Efficacy and safety of empagliflozin at different doses in patients with type 2 diabetes mellitus: A network meta-analysis based on randomized controlled trials

Two-Year Therapeutic Efficacy and Safety of Initial Triple Combination of Metformin, Sitagliptin, and Empagliflozin in Drug-Naïve Type 2 Diabetes Mellitus Patients

BACKGRUOUND

We investigated the long-term efficacy and safety of initial triple therapy using metformin, a dipeptidyl peptidase-4 inhibitor, and a sodium-glucose cotransporter-2 inhibitor, in patients with type 2 diabetes mellitus.

METHODS

We enrolled 170 drug-naïve patients with glycosylated hemoglobin (HbA1c) level >7.5% who had started triple therapy (metformin, sitagliptin, and empagliflozin). Glycemic, metabolic, and urinary parameters were measured for 24 months.

RESULTS

After 24 months, HbA1c level decreased significantly from 11.0%±1.8% to 7.0%±1.7%. At 12 and 24 months, the rates of achievement of the glycemic target goal (HbA1c <7.0%) were 72.5% and 61.7%, respectively, and homeostasis model assessment of β-cell function and insulin resistance indices improved. Whole-body fat percentage decreased by 1.08%, and whole-body muscle percentage increased by 0.97% after 24 months. Fatty liver indices and albuminuria improved significantly. The concentration of ketone bodies was elevated at the baseline but decreased after 24 months. There were no serious adverse events, including ketoacidosis.

CONCLUSION

Initial triple combination therapy with metformin, sitagliptin, and empagliflozin led to achievement of the glycemic target goal, which was maintained for 24 months without severe hypoglycemia but with improved metabolic function and albuminuria. This combination therapy may be a good strategy for drug-naïve patients with type 2 diabetes mellitus.

Empagliflozin and colchicine in patients with reduced left ventricular ejection fraction following ST-elevation myocardial infarction: a randomized, double-blinded, three-arm parallel-group, controlled trial

PURPOSE

There is accumulating evidence regarding the potential benefits of empagliflozin in individuals with acute myocardial infarction (MI). Based on the literature, colchicine could also reduce the risk of MI and death in individuals with cardiovascular disease (CVD). However, trials investigating the effects of the combination of empagliflozin with colchicine and high-dose empagliflozin monotherapy in this setting are lacking.

METHODS

In this trial, 106 non-diabetic participants with reduced left ventricular ejection fraction (LVEF) following recent ST-elevation MI were randomly assigned to empagliflozin 10 mg/day, empagliflozin 10 mg/day plus colchicine 0.5 mg twice daily, or empagliflozin 25 mg/day groups within 72 h after primary percutaneous coronary intervention (PCI). The study's primary outcomes were the changes in New York Heart Association (NYHA) functional class and high-sensitivity C-reactive protein (hs-CRP) over 12 weeks.

RESULTS

The baseline characteristics of individuals were statistically similar between the study groups. Changes in NYHA functional class over 12 weeks were not significantly different between the study groups. hs-CRP was significantly reduced in all groups (all P < 0.001); however, there was no significant change between the groups over the study period. Changes in tumor necrosis factor-alpha (TNF-α), LVEF, and left ventricular end-diastolic dimension (LVEDD) during the research period did not differ significantly between groups.

CONCLUSION

This study showed that neither the combination treatment of empagliflozin 10 mg/day with colchicine nor the monotherapy of empagliflozin 25 mg/day was superior to empagliflozin 10 mg/day in terms of changes in clinical, inflammatory, and echocardiographic outcome parameters in patients with recent MI with reduced LVEF over 3 months. Further studies are warranted to confirm the findings.

TRIAL REGISTRATION

Clinical trial ID: IRCT20111206008307N39. Registration date: 27 October 2022. https://www.irct.ir/trial/66216.

Empagliflozin Use among Patients with Heart Failure in the Outpatient Department of Medicine in a Tertiary Care Centre

Introduction

Sodium-glucose co-transporter 2 inhibitors were initially used in the treatment of type 2 diabetes mellitus and subsequently, it was shown to be useful in heart failure among patients with or without diabetes mellitus. This study aimed to find out the prevalence of empagliflozin use among patients with heart failure in an outpatient department of medicine in a tertiary care centre.

Methods

A descriptive cross-sectional study was conducted among patients with heart failure attending the outpatient Department of Internal Medicine from 1 December 2022 to 30 May 2023 after obtaining ethical approval from the Institutional Review Committee. All patients with heart failure in the given study period were included. A convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval.

