1
|
Johansen OE, Curti D, von Eynatten M, Rytz A, Lahiry A, Delodder F, Ufheil G, D'Urzo C, Orengo A, Thorne K, Lerea-Antes JS. Oligomalt, a New Slowly Digestible Carbohydrate, Is Well Tolerated in Healthy Young Men and Women at Intakes Up to 180 Gram per Day: A Randomized, Double-Blind, Crossover Trial. Nutrients 2023; 15:2752. [PMID: 37375656 DOI: 10.3390/nu15122752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/01/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
In this randomized, double-blind triple-crossover study (NCT05142137), the digestive tolerance and safety of a novel, slowly digestible carbohydrate (SDC), oligomalt, an α-1,3/α-1,6-glucan α-glucose-based polymer, was assessed in healthy adults over three separate 7-day periods, comparing a high dose of oligomalt (180 g/day) or a moderate dose of oligomalt (80 g/day in combination with 100 g maltodextrin/day) with maltodextrin (180 g/day), provided as four daily servings in 300 mL of water with a meal. Each period was followed by a one-week washout. A total of 24 subjects (15 females, age 34 years, BMI 22.2 kg/m2, fasting blood glucose 4.9 mmol/L) were recruited, of whom 22 completed the course. The effects on the primary endpoint (the Gastrointestinal Symptom Rating Score (GSRS)) showed a statistically significant dose dependency, albeit of limited clinical relevance, between a high dose of oligomalt and maltodextrin (mean (95% CI) 2.29 [2.04, 2.54] vs. 1.59 [1.34, 1.83], respectively; difference: [-1.01, -0.4], p < 0.0001), driven by the GSRS-subdomains "Indigestion" and "Abdominal pain". The GSRS difference ameliorated with product exposure, and the GSRS in those who received high-dose oligomalt as their third intervention period was similar to pre-intervention (mean ± standard deviation: 1.6 ± 0.4 and 1.4 ± 0.3, respectively). Oligomalt did not have a clinically meaningful impact on the Bristol Stool Scale, and it did not cause serious adverse events. These results support the use of oligomalt across various doses as an SDC in healthy, normal weight, young adults.
Collapse
Affiliation(s)
| | | | | | - Andreas Rytz
- Nestlé Research, Clinical Research Unit, 1000 Lausanne, Switzerland
| | - Anirban Lahiry
- Nestlé Research, Clinical Research Unit, 1000 Lausanne, Switzerland
| | | | - Gerhard Ufheil
- Nestlé Research and Development Konolfingen, Société des Produits Nestlé S.A., 3510 Konolfingen, Switzerland
- Nestlé Product Technology Center NHS, Société des Produits Nestlé S.A., Bridgewater, NJ 08807, USA
| | | | - Audrey Orengo
- Société des Produits Nestlé, 1000 Lausanne, Switzerland
| | - Kate Thorne
- Nestlé Health Science, 1000 Lausanne, Switzerland
| | - Jaclyn S Lerea-Antes
- Nestlé Product Technology Center NHS, Société des Produits Nestlé S.A., Bridgewater, NJ 08807, USA
- Nestlé Health Science, Bridgewater, NJ 08807, USA
| |
Collapse
|
2
|
Mohamed M, Zagury RL, Bhaskaran K, Neutel J, Mohd Yusof BN, Mooney L, Yeo L, Kirwan BA, Aprikian O, von Eynatten M, Johansen OE. A Randomized, Placebo-Controlled Crossover Study to Evaluate Postprandial Glucometabolic Effects of Mulberry Leaf Extract, Vitamin D, Chromium, and Fiber in People with Type 2 Diabetes. Diabetes Ther 2023; 14:749-766. [PMID: 36855010 PMCID: PMC10064401 DOI: 10.1007/s13300-023-01379-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 02/03/2023] [Indexed: 03/02/2023] Open
Abstract
INTRODUCTION Reducing postprandial (PP) hyperglycemia and PP glucose excursions is important for overall glycemic management. Although most therapeutic lifestyle interventions that reduce caloric intake would affect this, there is no particular nutritional intervention favored. METHODS We evaluated the effects of a novel natural food adjuvant combining mulberry leaf extract (MLE) with other bioactive ingredients, in people with type 2 diabetes (T2D) originating from Asia, on improving PP glucometabolic response in a randomized controlled exploratory crossover, two-center study (USA, Singapore). A 2-g blend of 250 mg MLE [containing 12.5 mg of 1-deoxynojirimycin (DNJ)], fiber (1.75 g), vitamin D3 (0.75 μg), and chromium (75 μg), compared with a similar blend without the MLE, was sprinkled over a 350-kcal breakfast meal (55.4 g carbs) and PP blood glucose (primary exploratory endpoint), insulin, and incretin hormones (GLP-1, GIP) were evaluated in blood samples over 3 h. Changes in incremental areas under the concentration curve (iAUC) and maximum concentrations (Cmax) were compared. RESULTS Thirty individuals (12 women, mean age 59 years, HbA1c 7.1%, BMI 26.5 kg/m2) were enrolled and the MLE-based blend relative to the blend without MLE significantly reduced glucose iAUC at 1 h (- 20%, p < 0.0001), 2 h (- 17%, p = 0.0001), and 3 h (- 15%, p = 0.0032) and Cmax [mean (95% CI) difference - 0.8 (- 1.2, - 0.3) mmol/L, p = 0.0006]. A statistically significant reduction in 1 h insulin iAUC (- 24%, p = 0.0236) was observed, but this reduction was no longer present at either 2 h or 3 h. No difference in GLP-1 was seen, but GIP response (iAUC and Cmax) was less with the MLE-based blend. CONCLUSIONS The observation of a significant glucose reduction paralleled with a significant lower insulin response supports a reduced gastrointestinal glucose absorption. These results support the use of a 2-g natural blend of MLE, fiber, vitamin D, and chromium in T2D as a convenient dietary adjuvant to improve PP glucometabolic response. CLINICALTRIALS gov identifier NCT04877366.
Collapse
Affiliation(s)
| | | | - Kalpana Bhaskaran
- Temasek Polytechnic, Glycemic Index Research Unit, Singapore, Singapore
| | | | | | - Linda Mooney
- Nestlé Health Science, Bridgewater Township, USA
| | - Lihe Yeo
- Nestlé Health Science, Bridgewater Township, USA
| | - Bridget-Anne Kirwan
- SOCAR Research, Nyon, Switzerland
- Faculty of Epidemiology and Public Health London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | |
Collapse
|
3
|
Lizzo G, Migliavacca E, Lamers D, Frézal A, Corthesy J, Vinyes-Parès G, Bosco N, Karagounis LG, Hövelmann U, Heise T, von Eynatten M, Gut P. A Randomized Controlled Clinical Trial in Healthy Older Adults to Determine Efficacy of Glycine and N-Acetylcysteine Supplementation on Glutathione Redox Status and Oxidative Damage. Front Aging 2022; 3:852569. [PMID: 35821844 PMCID: PMC9261343 DOI: 10.3389/fragi.2022.852569] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 02/08/2022] [Indexed: 01/23/2023]
Abstract
Glycine and cysteine are non-essential amino acids that are required to generate glutathione, an intracellular tripeptide that neutralizes reactive oxygen species and prevents tissue damage. During aging glutathione demand is thought to increase, but whether additional dietary intake of glycine and cysteine contributes towards the generation of glutathione in healthy older adults is not well understood. We investigated supplementation with glycine and n-acetylcysteine (GlyNAC) at three different daily doses for 2 weeks (low dose: 2.4 g, medium dose: 4.8 g, or high dose: 7.2 g/day, 1:1 ratio) in a randomized, controlled clinical trial in 114 healthy volunteers. Despite representing a cohort of healthy older adults (age mean = 65 years), we found significantly higher baseline levels of markers of oxidative stress, including that of malondialdehyde (MDA, 0.158 vs. 0.136 µmol/L, p < 0.0001), total cysteine (Cysteine-T, 314.8 vs. 276 µM, p < 0.0001), oxidized glutathione (GSSG, 174.5 vs. 132.3 µmol/L, p < 0.0001), and a lower ratio of reduced to oxidized glutathione (GSH-F:GSSG) (11.78 vs. 15.26, p = 0.0018) compared to a young reference group (age mean = 31.7 years, n = 20). GlyNAC supplementation was safe and well tolerated by the subjects, but did not increase levels of GSH-F:GSSG (end of study, placebo = 12.49 vs. 7.2 g = 12.65, p-value = 0.739) or that of total glutathione (GSH-T) (end of study, placebo = 903.5 vs. 7.2 g = 959.6 mg/L, p-value = 0.278), the primary endpoint of the study. Post-hoc analyses revealed that a subset of subjects characterized by high oxidative stress (above the median for MDA) and low baseline GSH-T status (below the median), who received the medium and high doses of GlyNAC, presented increased glutathione generation (end of study, placebo = 819.7 vs. 4.8g/7.2 g = 905.4 mg/L, p-value = 0.016). In summary GlyNAC supplementation is safe, well tolerated, and may increase glutathione levels in older adults with high glutathione demand. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT05041179, NCT05041179.
Collapse
Affiliation(s)
- Giulia Lizzo
- Nestlé Institute of Health Sciences, Lausanne, Switzerland
| | | | | | - Adrien Frézal
- Nestlé Institute of Food Safety and Analytical Sciences, Lausanne, Switzerland
| | - John Corthesy
- Nestlé Institute of Food Safety and Analytical Sciences, Lausanne, Switzerland
| | | | - Nabil Bosco
- Nestlé Institute of Health Sciences, Lausanne, Switzerland
| | - Leonidas G Karagounis
- Nestlé Health Science, Vevey, Switzerland.,Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | | | | | - Philipp Gut
- Nestlé Institute of Health Sciences, Lausanne, Switzerland
| |
Collapse
|
4
|
Ruggenenti P, Kraus BJ, Inzucchi SE, Zinman B, Hantel S, Mattheus M, von Eynatten M, Remuzzi G, Koitka-Weber A, Wanner C. Nephrotic-range proteinuria in type 2 diabetes: Effects of empagliflozin on kidney disease progression and clinical outcomes. EClinicalMedicine 2022; 43:101240. [PMID: 35005582 PMCID: PMC8718931 DOI: 10.1016/j.eclinm.2021.101240] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 11/16/2021] [Accepted: 11/24/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Diabetic kidney disease with nephrotic-range proteinuria (NRP) is commonly associated with rapid kidney function loss, increased cardiovascular risk, and premature mortality. We explored the effect of empagliflozin in patients with type 2 diabetes and cardiovascular disease, complicated by presence of this major risk factor for progressive kidney disease, in a post-hoc analysis of data from the EMPA-REG OUTCOME trial (NCT01131676). METHODS Cox proportional hazards models were used to investigate the risk of cardiovascular and kidney outcomes in participants with and without NRP, defined by urine albumin-to-creatinine ratio (UACR) ≥2200 mg/g at baseline. Annual loss of eGFR during chronic treatment (eGFR slopes) and hypothetical time to projected end-stage kidney disease (ESKD), conditioning upon linearity of eGFR change over time if a patient did not decease before projected ESKD, were calculated using a random-intercept random-coefficient model. Safety was described based on investigator-reported adverse events. FINDINGS 112 participants (pooled empagliflozin, n = 70; placebo, n = 42; median on-treatment follow-up of 1·9 years on placebo compared with 2·3 years on empagliflozin) presented with NRP at baseline; eGFR and UACR were balanced between treatments. Empagliflozin benefits on cardiovascular death, hospitalisation for heart failure, or kidney outcomes, were consistent in participants with and without NRP (pinteraction >0·1). Treatment effects of empagliflozin on adjusted annual mean eGFR slope were more pronounced in participants with NRP versus those without (pinteraction 0·005). Empagliflozin was estimated to double the median hypothetical time to projected ESKD in participants with NRP. The overall safety profile of empagliflozin was comparable between participants with and without NRP at baseline. INTERPRETATION Our data suggests that empagliflozin might slow kidney function loss and delay the estimated onset of projected ESKD in patients with type 2 diabetes and cardiovascular disease complicated by NRP.
Collapse
Affiliation(s)
- Piero Ruggenenti
- Department of Renal Medicine, Clinical Research Center for Rare Diseases "Aldo and Cele Daccò", Centro Anna Maria Astori (IRCCS), Science and Technology Park Kilometro Rosso, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Stezzano, 87, Bergamo 24126, Italy
- Unit of Nephrology, Azienda-Socio-Sanitaria-Territoriale, Papa Giovanni XXXIII, Bergamo, Italy
| | - Bettina J. Kraus
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
- Comprehensive Heart Failure Centre, University of Würzburg, Würzburg, Germany
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Silvio E. Inzucchi
- Section of Endocrinology, Yale University School of Medicine, New Haven, CT, USA
| | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, and University of Toronto, Toronto, Canada
| | - Stefan Hantel
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | | | - Maximilian von Eynatten
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Giuseppe Remuzzi
- Department of Renal Medicine, Clinical Research Center for Rare Diseases "Aldo and Cele Daccò", Centro Anna Maria Astori (IRCCS), Science and Technology Park Kilometro Rosso, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Stezzano, 87, Bergamo 24126, Italy
| | - Audrey Koitka-Weber
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, Australia
| | - Christoph Wanner
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| |
Collapse
|
5
|
Wanner C, Cooper ME, Johansen OE, Toto R, Rosenstock J, McGuire DK, Kahn SE, Pfarr E, Schnaidt S, von Eynatten M, George JT, Gollop ND, Marx N, Alexander JH, Zinman B, Perkovic V. Erratum to: Effect of linagliptin versus placebo on cardiovascular and kidney outcomes in nephrotic-range proteinuria and type 2 diabetes (t2d): the carmelina randomised controlled trial. Clin Kidney J 2021; 14:2136. [PMID: 34476096 PMCID: PMC8406051 DOI: 10.1093/ckj/sfab104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
[This corrects the article DOI: 10.1093/ckj/sfaa225.].
