Effect of Dapagliflozin in Patients with Heart Failure: A Systematic Review and Meta-Analysis

Analysis of specialist doctors' behavior towards SGLT2 inhibitors prescription in Indonesia: A qualitative study

Sodium-glucose cotransporter-2 inhibitors (SGLT2is) have a broad range of clinical indications and are recommended by various guidelines for the management of diabetes, heart failure, and chronic kidney disease. However, prescribing rates for these agents are suboptimal towards various intended indications in many countries, including Indonesia. The aim of this study was to analyze the prescribing practices of SGLT2is among endocrinologists, cardiologists, and nephrologists in Indonesia. A qualitative method was utilized to provide a comprehensive understanding of this phenomenon. Semi-structured online interviews were performed with 18 participants, comprising seven specialized doctors as primary informants; eight key informants representing pharmacies, governmental bodies, and pharmaceutical marketing representatives; and three patients as supplementary informants. Furthermore, closed observations of two specialist doctors were undertaken as an additional data collection method. Informants were recruited using criterion and snowball sampling methods. The Theoretical Domains Framework was used as an interview guide; all interviews were audio visual-recorded, transcribed verbatim, and subsequently analyzed for thematic content with NVivo version 12. Seven themes emerged concerning the prescribing behavior of SGLT2is: socioeconomic status, therapeutic rationality, utilization barriers, utilization optimization, the urge to prescribe, therapeutic expectations and targets, and aspects of the health system and ethical considerations. Most informants possessed favorable perspectives regarding using SGLT2is when prescribed appropriately, yet specific elements necessitate enhancement to refine therapeutic justification, including initiatives to incorporate SGLT2is into the national formulary.

Dapagliflozin in acute heart failure management: a systematic review and meta-analysis of safety and effectiveness

BACKGROUND

Acute Heart Failure (AHF) presents as a serious pathophysiological disease with significant morbidity and mortality rates, requiring immediate medical intervention. Traditional treatment involves diuretics and vasodilators, but a subset of patients develop resistance due to acute cardiorenal syndrome. Dapagliflozin, categorized as a sodium-glucose cotransporter-2 inhibitor (SGLT2i), has emerged as a promising therapy for AHF, demonstrating substantial benefits in reducing both mortality and morbidity among patients. The purpose of this meta-analysis and systematic review is to determine dapagliflozin's safety and efficacy in AHF patients.

METHODS

In accordance with PRISMA guidelines, we conducted a systematic search across several databases (PubMed, Science Direct, and Cochrane Library) up to June 2024 to identify randomized controlled trials (RCTs) that compared dapagliflozin with control treatments in patients with AHF. Key outcomes of interest included In-Hospital Cardiovascular mortality rates, duration of hospitalization, and instances of in-hospital worsening. Data extraction and quality assessment adhered to established protocols and the results were evaluated using Review Manager (RevMan Version 5.4.1) The assessment of bias risk follows the principles established in the Cochrane Handbook for Systematic Reviews and Meta-Analysis.

RESULTS

Five RCTs comprising 912 patients met the inclusion criteria. Dapagliflozin significantly reduced In-Hospital Cardiovascular mortality (RR 0.56, 95% CI 0.36-0.88, p = 0.01, I²=26%) and 30-day hospital readmissions (RR 0.73, CI 0.54-0.99, p = 0.05, I²=7%). However, dapagliflozin did not significantly affect the length of hospital stay (MD -0.11, CI -0.73-0.51, p = 0.72, I²=60%) or the incidence of hypotension (RR 0.82, CI 0.36-1.84, p = 0.63, I²=0%). A significant weight change was observed (MD 0.93, CI 0.03-1.83, p = 0.04, I²=95%), which was resolved upon sensitivity analysis (MD 1.34, CI 1.02-1.66, p < 0.0001, I²=0%). No significant effects were found for worsening renal failure or changes in GFR in this study.

CONCLUSION

Dapagliflozin appears to be beneficial in reducing In-Hospital Cardiovascular mortality and 30-day hospital readmissions in AHF patients. Although it demonstrates potential, additional research is needed to establish its significance in AHF management. Further investigation with larger sample sizes, different doses, and comprehensive safety and cost-effectiveness is imperative to thoroughly evaluate the safety and clinical efficacy of Dapagliflozin, underscoring the necessity for additional data to substantiate its role in managing patients with AHF.