Results

Out of 550 patients, 188 (34.18%) (30.22-38.15, 95% Confidence Interval) received empagliflozin. The mean age was 55.11±9.99 years. A total of 124 (65.95%) were male. The mean duration of use was 104.97±63.16 days. Among the adverse effects, electrolyte imbalance was present in 14 (7.44%), hypotension in 14 (7.44%), and acute kidney injury in 12 (6.38%).

Conclusions

The prevalence of empagliflozin use among patients with heart failure was found to be lower than mentioned in the guidelines.

Keywords

heart failure; outpatient care; patient safety; SGLT-2 inhibitors.

Is it time to relitigate SGLT2 Inhibitor dose for heart failure?

Over the past 40 years, we have observed the introduction of several medical therapies for heart failure (HF) with reduced ejection fraction (HFrEF). More recently, effective medical therapy (goal-directed medical therapy; GDMT) for patients who suffer from HF with preserved ejection fraction (HFpEF) has been identified in the form of sodium-glucose cotransporter 2 (SGLT2) inhibitors.¹ There has also been recognition that timely and aggressive GDMT titration to target doses leads to better outcomes.² This becomes more complex as the number of drug up-titrations increases (such as with β blockade at 4 doses), and corresponds to lower target dose achievement, even in Canadian centres of excellence.^3,4 Thus, there is interest in use of simplified dosage regimens, provided there is no significant benefit left unrealized.⁵ To define this tension, one must be able to identify the optimal dosage for any given medication.

Repurposing Drugs for Treatment of Age-Related Macular Degeneration

The need for new drugs to treat dry forms of age-related macular degeneration remains high. A promising approach is repurposing of FDA-approved medications to treat AMD. Databases containing medical and drug records allow for retroactive identification of drugs whose use correlates with reduced AMD diagnosis. This short review summarizes progress in several classes of drugs considered for repurposing: GPR-143 agonists (L-DOPA), anti-diabetic drugs (metformin, acarbose, empagliflozin, fenofibrate), mitochondrial activators (PU-91), and serotonin pathway drugs (fluoxetine, flibanserin, xaliproden, buspirone). The promises and caveats of repurposing are discussed herein.

Clinical Benefit of Switching from Low-Dose to High-Dose Empagliflozin in Patients with Type 2 Diabetes

INTRODUCTION

Sodium-dependent glucose cotransporter 2 (SGLT2) inhibitors ameliorate blood glucose levels in patients with type 2 diabetes mellitus (T2DM) by inhibiting the reabsorption of glucose from the kidneys, thus increasing urinary glucose excretion. Most SGLT2 inhibitors have been reported to exert dose-dependent effects. However, little is known about the benefits of increasing the dose of SGLT2 inhibitors in clinical use. The aim of the present study was to investigate the effect of increasing the dose of the SGLT2 inhibitor empagliflozin in T2DM.

METHODS

We collected 52 subjects with T2DM with inadequate glycemic control. The dose of empagliflozin was increased from 10 to 25 mg, taken once daily, and the alterations in glycemic control and several other clinical parameters were evaluated.

RESULTS

The increased dose of empagliflozin significantly ameliorated glycemic control. In addition, body weight (BW), body mass index (BMI), triglyceride (TG), and γ-glutamyltranspeptidase (GGT) were significantly decreased and hematocrit (Hct) was increased. Multivariate logistic regression analyses revealed that baseline diastolic blood pressure (DBP) (odds ratio 1.093, 95% CI 1.019-1.156, P = 0.012) and baseline TG (odds ratio 1.012, 95% CI 1.001-1.023, P = 0.026) were retained as independent predictors for the improvement of hemoglobin A1c (HbA1c) levels. Moreover, multivariate stepwise regression analyses revealed that changes in high-density lipoprotein cholesterol (β - 0.264, 95% CI - 1.217 to 0.000, P = 0.049) and HbA1c (β 0.302, 95% CI 0.077-1.096, P = 0.025) were retained as independent predictors for changes in BMI.

CONCLUSION

Increasing the dose of empagliflozin significantly ameliorated BW, BMI, GGT, TG, fasting plasma glucose and HbA1c and increased Hct in patients with T2DM. Moreover, baseline DBP and TG were independent predictors for the improvement of HbA1c. These findings may provide useful information when considering increasing the dosage of SGLT2 inhibitors in patients with T2DM who have inadequate glycemic control.

TRIAL REGISTRATION

UMIN Clinical Trials Registry (UMIN000041543).