Collapse
|
6
|
Klein T, Tammen H, Mark M, Benetti E, Delić D, Schepers C, von Eynatten M. Urinary dipeptidyl peptidase-4 protein is increased by linagliptin and is a potential predictive marker of urine albumin-to-creatinine ratio reduction in patients with type 2 diabetes. Diabetes Obes Metab 2021; 23:1968-1972. [PMID: 33881796 DOI: 10.1111/dom.14407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 03/31/2021] [Accepted: 04/14/2021] [Indexed: 12/01/2022]
Abstract
Results of a post hoc analysis of urinary dipeptidyl peptidase-4 (DPP-4) protein as a predictor of urine albumin-to-creatinine ratio (UACR) response to linagliptin treatment based on MARLINA-T2D trial data are described. MARLINA was a 24-week, phase 3b, multinational, placebo-controlled clinical trial, in which patients with type 2 diabetes (T2D), HbA1c 6.5%-10.0% and UACR 30-3000 mg/g (n = 360) were treated with linagliptin or placebo. After 24 weeks of treatment, linagliptin significantly inhibited urinary DPP-4 activity and increased urinary DPP-4 protein. Furthermore, medium urinary DPP-4 protein levels (between 5.5 and 7.5 natural logarithmic [ln] μg/g creatinine) at baseline allowed for prediction of improved UACR in linagliptin-treated individuals. In patients with lower or higher levels of urinary DPP-4 protein at baseline, no association between linagliptin treatment and improved UACR was present. This might suggest a varying degree of importance of DPP-4 as a pathophysiological factor in T2D-associated kidney disease. In summary, urinary DPP-4 might be a useful predictive biomarker for UACR improvement by linagliptin.
Collapse
Affiliation(s)
- Thomas Klein
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelhein, Germany
| | | | - Michael Mark
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelhein, Germany
| | - Elisa Benetti
- Dipartimento di Scienza e Tecnologia del Farmaco, Università degli Studi di Torino, Turin, Italy
| | - Denis Delić
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelhein, Germany
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology), University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
| | | | - Maximilian von Eynatten
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| |
Collapse
|
7
|
Perkovic V, Koitka-Weber A, Cooper ME, Schernthaner G, Pfarr E, Woerle HJ, von Eynatten M, Wanner C. Choice of endpoint in kidney outcome trials: considerations from the EMPA-REG OUTCOME® trial. Nephrol Dial Transplant 2021; 35:2103-2111. [PMID: 31495881 DOI: 10.1093/ndt/gfz179] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 08/01/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Doubling of serum creatinine [equivalent to 57% reduction in estimated glomerular filtration rate (eGFR)] is an established surrogate for end-stage kidney disease (ESKD); however, this endpoint necessitates lengthy follow-up and large sample sizes in clinical trials. We explored whether alternative eGFR decline thresholds provide more feasible surrogate kidney endpoints. METHODS The study involved post hoc analysis of the EMPA-REG OUTCOME® trial. Adults with type 2 diabetes, high cardiovascular risk and eGFR ≥30 mL/min/1.73 m2 were assigned empagliflozin 10 mg or 25 mg (n = 4687) or placebo (n = 2333), on top of standard of care. We assessed composite endpoints incorporating different eGFR decline thresholds (≥30, ≥40, ≥50 or ≥57%) combined with initiation of renal replacement therapy (RRT) or renal death. This trial is registered with ClinicalTrials.gov (NCT01131676). RESULTS Empagliflozin versus placebo significantly lowered the risk of decline in eGFR for each threshold listed above, combined with initiation of RRT or renal death, ranging from a hazard ratio (HR) of 0.81 [95% confidence interval (CI) 0.72-0.91] for endpoints based on 30% eGFR decline to an HR of 0.37 (0.23-0.61) for endpoints based on 57% eGFR decline. Lower thresholds (e.g. 30%) were associated with higher event rates but weaker treatment effects. The time to the 95% CI of the HR falling to <1.0 decreased with increasing eGFR threshold. CONCLUSIONS The composite of 40% decline in eGFR, ESKD or renal death appears to provide reliable results similar to the traditional 57% decline in eGFR.
Collapse
Affiliation(s)
- Vlado Perkovic
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Audrey Koitka-Weber
- Boehringer Ingelheim International GmbH, Ingelheim, Germany.,Department of Diabetes, Central Clinical School, Monash University, Melbourne, Australia.,Department of Medicine, Würzburg University Clinic, Würzburg, Germany
| | - Mark E Cooper
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, Australia
| | | | - Egon Pfarr
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Hans J Woerle
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | | | - Christoph Wanner
- Department of Medicine, Würzburg University Clinic, Würzburg, Germany
| |
Collapse
|
8
|
Kraus BJ, Weir MR, Bakris GL, Mattheus M, Cherney DZ, Sattar N, Heerspink HJ, Ritter I, von Eynatten M, Zinman B, Inzucchi SE, Wanner C, Koitka-Weber A. Characterization and implications of the initial estimated glomerular filtration rate ‘dip’ upon sodium-glucose cotransporter-2 inhibition with empagliflozin in the EMPA-REG OUTCOME trial. Kidney Int 2021; 99:750-762. [DOI: 10.1016/j.kint.2020.10.031] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/30/2020] [Accepted: 10/15/2020] [Indexed: 01/02/2023]
|
9
|
Wanner C, Cooper ME, Johansen OE, Toto R, Rosenstock J, McGuire DK, Kahn SE, Pfarr E, Schnaidt S, von Eynatten M, George JT, Gollop ND, Marx N, Alexander JH, Zinman B, Perkovic V. Effect of linagliptin versus placebo on cardiovascular and kidney outcomes in nephrotic-range proteinuria and type 2 diabetes: the CARMELINA randomized controlled trial. Clin Kidney J 2021; 14:226-236. [PMID: 33564423 PMCID: PMC7857804 DOI: 10.1093/ckj/sfaa225] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Nephrotic-range proteinuria (NRP) is associated with rapid kidney function loss and increased cardiovascular (CV) disease risk. We assessed the effects of linagliptin (LINA) on CV and kidney outcomes in people with Type 2 diabetes (T2D) with or without NRP. METHODS Cardiovascular and renal microvascular outcome study with LINA randomized participants with T2D and CV disease and/or kidney disease to LINA 5 mg or placebo (PBO). The primary endpoint [time to first occurrence of 3-point major adverse cardiac events (3P-MACE)], and kidney outcomes, were evaluated by NRP status [urinary albumin:creatinine ratio (UACR) ≥2200 mg/g] at baseline (BL) in participants treated with one or more dose of study medication. RESULTS NRP was present in 646/6979 [9.3% (LINA/PBO n = 317/n = 329); median UACR 3486 (Q1: 2746/Q3: 4941) mg/g] participants, who compared with no-NRP were younger (62.3/66.1 years) and had lower estimated glomerular filtration rate (eGFR) (39.9/56.1 mL/min/1.73 m2). Over a median of 2.2 years, 3P-MACE occurred with a 2.0-fold higher rate in NRP versus no-NRP (PBO group), with a neutral LINA effect, regardless of NRP. The composite of time to renal death, end-stage kidney disease (ESKD) or decrease of ≥40 or ≥50% in eGFR, occurred with 12.3- and 13.6-fold higher rate with NRP (PBO group); evidence of heterogeneity of effects with LINA was observed for the former [NRP yes/no: hazard ratio 0.80 (0.63-1.01)/1.25 (1.02-1.54); P-interaction 0.005], but not the latter [0.83 (0.64-1.09)/1.17 (0.91-1.51), P-interaction 0.07]. No heterogeneity was observed for renal death or ESKD [0.88 (0.64-1.21)/0.94 (0.67-1.31), P-interaction 0.79]. Glycated haemoglobin A1c (HbA1c) was significantly reduced regardless of NRP, without increasing hypoglycaemia risk. Regression to normoalbuminuria [1.20 (1.07-1.34)] and reduction of UACR ≥50% [1.15 (1.07-1.25)] from BL, occurred more frequently with LINA, regardless of NRP status (P-interactions >0.05). CONCLUSIONS Individuals with T2D and NRP have a high disease burden. LINA reduces their albuminuria burden and HbA1c, without affecting CV or kidney risk.
Collapse
Affiliation(s)
- Christoph Wanner
- Department of Medicine, Division of Nephrology, Würzburg University Clinic, Würzburg, Germany
| | - Mark E Cooper
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, Australia
| | | | - Robert Toto
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Julio Rosenstock
- Dallas Diabetes Research Center at Medical City, Dallas, TX, USA
| | - Darren K McGuire
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Steven E Kahn
- Department of Medicine, Division of Metabolism, Endocrinology and Nutrition, Puget Sound Health Care System and University of Washington, Seattle, WA, USA
| | - Egon Pfarr
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Sven Schnaidt
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | | | | | | | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | | | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada
- Division of Endocrinology, University of Toronto, Toronto, Canada
| | - Vlado Perkovic
- Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | | |
Collapse
|
10
|
McGuire DK, Zinman B, Inzucchi SE, Wanner C, Fitchett D, Anker SD, Pocock S, Kaspers S, George JT, von Eynatten M, Johansen OE, Jamal W, Mattheus M, Elsasser U, Hantel S, Lund SS. Effects of empagliflozin on first and recurrent clinical events in patients with type 2 diabetes and atherosclerotic cardiovascular disease: a secondary analysis of the EMPA-REG OUTCOME trial. Lancet Diabetes Endocrinol 2020; 8:949-959. [PMID: 33217335 DOI: 10.1016/s2213-8587(20)30344-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 09/22/2020] [Accepted: 09/22/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Patients with type 2 diabetes and atherosclerotic cardiovascular disease are at high clinical risk. We assessed the effect of the sodium-glucose co-transporter-2 inhibitor, empagliflozin, on total cardiovascular events and admissions to hospital in the EMPA-REG OUTCOME trial. METHODS The EMPA-REG OUTCOME trial was a randomised, double-blind, non-inferiority trial of patients (aged ≥18 years) with type 2 diabetes and atherosclerotic cardiovascular disease done between August, 2010, and April, 2015. Participants were randomly assigned (1:1:1) to empagliflozin 10 mg or 25 mg, or placebo. The primary outcome was major adverse cardiovascular events: a composite of cardiovascular death, non-fatal stroke, or non-fatal myocardial infarction. As prespecified, the effects of pooled empagliflozin versus placebo were assessed on total (first plus recurrent) events of major adverse cardiovascular events, fatal or non-fatal myocardial infarction, fatal or non-fatal stroke, and admission to hospital for heart failure. We also did post-hoc analyses on additional cardiovascular and admission to hospital outcomes. We used statistical models that preserve randomisation and account for correlation of recurrent events, including negative binomial regression, as prespecified for the primary analyses. The EMPA-REG OUTCOME trial is registered with ClinicalTrials.gov, NCT01131676, and is closed to accrual. FINDINGS In the EMPA-REG OUTCOME trial, 7020 patients were randomly assigned and treated with empagliflozin 10 mg (n=2345), empagliflozin 25 mg (n=2342), or placebo (n=2333) and followed up for a median of 3·2 years (IQR 2·2 to 3·6) in the pooled empagliflozin group and 3·1 years (2·2 to 3·5) in the placebo group. Analysing total (first plus recurrent) events, empagliflozin versus placebo reduced the risk of major adverse cardiovascular events (rate ratio [RR] 0·78 [95% CI 0·67 to 0·91]; p=0·0020; 12·88 [95% CI 3·74 to 22·02] events prevented per 1000 patient-years); fatal or non-fatal myocardial infarction (0·79 [0·62 to 0·998]; p=0·049; 4·97 [-0·68 to 10·61] events prevented per 1000 patient-years); the composite of fatal or non-fatal myocardial infarction, or coronary revascularisation (0·80 [0·67 to 0·95]; p=0·012; 11·65 [1·25 to 22·05] events prevented per 1000 patient-years); admission to hospital for heart failure (0·58 [0·42 to 0·81]; p=0·0012; 9·67 [3·07 to 16·28] events prevented per 1000 patient-years); and all-cause admission to hospital (0·83 [0·76 to 0·91]; p<0·0001; 50·41 [26·20 to 74·63] events prevented per 1000 patient-years). For outcomes significantly reduced with empagliflozin, risk reductions were numerically larger for total events than for first events. Total fatal or non-fatal stroke was not significantly different between treatment groups (RR 1·10 [95% CI 0·82 to 1·49]; p=0·52). INTERPRETATION Empagliflozin reduced the total burden of cardiovascular complications and all-cause admission to hospital in patients with type 2 diabetes and atherosclerotic cardiovascular disease. FUNDING The Boehringer Ingelheim and Lilly Alliance.
