic acid, chloroquine, and furosemide are constrained in their therapeutic use and warrant meticulous consideration, rendering them less favorable for this specific application. This review emphasizes the importance of exploring alternative therapeutic strategies to improve outcomes in geriatric populations and suggests drug repurposing as a promising avenue to enhance treatment efficacy.

Assessing the Effectiveness and Safety of Combination Diuretic Therapy in Heart Failure: A Systematic Review and Meta-Analysis

Heart failure remains a significant clinical challenge due to the difficulty in managing refractory fluid overload. Combination diuretic strategies, involving various combinations, such as metolazone and furosemide, have been proposed to improve diuresis and patient outcomes. This systematic review and meta-analysis aimed to evaluate the efficacy and safety of combination therapies. A comprehensive search of PubMed, Cochrane Library, Embase, and Web of Science identified 61 articles, of which seven randomised controlled trials met the inclusion criteria. Data on mortality, hospital readmission rates, symptom improvement, electrolyte imbalances, renal function, and adverse events were extracted and analysed. The risk of bias was assessed using the established guidelines. The analysis revealed that combination diuretic therapies significantly reduced body weight (P=0.001) but did not significantly impact mortality (RR: 0.99, 95% CI: 0.90-1.09) or hospital readmission rates (RR: 1.05, 95% CI: 0.98-1.12) compared to placebo. Adverse effects, particularly electrolyte imbalances, such as hypo and hypernatraemia and hypokalaemia, and renal function deterioration were noted in the combined diuretic group. In contrast, serious adverse events were observed more in the placebo group. The mean difference of the Kansas City Cardiomyopathy Questionnaire (KCCQ) score was 2.43 (95% CI: 0.95-3.92). The risk ratio for hospital readmission was 1.05 (95% CI: 0.98-1.12), which was statistically non-significant. We used fixed-effect models for most variables due to less heterogeneity between the studies, and the corresponding I2 values were <50% for most variables. Funnel plots indicated minimal publication bias, although some heterogeneity was observed. Comparisons with other studies in the literature, such as the DAPA-HF and EVEREST trials, supported these findings but also highlighted the need for individualised treatment approaches. Combination diuretic therapies effectively manage fluid overload and reduce body weight in patients with heart failure but do not significantly affect mortality or hospital readmission rates. The potential for adverse events, particularly electrolyte imbalances and renal function deterioration, underscores the need for careful monitoring and personalised treatment plans. Future research should focus on optimising diuretic combinations and dosing strategies to enhance their safety and efficacy. These findings align with the current guidelines emphasising individualised treatment in heart failure management and highlight the importance of integrating combination diuretics into a comprehensive care plan to improve patient outcomes.