CLINICAL TRIAL NUMBER

Not applicable.

Evaluation of clinical events and costs associated with the addition of dapagliflozin to chronic kidney disease treatment: Cost offset analysis

BACKGROUND AND OBJECTIVES

Chronic kidney disease (CKD) is a serious health problem with an increasing clinical, social and economic impact in advanced stages. Dapagliflozin is a sodium-glucose cotransporter-2 inhibitor that reduces the risk of CKD progression, in addition to provide cardiovascular benefits and reduce all-cause mortality. The aim of this study was to determine the short-term clinical and economic impact of dapagliflozin as an add-on to renin-angiotensin-aldosterone system inhibitors (RAASi) standard therapy for CKD in Spain.

MATERIALS AND METHODS

A cost-offset model was used to compare the costs of clinical events and pharmacological per 100,000 CKD patients in a virtual cohort treated with dapagliflozin added to RAASi standard therapy versus RAASi standard therapy alone. Renal (progression to renal failure and acute kidney injury), cardiovascular (hospitalisation for heart failure [HF]), and all-cause mortality events were assessed. The incidence of clinical events by treatment arm was obtained from the DAPA-CKD study, and costs were obtained from national databases and the literature.

RESULTS

Over 3 years, treatment with dapagliflozin would reduce progression to renal failure (-33%; 7221 vs. 10,767), hospitalisation for HF (-49%; 2370 vs. 4683) and acute kidney injury (-29%; 4110 vs. 5819). The savings associated with this reduction in events was ;258 million per 100,000 patients, of which 63.4% is due to the avoidance of dialysis for renal failure. Considering the event and pharmacological treatment costs, the total net savings were estimated at ;158 million per 100,000 patients.

CONCLUSIONS

Delaying progression of CKD and reducing the incidence of clinical events thanks to the treatment with dapagliflozin could generate savings for the Spanish National Health System, even when pharmacological costs are taken into account.

Advances in pharmacotherapy for heart failure and reduced ejection fraction: what's new in 2024?

INTRODUCTION

Updated guidelines for heart failure with reduced ejection fraction (HFrEF) and acute decompensation have improved outcomes, but ongoing efforts are focused on uncovering new evidence and developing novel therapies. This review examines the limitations of current treatments and the potential impact of emerging therapies.

AREAS COVERED

A literature search focused on studies investigating drugs for HFrEF. We review recent clinical trials and emerging therapies to assess evidence strength, explore guideline updates, and identify strategies to optimize patient outcomes.

EXPERT OPINION

The HFrEF treatment landscape is rapidly evolving, with advances in therapies like sodium/glucose cotransporter inhibitors and sacubitril-valsartan. Though managing acute decompensated heart failure remains challenging, recent trials suggest improvements in diuretic strategies and anti-inflammatory treatments. Ongoing research is essential for validating these therapies and incorporating them into standard practice.

From Sweet to Sour: SGLT-2-Inhibitor-Induced Euglycemic Diabetic Ketoacidosis

Sodium-glucose cotransporter 2 (SGLT-2) inhibitors are highly selective, effective, and generally well-tolerated antihyperglycemic agents targeting the SGLT-2 transmembrane protein. Despite being primarily registered for diabetes treatment, due to their cardiorenal protective properties, SGLT-2 inhibitors caused a paradigm shift in the treatment of other diseases on the cardiorenal spectrum, becoming a fundamental part of heart failure and chronic kidney disease management. With their rapidly increasing use, there are also increased reports of a rare, often under-recognised and potentially deadly side effect, SGLT-2-inhibitor-induced euglycemic diabetic ketoacidosis (EDKA). The primary pathophysiological process behind its multifactorial aetiology comprises glucosuria and osmotic diuresis, which produce a significant carbohydrate deficit, leading to an increase in the glucagon-insulin ratio, thus resulting in accelerated ketogenesis. Although EDKA has a similar clinical presentation as diabetic ketoacidosis (DKA), the absence of the high glucose levels typically expected for DKA and the presence of urine ketone reabsorption contribute to a significant delay in its recognition and timely diagnosis. Given the broad use of SGLT-2 inhibitors, increased awareness, early recognition, and prompt identification of precipitating factors are essential. In this narrative review, we comprehensively explore the pathophysiological mechanisms of SGLT-2-inhibitor-induced EDKA, analyse its clinical manifestation, and identify the most common triggers for its development. We also discuss EDKA management and preventive strategies.