Collapse
Affiliation(s)
- Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, TX, USA.
| | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - Silvio E Inzucchi
- Section of Endocrinology, Yale University School of Medicine, New Haven, CT, USA
| | | | - David Fitchett
- St Michael's Hospital, Division of Cardiology, University of Toronto, Toronto, ON, Canada
| | - Stefan D Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | | | - Waheed Jamal
- Boehringer Ingelheim International, Ingelheim, Germany
| | | | | | | | - Søren S Lund
- Boehringer Ingelheim International, Ingelheim, Germany
| |
Collapse
|
11
|
Wanner C, Inzucchi SE, Zinman B, Koitka-Weber A, Mattheus M, George JT, von Eynatten M, Hauske SJ. Consistent effects of empagliflozin on cardiovascular and kidney outcomes irrespective of diabetic kidney disease categories: Insights from the EMPA-REG OUTCOME trial. Diabetes Obes Metab 2020; 22:2335-2347. [PMID: 32744354 DOI: 10.1111/dom.14158] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 07/10/2020] [Accepted: 07/27/2020] [Indexed: 12/25/2022]
Abstract
AIM To explore the cardiovascular (CV) and kidney effects of empagliflozin in patients with different clinical phenotypes of diabetic kidney disease (DKD) (i.e. with the presence or absence of overt albuminuria) participating in the EMPA-REG OUTCOME trial. MATERIALS AND METHODS EMPA-REG OUTCOME randomized participants (1:1:1) to empagliflozin 10 mg, 25 mg or placebo, added to standard of care. Post hoc, patients with different clinical phenotypes of DKD at baseline were categorized in three subgroups: (a) overt DKD (overt albuminuria [urinary albumin-to-creatinine ratio of >300 mg/g] with any estimated glomerular filtration rate [eGFR]; n = 769); (b) non-overt DKD (kidney impairment [eGFR < 60 mL/min/1.73 m2 ] without overt albuminuria [urinary albumin-to-creatinine ratio of ≤300 mg/g]; n = 1290); and (c) 'all others' (eGFR ≥ 60 mL/min/1.73 m2 without overt albuminuria; n = 4893). Analyses included CV (death, hospitalization for heart failure, all-cause hospitalization) and selected kidney outcomes, change in eGFR and kidney safety. Cox proportional hazards models assessed the consistency of treatment effect across subgroups. RESULTS Empagliflozin significantly reduced the risk of CV and kidney outcomes across all subgroups (P-values for interaction >.05), consistent with the overall trial population findings. Empagliflozin also significantly reduced the yearly loss of eGFR, assessed by chronic slopes, in all subgroups. The adverse event profile of empagliflozin was similar across all subgroups. CONCLUSIONS Empagliflozin may improve CV and kidney outcomes and slow the progression of kidney disease in type 2 diabetes patients with DKD, irrespective of its clinical form, both with or without the presence of overt albuminuria.
Collapse
Affiliation(s)
- Christoph Wanner
- Department of Medicine, Division of Nephrology, Wuerzburg University Clinic, Wuerzburg, Germany
| | - Silvio E Inzucchi
- Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Audrey Koitka-Weber
- Department of Medicine, Division of Nephrology, Wuerzburg University Clinic, Wuerzburg, Germany
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | | | | | | | - Sibylle J Hauske
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
- Vth Department of Medicine, University Medical Center Mannheim, University of Heidelberg, Heidelberg, Germany
| |
Collapse
|
12
|
Lepper PM, Bals R, Jüni P, von Eynatten M. Blood glucose, diabetes and metabolic control in patients with community-acquired pneumonia. Diabetologia 2020; 63:2488-2490. [PMID: 32676817 PMCID: PMC7366469 DOI: 10.1007/s00125-020-05225-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 06/25/2020] [Indexed: 01/30/2023]
Affiliation(s)
- Philipp M Lepper
- Department of Internal Medicine V - Pneumology, Allergology and Intensive Care Medicine, University Hospital of Saarland, Kirrberger Strasse 100, 66421, Homburg/Saar, Germany.
| | - Robert Bals
- Department of Internal Medicine V - Pneumology, Allergology and Intensive Care Medicine, University Hospital of Saarland, Kirrberger Strasse 100, 66421, Homburg/Saar, Germany
| | - Peter Jüni
- Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
- Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | | |
Collapse
|
13
|
Levin A, Perkovic V, Wheeler DC, Hantel S, George JT, von Eynatten M, Koitka-Weber A, Wanner C. Empagliflozin and Cardiovascular and Kidney Outcomes across KDIGO Risk Categories: Post Hoc Analysis of a Randomized, Double-Blind, Placebo-Controlled, Multinational Trial. Clin J Am Soc Nephrol 2020; 15:1433-1444. [PMID: 32994159 PMCID: PMC7536760 DOI: 10.2215/cjn.14901219] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 08/24/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND OBJECTIVES In the Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients (EMPA-REG Outcome), empagliflozin, in addition to standard of care, significantly reduced risk of cardiovascular death by 38%, hospitalization for heart failure by 35%, and incident or worsening nephropathy by 39% compared with placebo in patients with type 2 diabetes and established cardiovascular disease. Using EMPA-REG Outcome data, we assessed whether the Kidney Disease Improving Global Outcomes (KDIGO) CKD classification had an influence on the treatment effect of empagliflozin. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Patients with type 2 diabetes, established atherosclerotic cardiovascular disease, and eGFR≥30 ml/min per 1.73 m2 at screening were randomized to receive empagliflozin 10 mg, empagliflozin 25 mg, or placebo once daily in addition to standard of care. Post hoc, we analyzed cardiovascular and kidney outcomes, and safety, using the two-dimensional KDIGO classification framework. RESULTS Of 6952 patients with baseline eGFR and urinary albumin-creatinine ratio values, 47%, 29%, 15%, and 8% were classified into low, moderately increased, high, and very high KDIGO risk categories, respectively. Empagliflozin showed consistent risk reductions across KDIGO categories for cardiovascular outcomes (P values for treatment by subgroup interactions ranged from 0.26 to 0.85) and kidney outcomes (P values for treatment by subgroup interactions ranged from 0.16 to 0.60). In all KDIGO risk categories, placebo and empagliflozin had similar adverse event rates, the notable exception being genital infection events, which were more common with empagliflozin for each category. CONCLUSIONS The observed effects of empagliflozin versus placebo on cardiovascular and kidney outcomes were consistent across the KDIGO risk categories, indicating that the effect of treatment benefit of empagliflozin was unaffected by baseline CKD status. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER EMPA-REG OUTCOME, NCT01131676.
Collapse
Affiliation(s)
- Adeera Levin
- Division of Nephrology, University of British Columbia, Vancouver, Canada
| | - Vlado Perkovic
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - David C Wheeler
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,Centre for Nephrology, University College London, London, United Kingdom
| | - Stefan Hantel
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | | | | | - Audrey Koitka-Weber
- Boehringer Ingelheim International GmbH, Ingelheim, Germany.,Department of Diabetes, Central Clinical School, Monash University, Melbourne, Australia.,Department of Medicine, Würzburg University Clinic, Würzburg, Germany
| | - Christoph Wanner
- Department of Medicine, Würzburg University Clinic, Würzburg, Germany
| | | |
Collapse
|
14
|
Mayer GJ, Wanner C, Weir MR, Inzucchi SE, Koitka-Weber A, Hantel S, von Eynatten M, Zinman B, Cherney DZI. The authors reply. Kidney Int 2020; 97:213-214. [PMID: 31901342 DOI: 10.1016/j.kint.2019.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 09/06/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Gert J Mayer
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria.
| | - Christoph Wanner
- Division of Nephrology, Würzburg University Clinic, Würzburg, Germany
| | - Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Silvio E Inzucchi
- Section of Endocrinology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Audrey Koitka-Weber
- Division of Nephrology, Würzburg University Clinic, Würzburg, Germany; CardioMetabolism Respiratory Medicine, Boehringer Ingelheim International GmbH, Ingelheim, Germany; Department of Diabetes, Central Clinical School, Monash University, Melbourne, Australia
| | - Stefan Hantel
- CardioMetabolism Respiratory Medicine, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Maximilian von Eynatten
- CardioMetabolism Respiratory Medicine, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, Canada; Department of Physiology, Division of Nephrology, University Health Network, University of Toronto, Canada
| |
Collapse
|
15
|
Cooper ME, Inzucchi SE, Zinman B, Hantel S, von Eynatten M, Wanner C, Koitka-Weber A. Glucose Control and the Effect of Empagliflozin on Kidney Outcomes in Type 2 Diabetes: An Analysis From the EMPA-REG OUTCOME Trial. Am J Kidney Dis 2019; 74:713-715. [DOI: 10.1053/j.ajkd.2019.03.432] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 03/31/2019] [Indexed: 11/11/2022]
|
16
|
Ledesma G, Umpierrez GE, Morley JE, Lewis-D'Agostino D, Keller A, Meinicke T, van der Walt S, von Eynatten M. Efficacy and safety of linagliptin to improve glucose control in older people with type 2 diabetes on stable insulin therapy: A randomized trial. Diabetes Obes Metab 2019; 21:2465-2473. [PMID: 31297968 DOI: 10.1111/dom.13829] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 06/25/2019] [Accepted: 07/07/2019] [Indexed: 12/30/2022]
Abstract
AIM To assess the addition of linagliptin as an alternative to insulin uptitration in older people with type 2 diabetes on stable insulin therapy. MATERIALS AND METHODS This phase 4, randomized, multicentre, double-blinded, placebo-controlled, 24-week study recruited individuals on stable insulin, with baseline HbA1c 7.0%-10.0%, aged ≥60 years and body mass index ≤45 kg/m2 . HbA1c and fasting plasma glucose were measured at study visits, and participants assessed glycaemic control with a self-monitoring blood glucose device. Adverse events (AEs) were reported during the study. RESULTS Three hundred and two participants were randomized 1:1 to linagliptin 5 mg qd and placebo, with one third of patients from Japan. Study population age and HbA1c (baseline mean ± SD) were 72.4 ± 5.4 years and 8.2 ± 0.8%, respectively; ~80% of participants were aged ≥70 years; 80% had macrovascular complications, one third had a baseline estimated glomerular filtration rate <60 mL/min/1.73 m2 ; and half had been diagnosed with diabetes for >15 years. Linagliptin significantly improved glucose control at 24 weeks (HbA1c-adjusted mean change vs. placebo: -0.63%; P <0.0001) and the probability of achieving predefined HbA1c targets without hypoglycaemia (HbA1c <8.0%: OR 2.02; P <0.05 and HbA1c <7.0%: OR 2.44; P <0.01). Linagliptin versus placebo was well tolerated, with similar incidences of AEs, including clinically important hypoglycaemia (blood glucose <54 mg/dL) or severe hypoglycaemia. CONCLUSIONS Addition of linagliptin improves glucose control without an excess of hypoglycaemia in older patients with type 2 diabetes on stable insulin therapy.
Collapse
Affiliation(s)
| | | | - John E Morley
- Division of Geriatric Medicine, Saint Louis University, St. Louis, Missouri
| | | | - Annett Keller
- Global BDS, Boehringer Ingelheim Pharma GmbH & Co, KG, Ingelheim, Germany
| | - Thomas Meinicke
- TA CardioMetabolism, Boehringer Ingelheim International GmbH, Biberach, Germany
| | - Sandra van der Walt
- International Project Management Cardiometabolic/CNS, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | | |
Collapse
|
17
|
Rosenstock J, Kahn SE, Johansen OE, Zinman B, Espeland MA, Woerle HJ, Pfarr E, Keller A, Mattheus M, Baanstra D, Meinicke T, George JT, von Eynatten M, McGuire DK, Marx N. Effect of Linagliptin vs Glimepiride on Major Adverse Cardiovascular Outcomes in Patients With Type 2 Diabetes: The CAROLINA Randomized Clinical Trial. JAMA 2019; 322:1155-1166. [PMID: 31536101 PMCID: PMC6763993 DOI: 10.1001/jama.2019.13772] [Citation(s) in RCA: 342] [Impact Index Per Article: 68.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 08/15/2019] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Type 2 diabetes is associated with increased cardiovascular risk. In placebo-controlled cardiovascular safety trials, the dipeptidyl peptidase-4 inhibitor linagliptin demonstrated noninferiority, but it has not been tested against an active comparator. OBJECTIVE This trial assessed cardiovascular outcomes of linagliptin vs glimepiride (sulfonylurea) in patients with relatively early type 2 diabetes and risk factors for or established atherosclerotic cardiovascular disease. DESIGN, SETTING, AND PARTICIPANTS Randomized, double-blind, active-controlled, noninferiority trial, with participant screening from November 2010 to December 2012, conducted at 607 hospital and primary care sites in 43 countries involving 6042 participants. Adults with type 2 diabetes, glycated hemoglobin of 6.5% to 8.5%, and elevated cardiovascular risk were eligible for inclusion. Elevated cardiovascular risk was defined as documented atherosclerotic cardiovascular disease, multiple cardiovascular risk factors, aged at least 70 years, and evidence of microvascular complications. Follow-up ended in August 2018. INTERVENTIONS Patients were randomized to receive 5 mg of linagliptin once daily (n = 3023) or 1 to 4 mg of glimepiride once daily (n = 3010) in addition to usual care. Investigators were encouraged to intensify glycemic treatment, primarily by adding or adjusting metformin, α-glucosidase inhibitors, thiazolidinediones, or insulin, according to clinical need. MAIN OUTCOMES AND MEASURES The primary outcome was time to first occurrence of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke with the aim to establish noninferiority of linagliptin vs glimepiride, defined by the upper limit of the 2-sided 95.47% CI for the hazard ratio (HR) of linagliptin relative to glimepiride of less than 1.3. RESULTS Of 6042 participants randomized, 6033 (mean age, 64.0 years; 2414 [39.9%] women; mean glycated hemoglobin, 7.2%; median duration of diabetes, 6.3 years; 42% with macrovascular disease; 59% had undergone metformin monotherapy) were treated and analyzed. The median duration of follow-up was 6.3 years. The primary outcome occurred in 356 of 3023 participants (11.8%) in the linagliptin group and 362 of 3010 (12.0%) in the glimepiride group (HR, 0.98 [95.47% CI, 0.84-1.14]; P < .001 for noninferiority), meeting the noninferiority criterion but not superiority (P = .76). Adverse events occurred in 2822 participants (93.4%) in the linagliptin group and 2856 (94.9%) in the glimepiride group, with 15 participants (0.5%) in the linagliptin group vs 16 (0.5%) in the glimepiride group with adjudicated-confirmed acute pancreatitis. At least 1 episode of hypoglycemic adverse events occurred in 320 (10.6%) participants in the linagliptin group and 1132 (37.7%) in the glimepiride group (HR, 0.23 [95% CI, 0.21-0.26]). CONCLUSIONS AND RELEVANCE Among adults with relatively early type 2 diabetes and elevated cardiovascular risk, the use of linagliptin compared with glimepiride over a median 6.3 years resulted in a noninferior risk of a composite cardiovascular outcome. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01243424.
Collapse
Affiliation(s)
- Julio Rosenstock
- Dallas Diabetes Research Center at Medical City, Dallas, Texas
- University of Texas Southwestern Medical Center, Dallas
| | - Steven E. Kahn
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, VA Puget Sound Health Care System, Seattle, Washington
- University of Washington, Seattle
| | | | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada
- Division of Endocrinology, University of Toronto, Toronto, Canada
| | - Mark A. Espeland
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | | | - Egon Pfarr
- Boehringer Ingelheim International GmbH & Co KG, Ingelheim, Germany
| | - Annett Keller
- Boehringer Ingelheim International GmbH & Co KG, Ingelheim, Germany
| | | | | | - Thomas Meinicke
- Boehringer Ingelheim International GmbH & Co KG, Biberach, Germany
| | | | | | | | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Germany
| |
Collapse
|
18
|
Butler J, Zannad F, Fitchett D, Zinman B, Koitka-Weber A, von Eynatten M, Zwiener I, George J, Brueckmann M, Cheung AK, Wanner C. Empagliflozin Improves Kidney Outcomes in Patients With or Without Heart Failure. Circ Heart Fail 2019; 12:e005875. [PMID: 31163986 DOI: 10.1161/circheartfailure.118.005875] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background In EMPA-REG OUTCOME (Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients) empagliflozin significantly reduced the risk of cardiovascular and kidney outcomes in patients with type 2 diabetes mellitus and established cardiovascular disease. Post hoc, we evaluated empagliflozin on kidney outcomes in patients with or without heart failure (HF). Methods and Results Individuals were randomized to empagliflozin 10 mg, 25 mg, or placebo. Prespecified analyses by baseline HF status included risk of incident or worsening nephropathy and estimated glomerular filtration rate slope analyses. Cox proportional hazards models assessed consistency of treatment effect across subgroups. Safety evaluations included kidney-related adverse events. At baseline, 244 (10.5%) and 462 (9.9%) patients had HF in the placebo and empagliflozin groups, respectively. Overall, the incidence of kidney outcome events was numerically higher in patients with than without HF. In the HF group, empagliflozin reduced risk of incident or worsening nephropathy or cardiovascular death by 43% (hazard ratio, 0.57 [95% CI, 0.42-0.77]) and progression to macroalbuminuria by 50% (hazard ratio, 0.50 [0.33-0.75]). After an initial transient decrease, estimated glomerular filtration rate stabilized over time with empagliflozin but gradually declined with placebo. Kidney effects in patients with HF were consistent with those in the overall study population (all P values for interaction >0.05). Across groups, the incidence rate of kidney-related adverse events/100 patient-years was higher in patients with than without HF; however, overall rates were comparable between groups. Conclusions These findings from EMPA-REG OUTCOME support the hypothesis that empagliflozin could reduce the risk of clinically relevant kidney events and may slow progression of chronic kidney disease in individuals with type 2 diabetes mellitus regardless of HF status. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT01131676.
Collapse
Affiliation(s)
- Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson (J.B.)
| | - Faiez Zannad
- Institut Lorrain du Coeur et des Vaisseaux, Nancy, France (F.Z.)
| | - David Fitchett
- Division of Cardiology, St Michael's Hospital (D.F.), University of Toronto, Canada
| | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital (B.Z.), University of Toronto, Canada
| | - Audrey Koitka-Weber
- Boehringer Ingelheim International GmbH, Ingelheim, Germany (A.K.-W., M.v.E., J.G., M.B.).,Department of Diabetes, Central Clinical School, Monash University, Melbourne, Australia (A.K.-W.).,Department of Medicine, Würzburg University Clinic, Germany (A.K.-W., C.W.)
| | | | - Isabella Zwiener
- Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany (I.Z.)
| | - Jyothis George
- Boehringer Ingelheim International GmbH, Ingelheim, Germany (A.K.-W., M.v.E., J.G., M.B.)
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany (A.K.-W., M.v.E., J.G., M.B.).,Faculty of Medicine, University of Heidelberg, Mannheim, Germany (M.B.)
| | - Alfred K Cheung
- Division of Nephrology & Hypertension, University of Utah, Salt Lake City (A.K.C.)
| | - Christoph Wanner
- Department of Medicine, Würzburg University Clinic, Germany (A.K.-W., C.W.)
| |
Collapse
|
19
|
Kadowaki T, Nangaku M, Hantel S, Okamura T, von Eynatten M, Wanner C, Koitka‐Weber A. Empagliflozin and kidney outcomes in Asian patients with type 2 diabetes and established cardiovascular disease: Results from the EMPA-REG OUTCOME ® trial. J Diabetes Investig 2019; 10:760-770. [PMID: 30412655 PMCID: PMC6497612 DOI: 10.1111/jdi.12971] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 10/16/2018] [Accepted: 10/18/2018] [Indexed: 12/15/2022] Open
Abstract
AIMS/INTRODUCTION In the EMPA-REG OUTCOME® trial, empagliflozin added to standard of care improved clinically relevant kidney outcomes by 39%, slowed progression of chronic kidney disease, and reduced albuminuria in patients with type 2 diabetes and established cardiovascular disease. This exploratory analysis investigated the effects of empagliflozin on the kidneys in Asian patients. MATERIALS AND METHODS Participants in the EMPA-REG OUTCOME® trial were randomized (1:1:1) to empagliflozin 10 mg, 25 mg or a placebo. In patients of Asian race, we analyzed incident or worsening nephropathy (progression to macroalbuminuria, doubling of serum creatinine, initiation of renal-replacement therapy or renal death) and its components, estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio changes, and renal safety. RESULTS Of 7,020 treated patients, 1,517 (26.1%) were Asian. In this subgroup, consistent with the overall trial population, empagliflozin reduced the risk of incident or worsening nephropathy (hazard ratio 0.64, 95% confidence interval 0.49-0.83), progression to macroalbuminuria (hazard ratio 0.64, 95% confidence interval 0.49-0.85) and the composite of doubling of serum creatinine, initiation of renal-replacement therapy or renal death (hazard ratio 0.48, 95% confidence interval 0.25-0.92). Furthermore, empagliflozin-treated participants showed slower eGFR decline versus placebo, and showed rapid urine albumin-to-creatinine ratio reduction at week 12, maintained through week 164, with effects most pronounced in those with baseline microalbuminuria or macroalbuminuria. The kidney safety profile of empagliflozin in the Asian subgroup was similar to the overall trial population. CONCLUSIONS In Asian patients from the EMPA-REG OUTCOME® trial, empagliflozin improved kidney outcomes, slowed eGFR decline and lowered albuminuria versus placebo, consistent with the overall trial population findings.
Collapse
Affiliation(s)
| | - Masaomi Nangaku
- Graduate School of MedicineThe University of TokyoTokyoJapan
| | - Stefan Hantel
- Boehringer Ingelheim International GmbHBiberachGermany
| | | | | | | | - Audrey Koitka‐Weber
- Boehringer Ingelheim International GmbHIngelheimGermany
- Department of MedicineWürzburg University ClinicWürzburgGermany
- Department of DiabetesCentral Clinical SchoolMonash UniversityMelbourneVictoriaAustralia
| |
Collapse
|
20
|
Herrington WG, Preiss D, Haynes R, von Eynatten M, Staplin N, Hauske SJ, George JT, Green JB, Landray MJ, Baigent C, Wanner C. Erratum: The potential for improving cardio-renal outcomes by sodium-glucose co-transporter-2 inhibition in people with chronic kidney disease: a rationale for the EMPA-KIDNEY study. Clin Kidney J 2019; 13:722. [PMID: 32905262 PMCID: PMC7467589 DOI: 10.1093/ckj/sfz009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
[This corrects the article DOI: 10.1093/ckj/sfy090.].
Collapse
|
21
|
Siwy J, Klein T, Rosler M, von Eynatten M. Urinary Proteomics as a Tool to Identify Kidney Responders to Dipeptidyl Peptidase-4 Inhibition: A Hypothesis-Generating Analysis from the MARLINA-T2D Trial. Proteomics Clin Appl 2019; 13:e1800144. [PMID: 30632692 DOI: 10.1002/prca.201800144] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 12/27/2018] [Indexed: 01/13/2023]
Abstract
PURPOSE Chronic kidney disease (CKD) is a serious complication of hyperglycemia and treatment options to slow its progression are scarce. Dipeptidyl peptidase-4 (DPP-4) inhibitors are common glucose-lowering drugs in type 2 diabetes (T2D). Among these, linagliptin has been suggested to exert kidney protective effects. It is investigated whether an effect of linagliptin on kidney function could be unmasked by characterizing the urinary proteome profile (UPP) in albuminuric T2D individuals. EXPERIMENTAL DESIGN Participants of the MARLINA-T2D trial (NCT01792518) are randomized 1:1 to receive either linagliptin 5 mg or placebo for 24 weeks. A previously developed proteome-based classifier, CKD273, is assessed. RESULTS Results confirm a significant correlation between CKD273 and clinical kidney parameters as well as with eGFR decline. Patient stratification using CKD273 at baseline, show a trend toward attenuation of renal function loss in high CKD-risk patients treated with linagliptin. Moreover, characterized are linagliptin affected peptides of which the majority contained a DPP-4 target sequence. CONCLUSIONS AND CLINICAL RELEVANCE CKD273 is a promising tool for identifying patients at high risk for CKD progression and may unmask a potential of linagliptin to slow progressive kidney function loss in high CKD-risk patients. UPP characterization reveals a significant impact of linagliptin on urinary peptides.
Collapse
Affiliation(s)
- Justyna Siwy
- mosaiques-diagnostics GmbH, Rotenburger Str. 20, 30659, Hannover, Germany
| | - Thomas Klein
- Boehringer Ingelheim Pharma GmbH & Co. KG, Birkendorfer Str. 65, 88397, Biberach an der Riß, Germany
| | - Marcel Rosler
- Boehringer Ingelheim Pharma GmbH & Co. KG, Birkendorfer Str. 65, 88397, Biberach an der Riß, Germany
| | - Maximilian von Eynatten
- Boehringer Ingelheim International GmbH. KG, Binger Str. 173, 55216, Ingelheim am Rhein, Germany
| |
Collapse
|
22
|
McGuire DK, Alexander JH, Johansen OE, Perkovic V, Rosenstock J, Cooper ME, Wanner C, Kahn SE, Toto RD, Zinman B, Baanstra D, Pfarr E, Schnaidt S, Meinicke T, George JT, von Eynatten M, Marx N. Linagliptin Effects on Heart Failure and Related Outcomes in Individuals With Type 2 Diabetes Mellitus at High Cardiovascular and Renal Risk in CARMELINA. Circulation 2019; 139:351-361. [PMID: 30586723 DOI: 10.1161/circulationaha.118.038352] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Individuals with type 2 diabetes mellitus are at increased risk for heart failure (HF), particularly those with coexisting atherosclerotic cardiovascular disease and/or kidney disease. Some but not all dipeptidyl peptidase-4 inhibitors have been associated with increased HF risk. We performed secondary analyses of HF and related outcomes with the dipeptidyl peptidase-4 inhibitor linagliptin versus placebo in CARMELINA (The Cardiovascular and Renal Microvascular Outcome Study With Linagliptin), a cardiovascular outcomes trial that enrolled participants with type 2 diabetes mellitus and atherosclerotic cardiovascular disease and/or kidney disease. METHODS Participants in 27 countries with type 2 diabetes mellitus and concomitant atherosclerotic cardiovascular disease and/or kidney disease were randomized 1:1 to receive once daily oral linagliptin 5 mg or placebo, on top of standard of care. All hospitalization for HF (hHF), cardiovascular outcomes, and deaths were prospectively captured and centrally adjudicated. In prespecified and post hoc analyses of HF and related events, Cox proportional hazards models adjusting for region and baseline history of HF were used. Recurrent hHF events were analyzed using a negative binomial model. In a subset of participants with left ventricular ejection fraction captured within the year before randomization, HF-related outcomes were assessed in subgroups stratified by left ventricular ejection fraction > or ≤50%. RESULTS CARMELINA enrolled 6979 participants (mean age, 65.9 years; estimated glomerular filtration rate, mL/min per 1.73m2; hemoglobin A1c, 8.0%; 62.9% men; diabetes mellitus duration, 14.8 years), including 1873 (26.8%) with a history of HF at baseline. Median follow-up was 2.2 years. Linagliptin versus placebo did not affect the incidence of hHF (209/3494 [6.0%] versus 226/3485 [6.5%], respectively; hazard ratio [HR], 0.90; 95% CI, 0.74-1.08), the composite of cardiovascular death/hHF (HR, 0.94; 95% CI, 0.82-1.08), or risk for recurrent hHF events (326 versus 359 events, respectively; rate ratio, 0.94; 95% CI, 0.75-1.20). There was no heterogeneity of linagliptin effects on hHF by history of HF at baseline, baseline estimated glomerular filtration rate or urine albumin-creatinine ratio, or prerandomization left ventricular ejection fraction. CONCLUSIONS In a large, international cardiovascular outcome trial in participants with type 2 diabetes mellitus and concomitant atherosclerotic cardiovascular disease and/or kidney disease, linagliptin did not affect the risk of hHF or other selected HF-related outcomes, including among participants with and without a history of HF, across the spectrum of kidney disease, and independent of previous left ventricular ejection fraction. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT01897532.