Effect of dapagliflozin on ferroptosis through the gut microbiota metabolite TMAO during myocardial ischemia-reperfusion injury in diabetes mellitus rats

Dapagliflozin (DAPA) demonstrates promise in the management of diabetic mellitus (DM) and cardiomyopathy. Trimethylamine N-oxide (TMAO) is synthesized by the gut microbiota through the metabolic conversion of choline and phosphatidylcholine. Ferroptosis may offer novel therapeutic avenues for the management of diabetes and myocardial ischemia-reperfusion injury (IRI). However, the precise mechanism underlying ferroptosis in cardiomyocytes and the specific role of TMAO generated by gut microbiota in the therapeutic approach for DM and myocardial IRI utilizing DAPA need to be further explored. Nine male SD rats with specific pathogen-free (SPF) status were randomly divided equally into the normal group, the DM + IRI (DIR) group, and the DAPA group. The diversity of the gut microbiota was analyzed using 16S rRNA gene sequencing. Additionally, the Wekell technique was employed to measure the levels of TMAO in the three groups. Application of network pharmacology to search for intersection targets of DAPA, DIR, and ferroptosis, and RT-PCR experimental verification. Ultimately, the overlapping targets that were acquired were subjected to molecular docking analysis with TMAO. The changes of Bacteroidetes and Firmicutes in the gut microbiota of DIR rats were most significantly affected by DAPA. Escherichia-Shigella and Prevotella_9 within the phylum Bacteroidetes could be identified as the primary effects of DAPA on DIR. Compared with the normal group, the TMAO content in the DIR group was significantly increased, while the TMAO content in the DAPA group was decreased compared to the DIR group. For the network pharmacology analysis, DAPA and DIR generated 43 intersecting target genes, and then further intersected with ferroptosis-related genes, resulting in 11 overlapping target genes. The mRNA expression of ALB, HMOX1, PPARG, CBS, LCN2, and PPARA decreased in the DIR group through reverse transcription polymerase chain reaction (RT-PCR) validation, while the opposite trend was observed in the DAPA group. The docking score between TMAO and DPP4 was - 5.44, and the MM-GBSA result of - 22.02 kcal/mol. It epitomizes the finest docking performance among all the target genes with the lowest score. DAPA could reduce the levels of metabolite TMAO produced by gut microbiota, thereby regulating related target genes to decrease ferroptosis in DIR cardiomyocytes.

Therapeutic Potential of Ginsenoside Rb1-PLGA Nanoparticles for Heart Failure Treatment via the ROS/PPARα/PGC1α Pathway

(1) Background: Ginsenoside Rb1-PLGA nanoparticles (GRb1@PLGA@NPs) represent a novel nanotherapeutic system, yet their therapeutic efficacy and underlying mechanisms for treating heart failure (HF) remain unexplored. This study aims to investigate the potential mechanisms underlying the therapeutic effects of GRb1@PLGA@NPs in HF treatment; (2) Methods: The left anterior descending coronary artery ligation was employed to establish a HF model in Sprague-Dawley rats, along with an in vitro oxidative stress model using H9c2 myocardial cells. Following treatment with GRb1@PLGA@NPs, cardiac tissue pathological changes and cell proliferation were observed. Additionally, the serum levels of biomarkers such as NT-proBNP, TNF-α, and IL-1β were measured, along with the expression of the ROS/PPARα/PGC1α pathway; (3) Results: GRb1@PLGA@NPs effectively ameliorated the pathological status of cardiac tissues in HF rats, mitigated oxidative stress-induced myocardial cell damage, elevated SOD and MMP levels, and reduced LDH, MDA, ROS, NT-proBNP, TNF-α, and IL-1β levels. Furthermore, the expression of PPARα and PGC1α proteins was upregulated; (4) Conclusions: GRb1@PLGA@NPs may attenuate myocardial cell injury and treat HF through the ROS/PPARα/PGC1α pathway.