Collapse
Affiliation(s)
- Darren K McGuire
- University of Texas Southwestern Medical Center, Dallas (D.K.M., R.D.T.)
| | - John H Alexander
- Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A.)
| | | | - Vlado Perkovic
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (V.P.)
| | | | - Mark E Cooper
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, Australia (M.E.C.)
| | - Christoph Wanner
- Department of Medicine, Division of Nephrology, Würzburg University Clinic, Germany (C.W.)
| | - Steven E Kahn
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, Veterans' Administration Puget Sound Health Care System and University of Washington, Seattle (S.E.K.)
| | - Robert D Toto
- University of Texas Southwestern Medical Center, Dallas (D.K.M., R.D.T.)
| | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, and Division of Endocrinology, University of Toronto, Canada (B.Z.)
| | | | - Egon Pfarr
- Boehringer Ingelheim Pharma GmbH & Co. Ingelheim, Germany (E.P., S.S.)
| | - Sven Schnaidt
- Boehringer Ingelheim Pharma GmbH & Co. Ingelheim, Germany (E.P., S.S.)
| | - Thomas Meinicke
- Boehringer Ingelheim International GmbH, Biberach, Germany (T.M.)
| | - Jyothis T George
- Boehringer Ingelheim International, Ingelheim, Germany (J.T.G., M.v.E.)
| | | | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital Aachen, Rheinisch-Westfälische Technische Hochschule Aachen University, Germany (N.M.)
| |
Collapse
|
23
|
Rosenstock J, Perkovic V, Johansen OE, Cooper ME, Kahn SE, Marx N, Alexander JH, Pencina M, Toto RD, Wanner C, Zinman B, Woerle HJ, Baanstra D, Pfarr E, Schnaidt S, Meinicke T, George JT, von Eynatten M, McGuire DK. Effect of Linagliptin vs Placebo on Major Cardiovascular Events in Adults With Type 2 Diabetes and High Cardiovascular and Renal Risk: The CARMELINA Randomized Clinical Trial. JAMA 2019; 321:69-79. [PMID: 30418475 PMCID: PMC6583576 DOI: 10.1001/jama.2018.18269] [Citation(s) in RCA: 692] [Impact Index Per Article: 138.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Type 2 diabetes is associated with increased cardiovascular (CV) risk. Prior trials have demonstrated CV safety of 3 dipeptidyl peptidase 4 (DPP-4) inhibitors but have included limited numbers of patients with high CV risk and chronic kidney disease. OBJECTIVE To evaluate the effect of linagliptin, a selective DPP-4 inhibitor, on CV outcomes and kidney outcomes in patients with type 2 diabetes at high risk of CV and kidney events. DESIGN, SETTING, AND PARTICIPANTS Randomized, placebo-controlled, multicenter noninferiority trial conducted from August 2013 to August 2016 at 605 clinic sites in 27 countries among adults with type 2 diabetes, hemoglobin A1c of 6.5% to 10.0%, high CV risk (history of vascular disease and urine-albumin creatinine ratio [UACR] >200 mg/g), and high renal risk (reduced eGFR and micro- or macroalbuminuria). Participants with end-stage renal disease (ESRD) were excluded. Final follow-up occurred on January 18, 2018. INTERVENTIONS Patients were randomized to receive linagliptin, 5 mg once daily (n = 3494), or placebo once daily (n = 3485) added to usual care. Other glucose-lowering medications or insulin could be added based on clinical need and local clinical guidelines. MAIN OUTCOMES AND MEASURES Primary outcome was time to first occurrence of the composite of CV death, nonfatal myocardial infarction, or nonfatal stroke. Criteria for noninferiority of linagliptin vs placebo was defined by the upper limit of the 2-sided 95% CI for the hazard ratio (HR) of linagliptin relative to placebo being less than 1.3. Secondary outcome was time to first occurrence of adjudicated death due to renal failure, ESRD, or sustained 40% or higher decrease in eGFR from baseline. RESULTS Of 6991 enrollees, 6979 (mean age, 65.9 years; eGFR, 54.6 mL/min/1.73 m2; 80.1% with UACR >30 mg/g) received at least 1 dose of study medication and 98.7% completed the study. During a median follow-up of 2.2 years, the primary outcome occurred in 434 of 3494 (12.4%) and 420 of 3485 (12.1%) in the linagliptin and placebo groups, respectively, (absolute incidence rate difference, 0.13 [95% CI, -0.63 to 0.90] per 100 person-years) (HR, 1.02; 95% CI, 0.89-1.17; P < .001 for noninferiority). The kidney outcome occurred in 327 of 3494 (9.4%) and 306 of 3485 (8.8%), respectively (absolute incidence rate difference, 0.22 [95% CI, -0.52 to 0.97] per 100 person-years) (HR, 1.04; 95% CI, 0.89-1.22; P = .62). Adverse events occurred in 2697 (77.2%) and 2723 (78.1%) patients in the linagliptin and placebo groups; 1036 (29.7%) and 1024 (29.4%) had 1 or more episodes of hypoglycemia; and there were 9 (0.3%) vs 5 (0.1%) events of adjudication-confirmed acute pancreatitis. CONCLUSIONS AND RELEVANCE Among adults with type 2 diabetes and high CV and renal risk, linagliptin added to usual care compared with placebo added to usual care resulted in a noninferior risk of a composite CV outcome over a median 2.2 years. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01897532.
Collapse
Affiliation(s)
- Julio Rosenstock
- Dallas Diabetes Research Center at Medical City, Dallas, Texas
- University of Texas Southwestern Medical Center, Dallas
| | - Vlado Perkovic
- George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | | | - Mark E. Cooper
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, Australia
| | - Steven E. Kahn
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, VA Puget Sound Health Care System and University of Washington, Seattle
| | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Germany
| | - John H. Alexander
- Duke Clinical Research Institute, Duke Health, Durham, North Carolina
| | - Michael Pencina
- Duke Clinical Research Institute, Duke Health, Durham, North Carolina
| | | | - Christoph Wanner
- Division of Nephrology, Department of Medicine, Würzburg University Clinic, Würzburg, Germany
| | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
- Division of Endocrinology, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Egon Pfarr
- Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany
| | - Sven Schnaidt
- Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany
| | | | | | | | | |
Collapse
|
24
|
Herrington WG, Preiss D, Haynes R, von Eynatten M, Staplin N, Hauske SJ, George JT, Green JB, Landray MJ, Baigent C, Wanner C. The potential for improving cardio-renal outcomes by sodium-glucose co-transporter-2 inhibition in people with chronic kidney disease: a rationale for the EMPA-KIDNEY study. Clin Kidney J 2018; 11:749-761. [PMID: 30524708 PMCID: PMC6275453 DOI: 10.1093/ckj/sfy090] [Citation(s) in RCA: 166] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 09/03/2018] [Indexed: 02/06/2023] Open
Abstract
Diabetes is a common cause of chronic kidney disease (CKD), but in aggregate, non-diabetic diseases account for a higher proportion of cases of CKD than diabetes in many parts of the world. Inhibition of the renin–angiotensin system reduces the risk of kidney disease progression and treatments that lower blood pressure (BP) or low-density lipoprotein cholesterol reduce cardiovascular (CV) risk in this population. Nevertheless, despite such interventions, considerable risks for kidney and CV complications remain. Recently, large placebo-controlled outcome trials have shown that sodium-glucose co-transporter-2 (SGLT-2) inhibitors reduce the risk of CV disease (including CV death and hospitalization for heart failure) in people with type 2 diabetes who are at high risk of atherosclerotic disease, and these effects were largely independent of improvements in hyperglycaemia, BP and body weight. In the kidney, increased sodium delivery to the macula densa mediated by SGLT-2 inhibition has the potential to reduce intraglomerular pressure, which may explain why SGLT-2 inhibitors reduce albuminuria and appear to slow kidney function decline in people with diabetes. Importantly, in the trials completed to date, these benefits appeared to be maintained at lower levels of kidney function, despite attenuation of glycosuric effects, and did not appear to be dependent on ambient hyperglycaemia. There is therefore a rationale for studying the cardio-renal effects of SGLT-2 inhibition in people at risk of CV disease and hyperfiltration (i.e. those with substantially reduced nephron mass and/or albuminuria), irrespective of whether they have diabetes.
Collapse
Affiliation(s)
- William G Herrington
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - David Preiss
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Richard Haynes
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Natalie Staplin
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Li Ka Shing Centre for Health Information and Discovery, Big Data Institute, University of Oxford, Oxford, UK
| | | | | | - Jennifer B Green
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Martin J Landray
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Li Ka Shing Centre for Health Information and Discovery, Big Data Institute, University of Oxford, Oxford, UK
| | - Colin Baigent
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | |
Collapse
|
25
|
Wanner C, Heerspink HJL, Zinman B, Inzucchi SE, Koitka-Weber A, Mattheus M, Hantel S, Woerle HJ, Broedl UC, von Eynatten M, Groop PH. Empagliflozin and Kidney Function Decline in Patients with Type 2 Diabetes: A Slope Analysis from the EMPA-REG OUTCOME Trial. J Am Soc Nephrol 2018; 29:2755-2769. [PMID: 30314978 DOI: 10.1681/asn.2018010103] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 09/02/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Empagliflozin slowed the progression of CKD in patients with type 2 diabetes and cardiovascular disease in the EMPA-REG OUTCOME Trial. In a prespecified statistical approach, we assessed treatment differences in kidney function by analyzing slopes of eGFR changes. METHODS Participants (n=7020) were randomized (1:1:1) to empagliflozin 10 mg/d, empagliflozin 25 mg/d, or placebo added to standard of care. We calculated eGFR slopes using random-intercept/random-coefficient models for prespecified study periods: treatment initiation (baseline to week 4), chronic maintenance treatment (week 4 to last value on treatment), and post-treatment (last value on treatment to follow-up). RESULTS Compared with placebo, empagliflozin was associated with uniform shifts in individual eGFR slopes across all periods. On treatment initiation, adjusted mean slope (eGFR change per week, ml/min per 1.73 m2) decreased with empagliflozin (-0.77; 95% confidence interval, -0.83 to -0.71; placebo: 0.01; 95% confidence interval, -0.08 to 0.10; P<0.001). However, annual mean slope (ml/min per 1.73 m2 per year) did not decline with empagliflozin during chronic treatment (empagliflozin: 0.23; 95% confidence interval, 0.05 to 0.40; placebo: -1.46; 95% confidence interval, -1.74 to -1.17; P<0.001). After drug cessation, the adjusted mean eGFR slope (ml/min per 1.73 m2 per week) increased and mean eGFR returned toward baseline level only in the empagliflozin group (0.56; 95% confidence interval, 0.49 to 0.62; placebo -0.02; 95% confidence interval, -0.12 to 0.08; P<0.001). Results were consistent across patient subgroups at higher CKD risk. CONCLUSIONS The hemodynamic effects of empagliflozin, associated with reduction in intraglomerular pressure, may contribute to long-term preservation of kidney function.
Collapse
Affiliation(s)
- Christoph Wanner
- Division of Nephrology, Department of Medicine, Würzburg University Clinic, Würzburg, Germany;
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Silvio E Inzucchi
- Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut
| | - Audrey Koitka-Weber
- Division of Nephrology, Department of Medicine, Würzburg University Clinic, Würzburg, Germany.,Boehringer Ingelheim International GmbH, Ingelheim, Germany.,Department of Diabetes, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | | | - Stefan Hantel
- Boehringer Ingelheim International GmbH, Biberach, Germany
| | | | - Uli C Broedl
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | | | - Per-Henrik Groop
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland.,Abdominal Centre Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; and.,Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland
| | | |
Collapse
|
26
|
Wanner C, von Eynatten M, Zinman B. Response by Wanner et al to Letters Regarding Article, "Empagliflozin and Clinical Outcomes in Patients With Type 2 Diabetes Mellitus, Established Cardiovascular Disease, and Chronic Kidney Disease". Circulation 2018; 138:850-851. [PMID: 30359123 DOI: 10.1161/circulationaha.118.035881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Christoph Wanner
- Department of Medicine, Division of Nephrology, University Hospital of Würzburg, Germany (C.W.)
| | | | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Canada (B.Z.)
| |
Collapse
|
27
|
Bjornstad P, Laffel L, Tamborlane WV, Simons G, Hantel S, von Eynatten M, George J, Marquard J, Cherney DZI. Acute Effect of Empagliflozin on Fractional Excretion of Sodium and eGFR in Youth With Type 2 Diabetes. Diabetes Care 2018; 41:e129-e130. [PMID: 29941496 PMCID: PMC6054503 DOI: 10.2337/dc18-0394] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 05/13/2018] [Indexed: 02/03/2023]
Affiliation(s)
- Petter Bjornstad
- Section of Endocrinology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Lori Laffel
- Joslin Diabetes Center, Harvard Medical School, Boston, MA
| | | | - Gudrun Simons
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany
| | - Stefan Hantel
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany
| | | | - Jyothis George
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Jan Marquard
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - David Z I Cherney
- Department of Physiology and Division of Nephrology, Department of Medicine, and Banting & Best Diabetes Centre, University Health Network, University of Toronto, Toronto, Canada
| |
Collapse
|
28
|
Ruggenenti P, Inzucchi S, Zinman B, Hantel S, Koitka-Weber A, von Eynatten M, Wanner C. SP415EMPAGLIFLOZIN AND PROGRESSION OF CHRONIC KIDNEY DISEASE IN TYPE 2 DIABETES COMPLICATED BY NEPHROTIC-RANGE PROTEINURIA: INSIGHTS FROM THE EMPA-REG OUTCOME® TRIAL. Nephrol Dial Transplant 2018. [DOI: 10.1093/ndt/gfy104.sp415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Piero Ruggenenti
- Clinical Research Center for Rare Diseases "Aldo e Cele Daccò" (IRCCS), Istituto di Ricerche Farmacologiche Mario Negri, Bergamo, Italy
| | - Silvio Inzucchi
- Yale University School of Medicine, Section of Endocrinology, New Haven, CT, United States
| | - Bernard Zinman
- University of Toronto, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - Stefan Hantel
- GmbH & Co. KG, Boehringer Ingelheim Pharma, Biberach, Germany
| | | | | | - Christoph Wanner
- Würzburg University Clinic, Department of Medicine, Division of Nephrology, Würzburg, Germany
| |
Collapse
|
29
|
Siwy J, Mischak H, Klein T, von Eynatten M. FO041URINARY PROTEOMICS MAY UNMASK THE RENAL POTENTIAL OF THE DPP-4 INHIBITOR LINAGLIPTIN IN PATIENTS WITH DIABETIC KIDNEY DISEASE. Nephrol Dial Transplant 2018. [DOI: 10.1093/ndt/gfy104.fo041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Justyna Siwy
- Research and Development, Mosaiques-diagnostics, Hannover, Germany
| | - Harald Mischak
- Research and Development, Mosaiques-diagnostics GmbH, Hannover, Germany
| | - Thomas Klein
- Cardio-metabolic Diseases, Boehringer Ingelheim Pharma GmbH & Co, Ingelheim, Germany
| | | |
Collapse
|
30
|
Yasui A, Lee G, Hirase T, Kaneko T, Kaspers S, von Eynatten M, Okamura T. Empagliflozin Induces Transient Diuresis Without Changing Long-Term Overall Fluid Balance in Japanese Patients With Type 2 Diabetes. Diabetes Ther 2018; 9:863-871. [PMID: 29488164 PMCID: PMC6104279 DOI: 10.1007/s13300-018-0385-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Empagliflozin, a sodium glucose co-transporter 2 (SGLT2) inhibitor, ameliorates hyperglycemia in patients with type 2 diabetes (T2D) by inducing sustained glucosuria. Empagliflozin treatment was previously associated with a transient increase in 24-h urine volume in Caucasian patients with T2D, however comparable evidence in Japanese T2D individuals is scarce. We therefore assessed acute and chronic changes in 24-h urine volume and fluid intake with empagliflozin in Japanese patients with T2D. METHODS In this randomized, double-blind, placebo-controlled, parallel-group, multiple-dose, 4-week trial, 100 Japanese patients with T2D were randomized to receive either 1, 5, 10, or 25 mg empagliflozin or placebo once-daily. Changes from baseline in 24-h urine volume and fluid intake were assessed at days 1, 27, and 28 after the initiation of empagliflozin. RESULTS The 24-h urine volume and fluid intake were comparable across all treatment groups at baseline. Patients treated with either 10 or 25 mg empagliflozin (i.e., the licensed doses in Japan) showed a significant increase in 24-h urine volume compared to placebo at day 1 (mean change from baseline: + 0.83, + 1.08, and + 0.29 L/day in the empagliflozin 10 and 25 mg groups and the placebo group, respectively; both p < 0.001 vs. placebo). However, 24-h urine volume levels in the empagliflozin groups were comparable to placebo at day 27 and 28 (differences vs placebo < 0.1 L/day; p > 0.05). The 24-h fluid intake was comparable across all study groups throughout the entire study period. No events consistent with dehydration were reported during empagliflozin treatment. CONCLUSION Treatment initiation with empagliflozin in Japanese patients with T2D was associated with transient diuresis; however, overall urine volume returned towards baseline levels within 4 weeks of treatment. These findings are consistent with a physiological, adaptive mechanism of the kidney to maintain overall body fluid balance in response to treatment initiation with a SGLT2 inhibitor. TRIAL REGISTRATION NUMBER NCT00885118. FUNDING Nippon Boehringer Ingelheim Co., Ltd.
Collapse
Affiliation(s)
| | | | | | | | - Stefan Kaspers
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim/Rhein, Germany
| | | | | |
Collapse
|
31
|
Rosenstock J, Perkovic V, Alexander JH, Cooper ME, Marx N, Pencina MJ, Toto RD, Wanner C, Zinman B, Baanstra D, Pfarr E, Mattheus M, Broedl UC, Woerle HJ, George JT, von Eynatten M, McGuire DK. Rationale, design, and baseline characteristics of the CArdiovascular safety and Renal Microvascular outcomE study with LINAgliptin (CARMELINA ®): a randomized, double-blind, placebo-controlled clinical trial in patients with type 2 diabetes and high cardio-renal risk. Cardiovasc Diabetol 2018. [PMID: 29540217 PMCID: PMC5870815 DOI: 10.1186/s12933-018-0682-3] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background Cardiovascular (CV) outcome trials in type 2 diabetes (T2D) have underrepresented patients with chronic kidney disease (CKD), leading to uncertainty regarding their kidney efficacy and safety. The CARMELINA® trial aims to evaluate the effects of linagliptin, a DPP-4 inhibitor, on both CV and kidney outcomes in a study population enriched for cardio-renal risk. Methods CARMELINA® is a randomized, double-blind, placebo-controlled clinical trial conducted in 27 countries in T2D patients at high risk of CV and/or kidney events. Participants with evidence of CKD with or without CV disease and HbA1c 6.5–10.0% (48–86 mmol/mol) were randomized 1:1 to receive linagliptin once daily or matching placebo, added to standard of care adjusted according to local guidelines. The primary outcome is time to first occurrence of CV death, non-fatal myocardial infarction, or non-fatal stroke. The key secondary outcome is a composite of time to first sustained occurrence of end-stage kidney disease, ≥ 40% decrease in estimated glomerular filtration rate (eGFR) from baseline, or renal death. CV and kidney events are prospectively adjudicated by independent, blinded clinical event committees. CARMELINA® was designed to continue until at least 611 participants had confirmed primary outcome events. Assuming a hazard ratio of 1.0, this provides 90% power to demonstrate non-inferiority of linagliptin versus placebo within the pre-specified non-inferiority margin of 1.3 at a one-sided α-level of 2.5%. If non-inferiority of linagliptin for the primary outcome is demonstrated, then its superiority for both the primary outcome and the key secondary outcome will be investigated with a sequentially rejective multiple test procedure. Results Between July 2013 and August 2016, 6980 patients were randomized and took ≥ 1 dose of study drug (40.6, 33.1, 16.9, and 9.4% from Europe, South America, North America, and Asia, respectively). At baseline, mean ± SD age was 65.8 ± 9.1 years, HbA1c 7.9 ± 1.0%, BMI 31.3 ± 5.3 kg/m2, and eGFR 55 ± 25 mL/min/1.73 m2. A total of 5148 patients (73.8%) had prevalent kidney disease (defined as eGFR < 60 mL/min/1.73 m2 or macroalbuminuria [albumin-to-creatinine ratio > 300 mg/g]) and 3990 patients (57.2%) had established CV disease with increased albuminuria; these characteristics were not mutually exclusive. Microalbuminuria (n = 2896 [41.5%]) and macroalbuminuria (n = 2691 [38.6%]) were common. Conclusions CARMELINA® will add important information regarding the CV and kidney disease clinical profile of linagliptin by including an understudied, vulnerable cohort of patients with T2D at highest cardio-renal risk. Trial registration ClinicalTrials.gov identifier—NCT01897532; registered July 9, 2013 Electronic supplementary material The online version of this article (10.1186/s12933-018-0682-3) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Julio Rosenstock
- Dallas Diabetes Research Center at Medical City, 7777 Forest Lane, Suite C-685, Dallas, TX, 75230, USA.
| | - Vlado Perkovic
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | | | - Mark E Cooper
- Head of Diabetes, Monash University, Melbourne, VIC, Australia
| | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | | | - Robert D Toto
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada.,University of Toronto, Toronto, Canada
| | | | - Egon Pfarr
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | | | - Uli C Broedl
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | | | | | | | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | |
Collapse
|
32
|
Wanner C, Lachin JM, Inzucchi SE, Fitchett D, Mattheus M, George J, Woerle HJ, Broedl UC, von Eynatten M, Zinman B. Empagliflozin and Clinical Outcomes in Patients With Type 2 Diabetes Mellitus, Established Cardiovascular Disease, and Chronic Kidney Disease. Circulation 2018; 137:119-129. [DOI: 10.1161/circulationaha.117.028268] [Citation(s) in RCA: 283] [Impact Index Per Article: 47.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 08/31/2017] [Indexed: 12/13/2022]
Affiliation(s)
- Christoph Wanner
- Comprehensive Heart Failure Center and Renal Division, University of Wuerzburg and Hospital, Germany (C.W.)
| | - John M. Lachin
- Biostatistics Center, George Washington University, Rockville, MD (J.M.L.)
| | - Silvio E. Inzucchi
- Section of Endocrinology, Yale University School of Medicine, New Haven, CT (S.E.I.)
| | - David Fitchett
- St. Michael’s Hospital, Division of Cardiology, University of Toronto, Canada (D.F.)
| | - Michaela Mattheus
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany (M.M., J.G., H.J.W., U.C.B., M.v.E.)
| | - Jyothis George
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany (M.M., J.G., H.J.W., U.C.B., M.v.E.)
| | - Hans J. Woerle
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany (M.M., J.G., H.J.W., U.C.B., M.v.E.)
| | - Uli C. Broedl
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany (M.M., J.G., H.J.W., U.C.B., M.v.E.)
| | - Maximilian von Eynatten
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany (M.M., J.G., H.J.W., U.C.B., M.v.E.)
| | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada (B.Z.) and Division of Endocrinology, University of Toronto, Canada (B.Z.)
| |
Collapse
|
33
|
Groop P, Cooper ME, Perkovic V, Hocher B, Kanasaki K, Haneda M, Schernthaner G, Sharma K, Stanton RC, Toto R, Cescutti J, Gordat M, Meinicke T, Koitka‐Weber A, Thiemann S, von Eynatten M. Linagliptin and its effects on hyperglycaemia and albuminuria in patients with type 2 diabetes and renal dysfunction: the randomized MARLINA-T2D trial. Diabetes Obes Metab 2017; 19. [PMID: 28636754 PMCID: PMC5655723 DOI: 10.1111/dom.13041] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AIMS The MARLINA-T2D study (ClinicalTrials.gov, NCT01792518) was designed to investigate the glycaemic and renal effects of linagliptin added to standard-of-care in individuals with type 2 diabetes and albuminuria. METHODS A total of 360 individuals with type 2 diabetes, HbA1c 6.5% to 10.0% (48-86 mmol/mol), estimated glomerular filtration rate (eGFR) ≥30 mL/min/1.73 m2 and urinary albumin-to-creatinine ratio (UACR) 30-3000 mg/g despite single agent renin-angiotensin-system blockade were randomized to double-blind linagliptin (n = 182) or placebo (n = 178) for 24 weeks. The primary and key secondary endpoints were change from baseline in HbA1c at week 24 and time-weighted average of percentage change from baseline in UACR over 24 weeks, respectively. RESULTS Baseline mean HbA1c and geometric mean (gMean) UACR were 7.8% ± 0.9% (62.2 ± 9.6 mmol/mol) and 126 mg/g, respectively; 73.7% and 20.3% of participants had microalbuminuria or macroalbuminuria, respectively. After 24 weeks, the placebo-adjusted mean change in HbA1c from baseline was -0.60% (-6.6 mmol/mol) (95% confidence interval [CI], -0.78 to -0.43 [-8.5 to -4.7 mmol/mol]; P < .0001). The placebo-adjusted gMean for time-weighted average of percentage change in UACR from baseline was -6.0% (95% CI, -15.0 to 3.0; P = .1954). The adverse-event profile, including renal safety and change in eGFR, was similar between the linagliptin and placebo groups. CONCLUSIONS In individuals at early stages of diabetic kidney disease, linagliptin significantly improved glycaemic control but did not significantly lower albuminuria. There was no significant change in placebo-adjusted eGFR. Detection of clinically relevant renal effects of linagliptin may require longer treatment, as its main experimental effects in animal studies have been to reduce interstitial fibrosis rather than alter glomerular haemodynamics.
Collapse
Affiliation(s)
- Per‐Henrik Groop
- Folkhälsan Institute of GeneticsFolkhälsan Research Center, Biomedicum HelsinkiHelsinkiFinland
- Abdominal Center NephrologyUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
- Baker IDI Heart and Diabetes InstituteMelbourneAustralia
| | - Mark E. Cooper
- Baker IDI Heart and Diabetes InstituteMelbourneAustralia
| | - Vlado Perkovic
- The George Institute for Global Health, Faculty of MedicineUniversity of SydneySydneyAustralia
| | - Berthold Hocher
- Institute of Nutritional ScienceUniversity of PotsdamPotsdamGermany
- Department of Histology and EmbryologyMedical College, Jinan UniversityGuangzhouChina
- IFLb, Institut für Laboratoriumsmedizin Berlin GmbHBerlinGermany
| | - Keizo Kanasaki
- Department of Diabetology and EndocrinologyKanazawa Medical UniversityKanazawaJapan
- Division of Anticipatory Molecular Food Science and TechnologyMedical Research Institute, Kanazawa Medical UniversityKanazawaJapan
| | - Masakazu Haneda
- Division of Metabolism and Biosystemic Science, Department of MedicineAsahikawa Medical UniversityAsahikawaJapan
| | | | - Kumar Sharma
- Department of Medicine, Center for Renal Translational MedicineUniversity of CaliforniaSan DiegoCalifornia
| | | | - Robert Toto
- Department of Internal MedicineUniversity of Texas Southwestern Medical CenterDallasTexas
| | | | - Maud Gordat
- Boehringer Ingelheim France S.A.SReimsFrance
| | | | | | | | | |
Collapse
|
34
|
Ma RCW, Del Prato S, Gallwitz B, Shivane VK, Lewis‐D'Agostino D, Bailes Z, Patel S, Lee J, von Eynatten M, Di Domenico M, Ross SA. Oral glucose lowering with linagliptin and metformin compared with linagliptin alone as initial treatment in Asian patients with newly diagnosed type 2 diabetes and marked hyperglycemia: Subgroup analysis of a randomized clinical trial. J Diabetes Investig 2017; 9:579-586. [PMID: 28921919 PMCID: PMC5934255 DOI: 10.1111/jdi.12746] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 08/21/2017] [Accepted: 09/13/2017] [Indexed: 12/21/2022] Open
Abstract
AIMS/INTRODUCTION Type 2 diabetes mellitus is an epidemic in Asia, yet clinical trials of glucose-lowering therapies often enroll predominantly Western populations. We explored the initial combination of metformin and linagliptin, a dipeptidyl peptidase-4 inhibitor, in newly diagnosed type 2 diabetes mellitus patients in Asia with marked hyperglycemia. MATERIALS AND METHODS This was a post-hoc subgroup analysis of a multinational, parallel-group clinical trial in which 316 newly diagnosed type 2 diabetes mellitus patients with glycated hemoglobin A1c (HbA1c) 8.5-12.0% were randomized to double-blind oral treatment with linagliptin/metformin or linagliptin monotherapy. The primary end-point was the change from baseline in HbA1c at week 24. We evaluated data for the 125 participants from Asian countries. RESULTS After 24 weeks, the mean ± standard error reduction from baseline in HbA1c (mean 10.0%) was -2.99 ± 0.18% with linagliptin/metformin and -1.84 ± 0.18% with linagliptin; a treatment difference of -1.15% (95% confidence interval -1.65 to -0.66, P < 0.0001). HbA1c <7.0% was achieved by 60% of participants receiving linagliptin/metformin. The mean bodyweight change after 24 weeks was -0.45 ± 0.41 kg and 1.33 ± 0.45 kg in the linagliptin/metformin and linagliptin groups, respectively (treatment difference -1.78 kg [95% confidence interval -2.99 to -0.57, P = 0.0043]). Drug-related adverse events occurred in 9.7% of participants receiving linagliptin/metformin and 4.8% of those receiving linagliptin. Hypoglycemia occurred in 6.5% and 4.8% of the linagliptin/metformin and linagliptin groups, respectively, with no severe episodes. Gastrointestinal disorders occurred in 12.9% and 12.7% of the linagliptin/metformin and linagliptin groups, respectively, with no associated treatment discontinuations. CONCLUSIONS In people from Asia with newly diagnosed type 2 diabetes mellitus and marked hyperglycemia, the initial combination of linagliptin and metformin substantially improved glycemic control without weight gain and with infrequent hypoglycemia. Initial oral combination therapy might be a viable treatment for such individuals.
Collapse
Affiliation(s)
- Ronald CW Ma
- Department of Medicine and TherapeuticsThe Chinese University of Hong KongHong KongChina
| | - Stefano Del Prato
- Section of DiabetesDepartment of Endocrinology and MetabolismUniversity of PisaPisaItaly
| | - Baptist Gallwitz
- Department of Medicine IVUniversity Hospital TübingenTübingenGermany
| | - Vyankatesh K Shivane
- Department of EndocrinologySeth G. S. Medical College and KEM HospitalMumbaiIndia
| | - Diane Lewis‐D'Agostino
- Boehringer Ingelheim Pharmaceuticals Inc.ConnecticutUSA
- Present address:
Purdue Pharmaceuticals LPUSA
| | - Zelie Bailes
- Boehringer Ingelheim LtdBracknellUK
- Present address:
GlaxoSmithKline plcUK
| | - Sanjay Patel
- Boehringer Ingelheim LtdBracknellUK
- Present address:
ProMetic Pharma SMT LtdCambridgeUK
| | - Jisoo Lee
- Boehringer Ingelheim Pharma GmbH & Co. KGIngelheimGermany
| | | | | | - Stuart A Ross
- University of CalgaryLMC Endocrinology CentersAlbertaCanada
| |
Collapse
|
35
|
Marx N, McGuire DK, Perkovic V, Woerle HJ, Broedl UC, von Eynatten M, George JT, Rosenstock J. Composite Primary End Points in Cardiovascular Outcomes Trials Involving Type 2 Diabetes Patients: Should Unstable Angina Be Included in the Primary End Point? Diabetes Care 2017; 40:1144-1151. [PMID: 28830955 DOI: 10.2337/dc17-0068] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 05/26/2017] [Indexed: 02/03/2023]
Abstract
Reductions in cardiovascular (CV) outcomes in recently reported trials, along with the recent approval by the U.S. Food and Drug Administration of an additional indication for empagliflozin to reduce the risk of CV death in type 2 diabetes patients with evidence of CV disease, have renewed interest in CV outcome trials (CVOTs) of glucose-lowering drugs. Composite end points are a pragmatic necessity in CVOTs to ensure that sample size and duration of follow-up remain reasonable. Combining clinical outcomes into a composite end point increases the numbers of events ascertained and thus statistical power and precision. Historically, composite CV end points in diabetes trials have included a larger number of components, while more recent CVOTs almost exclusively use a composite of CV death, nonfatal myocardial infarction (MI), and nonfatal stroke-the so-called three-point major adverse CV event (3P-MACE) composite-or add hospitalization for unstable angina (HUA) to these three outcomes (4P-MACE). The inclusion of HUA increases the number of events for analysis, but noteworthy disadvantages include clinical subjectivity in ascertainment of HUA and its lower prognostic relevance compared with CV death, MI, or stroke. Furthermore, results from recent CVOTs indicate that glucose-lowering agents seem to have minimal impact on HUA. Its inclusion therefore potentially favors a shift of the hazard ratio (HR) toward the null, which is especially problematic in trials designed to demonstrate noninferiority. The primary outcome of 3P-MACE may offer a better balance than 4P-MACE between statistical efficiency, operational complexity, the likelihood of diagnostic precision (and therefore clinical relevance) for each of the component outcomes, clinical importance, and the aim to adequately capture any potential treatment effect of the intervention. Nevertheless, as individual medications may mechanistically differ in their impact on CV outcomes, no particular individual or composite end point can be seen as a "gold standard" for CVOTs of all glucose-lowering drugs.
Collapse
Affiliation(s)
- Nikolaus Marx
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Vlado Perkovic
- The George Institute for Global Health, University of Sydney, Sydney, Australia
| | | | - Uli C Broedl
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | | | | | | |
Collapse
|
36
|
Cherney DZI, Zinman B, Inzucchi SE, Koitka-Weber A, Mattheus M, von Eynatten M, Wanner C. Effects of empagliflozin on the urinary albumin-to-creatinine ratio in patients with type 2 diabetes and established cardiovascular disease: an exploratory analysis from the EMPA-REG OUTCOME randomised, placebo-controlled trial. Lancet Diabetes Endocrinol 2017; 5:610-621. [PMID: 28666775 DOI: 10.1016/s2213-8587(17)30182-1] [Citation(s) in RCA: 254] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 05/08/2017] [Accepted: 05/09/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND In a pooled analysis of short-term trials, short-term treatment with the sodium-glucose co-transporter-2 (SGLT2) inhibitor empagliflozin reduced albuminuria in patients with type 2 diabetes and prevalent albuminuria. In this exploratory analysis of the EMPA-REG OUTCOME trial, we report the short-term and long-term effects of empagliflozin on albuminuria in patients with type 2 diabetes and established cardiovascular disease, according to patients' baseline albuminuria status. METHODS In this randomised, double-blind, placebo-controlled trial at 590 sites in 42 countries, we randomly assigned patients aged 18 years and older with type 2 diabetes and established cardiovascular disease (1:1:1) to empagliflozin 10 mg, empagliflozin 25 mg, or placebo in addition to standard of care until at least 691 patients experienced an adjudicated event included in the primary outcome. We did the randomisation with a computer-generated random-sequence and interactive voice-response and web-response system, stratified by HbA1c, BMI, region, and estimated glomerular filtration rate. Patients, investigators, and individuals involved in analysis of trial data were masked to treatment assignment. The primary and secondary efficacy and safety endpoints of this trial have been reported previously. Here, we report urinary albumin-to-creatinine ratio (UACR) data for the pooled empagliflozin group versus placebo according to albuminuria status at baseline (normoalbuminuria: UACR <30 mg/g; microalbuminuria: UACR ≥30 to ≤300 mg/g; and macroalbuminuria: UACR >300 mg/g). We did the analysis with mixed-model repeated measures including prespecified and post-hoc tests. This study is completed and registered with ClinicalTrials.gov, number NCT01131676. FINDINGS Between Sept 1, 2010, and April 22, 2013, we randomly assigned 7028 patients to treatment groups and 7020 patients received treatment. At baseline, we had UACR data for 6953 patients: 4171 (59% of treated patients; 1382 assigned to placebo and 2789 assigned to empagliflozin) had normoalbuminuria, 2013 (29%; 675 assigned to placebo and 1338 assigned to empagliflozin) had microalbuminuria, and 769 (11%; 260 assigned to placebo and 509 assigned to empagliflozin) had macroalbuminuria. Median treatment duration was 2·6 years (IQR 2·0-3·4; 136 weeks) and median observation time was 3·1 years (2·2-3·6; 164 weeks). After short-term treatment at week 12, the placebo-adjusted geometric mean ratio of UACR change from baseline with empagliflozin was -7% (95% CI -12 to -2; p=0·013) in patients with normoalbuminuria, -25% (-31 to -19; p<0·0001) in patients with microalbuminuria, and -32% (-41 to -23; p<0·0001) in patients with macroalbuminuria. The reductions in UACR were maintained with empagliflozin in all three groups compared with placebo during long-term treatment when measured at 164 weeks. At follow-up, after cessation of treatment for a median of 34 or 35 days, UACR was lower in the empagliflozin versus placebo group in those with baseline microalbuminuria (placebo-corrected adjusted geometric mean ratio of relative change from baseline with empagliflozin: -22%, 95% CI -32 to -11; p=0·0003) or macroalbuminuria (-29%, -44 to -10; p=0·0048), but not for patients with baseline normoalbuminuria (1%, -8 to 10; p=0·8911). Patients treated with empagliflozin were more likely to experience a sustained improvement from microalbuminuria to normoalbuminuria (hazard ratio [HR] 1·43, 95% CI 1·22 to 1·67; p<0·0001) or from macroalbuminuria to microalbuminuria or normoalbuminuria (HR 1·82, 1·40 to 2·37; p<0·0001), and less likely to experience a sustained deterioration from normoalbuminuria to microalbuminuria or macroalbuminuria (HR 0·84, 0·74 to 0·95; p=0·0077). The proportions of patients with any adverse events, serious adverse events, and adverse events leading to discontinuation increased with worsening UACR status at baseline, but were similar between treatment groups. The proportion of patients with genital infections was greater with empagliflozin than placebo in all subgroups by UACR status. INTERPRETATION These results support short-term and long-term benefits of empagliflozin on urinary albumin excretion, irrespective of patients' albuminuria status at baseline. FUNDING Boehringer Ingelheim & Eli Lilly and Company Diabetes Alliance.
Collapse
Affiliation(s)
- David Z I Cherney
- Department of Medicine and Department of Physiology, Division of Nephrology, University Health Network, University of Toronto, Toronto, ON, Canada; Toronto General Hospital, Toronto, ON, Canada.
| | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Silvio E Inzucchi
- Section of Endocrinology, Yale School of Medicine, New Haven, CT, USA
| | | | | | | | - Christoph Wanner
- Division of Nephrology, Würzburg University Clinic, Würzburg, Germany
| |
Collapse
|
37
|
Škrtić M, Yang GK, Perkins BA, Soleymanlou N, Lytvyn Y, von Eynatten M, Woerle HJ, Johansen OE, Broedl UC, Hach T, Silverman M, Cherney DZI. Erratum to: Characterisation of glomerular haemodynamic responses to SGLT2 inhibition in patients with type 1 diabetes and renal hyperfiltration. Diabetologia 2017; 60:1159-1160. [PMID: 28374067 DOI: 10.1007/s00125-017-4241-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Marko Škrtić
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, 585 University Ave, 8N-845, Toronto, ON, Canada, M5G 2N2
| | - Gary K Yang
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, 585 University Ave, 8N-845, Toronto, ON, Canada, M5G 2N2
| | - Bruce A Perkins
- Department of Medicine, Division of Endocrinology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Yuliya Lytvyn
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, 585 University Ave, 8N-845, Toronto, ON, Canada, M5G 2N2
| | | | - Hans J Woerle
- Boehringer Ingelheim Pharma GmbH & Co.KG, Ingelheim, Germany
| | | | - Uli C Broedl
- Boehringer Ingelheim Pharma GmbH & Co.KG, Ingelheim, Germany
| | - Thomas Hach
- Boehringer Ingelheim Pharma GmbH & Co.KG, Ingelheim, Germany
| | - Melvin Silverman
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, 585 University Ave, 8N-845, Toronto, ON, Canada, M5G 2N2
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, 585 University Ave, 8N-845, Toronto, ON, Canada, M5G 2N2.
| |
Collapse
|
38
|
Perkovic V, Levin A, Wheeler D, Koitka-Weber A, Mattheus M, George J, von Eynatten M, Wanner C. SO019EFFECTS OF EMPAGLIFLOZIN ON CARDIOVASCULAR OUTCOMES ACROSS KDIGO RISK CATEGORIES: RESULTS FROM THE EMPA-REG OUTCOME® TRIAL. Nephrol Dial Transplant 2017. [DOI: 10.1093/ndt/gfx103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
39
|
Jax T, Stirban A, Terjung A, Esmaeili H, Berk A, Thiemann S, Chilton R, von Eynatten M, Marx N. A randomised, active- and placebo-controlled, three-period crossover trial to investigate short-term effects of the dipeptidyl peptidase-4 inhibitor linagliptin on macro- and microvascular endothelial function in type 2 diabetes. Cardiovasc Diabetol 2017; 16:13. [PMID: 28109295 PMCID: PMC5251248 DOI: 10.1186/s12933-016-0493-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 12/28/2016] [Indexed: 01/15/2023] Open
Abstract
Background Studies of dipeptidyl peptidase (DPP)-4 inhibitors report heterogeneous effects on endothelial function in patients with type 2 diabetes (T2D). This study assessed the effects of the DPP-4 inhibitor linagliptin versus the sulphonylurea glimepiride and placebo on measures of macro- and microvascular endothelial function in patients with T2D who represented a primary cardiovascular disease prevention population. Methods This crossover study randomised T2D patients (n = 42) with glycated haemoglobin (HbA1c) ≤7.5%, no diagnosed macro- or microvascular disease and on stable metformin background to linagliptin 5 mg qd, glimepiride 1–4 mg qd or placebo for 28 days. Fasting and postprandial macrovascular endothelial function, measured using brachial flow-mediated vasodilation, and microvascular function, measured using laser-Doppler on the dorsal thenar site of the right hand, were analysed after 28 days. Results Baseline mean (standard deviation) age, body mass index and HbA1c were 60.3 (6.0) years, 30.3 (3.0) kg/m2 and 7.41 (0.61)%, respectively. After 28 days, changes in fasting flow-mediated vasodilation were similar between the three study arms (treatment ratio, gMean [90% confidence interval]: linagliptin vs glimepiride, 0.884 [0.633–1.235]; linagliptin vs placebo, 0.884 [0.632–1.235]; glimepiride vs placebo, 1.000 [0.715–1.397]; P = not significant for all comparisons). Similarly, no differences were seen in postprandial flow-mediated vasodilation. However, under fasting conditions, linagliptin significantly improved microvascular function as shown by a 34% increase in hyperaemia area (P = 0.045 vs glimepiride), a 34% increase in resting blow flow (P = 0.011 vs glimepiride, P = 0.003 vs placebo), and a 25% increase in peak blood flow (P = 0.009 vs glimepiride, P = 0.003 vs placebo). There were no significant differences between treatments in postprandial changes. Linagliptin had no effect on heart rate or blood pressure. Rates of overall adverse events with linagliptin, glimepiride and placebo were 27.5, 61.0 and 35.0%, respectively. Fewer hypoglycaemic events were seen with linagliptin (5.0%) and placebo (2.5%) than with glimepiride (39.0%). Conclusions Linagliptin had no effect on macrovascular function in T2D, but significantly improved microvascular function in the fasting state. Trial registration ClinicalTrials.gov identifier—NCT01703286; registered October 1, 2012 Electronic supplementary material The online version of this article (doi:10.1186/s12933-016-0493-3) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Thomas Jax
- Profil Institut für Stoffwechselforschung GmbH, Hellersbergstr. 9, 41460, Neuss, Germany. .,Herzzentrum Wuppertal, Universität Witten/Herdecke, Witten, Germany.
| | - Alin Stirban
- Profil Institut für Stoffwechselforschung GmbH, Hellersbergstr. 9, 41460, Neuss, Germany
| | - Arne Terjung
- Profil Institut für Stoffwechselforschung GmbH, Hellersbergstr. 9, 41460, Neuss, Germany
| | | | - Andreas Berk
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Sandra Thiemann
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Robert Chilton
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | | | - Nikolaus Marx
- RWTH Aachen University, University Hospital Aachen, Aachen, Germany
| |
Collapse
|
40
|
Ross SA, Caballero AE, Del Prato S, Gallwitz B, Lewis-D'Agostino D, Bailes Z, Thiemann S, Patel S, Woerle HJ, von Eynatten M. Linagliptin plus metformin in patients with newly diagnosed type 2 diabetes and marked hyperglycemia. Postgrad Med 2016; 128:747-754. [PMID: 27684308 DOI: 10.1080/00325481.2016.1238280] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Few studies of oral glucose-lowering drugs exist in newly diagnosed type 2 diabetes (T2D) patients with marked hyperglycemia, and insulin is often proposed as initial treatment. We evaluated the oral initial combination of metformin and linagliptin, a dipeptidyl peptidase-4 inhibitor, in this population. METHODS We performed a pre-specified subgroup analysis of a randomized study in which newly diagnosed T2D patients with glycated hemoglobin A1c (HbA1c) 8.5%-12.0% received linagliptin/metformin or linagliptin monotherapy. Subgroups of baseline HbA1c, age, body-mass index (BMI), renal function, race, and ethnicity were evaluated, with efficacy measured by HbA1c change from baseline after 24 weeks. RESULTS HbA1c reductions from baseline (mean 9.7%) at week 24 in the overall population were an adjusted mean -2.81% ± 0.12% with linagliptin/metformin (n = 132) and -2.02% ± 0.13% with linagliptin (n = 113); treatment difference -0.79% (95% CI -1.13 to -0.46, P < 0.0001). In patients with baseline HbA1c ≥9.5%, HbA1c reduction was -3.37% with linagliptin/metformin (n = 76) and -2.53% with linagliptin (n = 61); difference -0.84% (95% CI -1.32 to -0.35). In those with baseline HbA1c <9.5%, HbA1c reduction was -2.08% with linagliptin/metformin (n = 56) and -1.39% with linagliptin (n = 52); difference -0.69% (95% CI -1.23 to -0.15). Changes in HbA1c and treatment differences between the linagliptin/metformin and linagliptin groups were of similar magnitudes to the overall population across patient subgroups based on age, BMI, renal function, and race. Drug-related adverse events occurred in 8.8% and 5.7% of linagliptin/metformin and linagliptin patients, respectively; no severe hypoglycemia occurred. CONCLUSION Linagliptin/metformin combination in newly diagnosed T2D patients with marked hyperglycemia was well tolerated and elicited substantial improvements in glycemic control regardless of baseline HbA1c, age, BMI, renal function, or race. Thus, newly diagnosed, markedly hyperglycemic patients may be effectively treated by combinations of oral agents. CLINICAL TRIAL REGISTRATION www.clinicaltrials.gov identifier is NCT01512979.
Collapse
Affiliation(s)
- Stuart A Ross
- a LMC Endocrinology Centres , University of Calgary , Calgary , Canada
| | | | - Stefano Del Prato
- c Department of Endocrinology and Metabolism, Section of Diabetes , University of Pisa , Pisa , Italy
| | - Baptist Gallwitz
- d Department of Medicine IV , Universitätsklinikum Tübingen , Tübingen , Germany
| | | | | | - Sandra Thiemann
- g Boehringer Ingelheim Pharma GmbH & Co. KG , Ingelheim , Germany
| | | | | | | |
Collapse
|
41
|
Cherney D, Lund SS, Perkins BA, Groop PH, Cooper ME, Kaspers S, Pfarr E, Woerle HJ, von Eynatten M. The effect of sodium glucose cotransporter 2 inhibition with empagliflozin on microalbuminuria and macroalbuminuria in patients with type 2 diabetes. Diabetologia 2016; 59:1860-70. [PMID: 27316632 DOI: 10.1007/s00125-016-4008-2] [Citation(s) in RCA: 124] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 05/13/2016] [Indexed: 11/30/2022]
Abstract
AIMS/HYPOTHESIS Sodium glucose cotransporter 2 (SGLT2) inhibition lowers HbA1c, systolic BP (SBP) and weight in patients with type 2 diabetes and reduces renal hyperfiltration associated with type 1 diabetes, suggesting decreased intraglomerular hypertension. As lowering HbA1c, SBP, weight and intraglomerular pressure is associated with anti-albuminuric effects in diabetes, we hypothesised that SGLT2 inhibition would reduce the urine albumin-to-creatinine ratio (UACR) to a clinically meaningful extent. METHODS We examined the effect of the SGLT2 inhibitor empagliflozin on UACR by pooling data from patients with type 2 diabetes and prevalent microalbuminuria (UACR = 30-300 mg/g; n = 636) or macroalbuminuria (UACR > 300 mg/g; n = 215) who participated in one of five phase III randomised clinical trials. Primary assessment was defined as percentage change in geometric mean UACR from baseline to week 24. RESULTS After controlling for clinical confounders including baseline log-transformed UACR, HbA1c, SBP and estimated GFR (according to the Modification of Diet in Renal Disease [MDRD] formula), treatment with empagliflozin significantly reduced UACR in patients with microalbuminuria (-32% vs placebo; p < 0.001) or macroalbuminuria (-41% vs placebo; p < 0.001). Intriguingly, in regression models, most of the UACR-lowering effect with empagliflozin was not explained by SGLT2 inhibition-related improvements in HbA1c, SBP or weight. CONCLUSIONS/INTERPRETATION In patients with type 2 diabetes and either micro- or macroalbuminuria, empagliflozin reduced UACR by a clinically meaningful amount. This effect was largely independent of the known metabolic or systemic haemodynamic effects of this drug class. Our results further support a direct renal effect of SGLT2 inhibitors. Prospective studies are needed to explore the potential of this intervention to alter the course of kidney disease in high-risk patients with diabetes. TRIAL REGISTRATION Clinicaltrials.gov NCT01177813 (study 1); NCT01159600 (study 2); NCT01159600 (study 3); NCT01210001 (study 4); and NCT01164501 (study 5).
Collapse
Affiliation(s)
- David Cherney
- Toronto General Hospital, 585 University Ave, 8N-845, Toronto, ON, Canada, M5G 2N2.
- Department of Medicine, Division of Nephrology, and Department of Physiology, University of Toronto, Toronto, ON, Canada.
| | - Søren S Lund
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Bruce A Perkins
- Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Per-Henrik Groop
- Abdominal Centre Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Folkhälsan Research Centre, Biomedicum Helsinki, Helsinki, Finland
- Baker IDI Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Mark E Cooper
- Baker IDI Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Stefan Kaspers
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Egon Pfarr
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Hans J Woerle
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | | |
Collapse
|
42
|
Wanner C, Inzucchi SE, Lachin JM, Fitchett D, von Eynatten M, Mattheus M, Johansen OE, Woerle HJ, Broedl UC, Zinman B. Empagliflozin and Progression of Kidney Disease in Type 2 Diabetes. N Engl J Med 2016; 375:323-34. [PMID: 27299675 DOI: 10.1056/nejmoa1515920] [Citation(s) in RCA: 2286] [Impact Index Per Article: 285.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Diabetes confers an increased risk of adverse cardiovascular and renal events. In the EMPA-REG OUTCOME trial, empagliflozin, a sodium-glucose cotransporter 2 inhibitor, reduced the risk of major adverse cardiovascular events in patients with type 2 diabetes at high risk for cardiovascular events. We wanted to determine the long-term renal effects of empagliflozin, an analysis that was a prespecified component of the secondary microvascular outcome of that trial. METHODS We randomly assigned patients with type 2 diabetes and an estimated glomerular filtration rate of at least 30 ml per minute per 1.73 m(2) of body-surface area to receive either empagliflozin (at a dose of 10 mg or 25 mg) or placebo once daily. Prespecified renal outcomes included incident or worsening nephropathy (progression to macroalbuminuria, doubling of the serum creatinine level, initiation of renal-replacement therapy, or death from renal disease) and incident albuminuria. RESULTS Incident or worsening nephropathy occurred in 525 of 4124 patients (12.7%) in the empagliflozin group and in 388 of 2061 (18.8%) in the placebo group (hazard ratio in the empagliflozin group, 0.61; 95% confidence interval, 0.53 to 0.70; P<0.001). Doubling of the serum creatinine level occurred in 70 of 4645 patients (1.5%) in the empagliflozin group and in 60 of 2323 (2.6%) in the placebo group, a significant relative risk reduction of 44%. Renal-replacement therapy was initiated in 13 of 4687 patients (0.3%) in the empagliflozin group and in 14 of 2333 patients (0.6%) in the placebo group, representing a 55% lower relative risk in the empagliflozin group. There was no significant between-group difference in the rate of incident albuminuria. The adverse-event profile of empagliflozin in patients with impaired kidney function at baseline was similar to that reported in the overall trial population. CONCLUSIONS In patients with type 2 diabetes at high cardiovascular risk, empagliflozin was associated with slower progression of kidney disease and lower rates of clinically relevant renal events than was placebo when added to standard care. (Funded by the Boehringer Ingelheim and Eli Lilly and Company Diabetes Alliance; EMPA-REG OUTCOME ClinicalTrials.gov number, NCT01131676.).
Collapse
Affiliation(s)
- Christoph Wanner
- From the Department of Medicine, Division of Nephrology, Würzburg University Clinic, Würzburg (C.W.), and Boehringer Ingelheim Pharma, Ingelheim (M.E., M.M., H.J.W., U.C.B.) - both in Germany; the Section of Endocrinology, Yale University School of Medicine, New Haven, CT (S.E.I.); the Biostatistics Center, George Washington University, Rockville, MD (J.M.L.); the Divisions of Cardiology (D.F.) and Endocrinology (B.Z.), University of Toronto, and the Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital (B.Z.) - both in Toronto; and Boehringer Ingelheim Norway, Asker, Norway (O.E.J.)
| | - Silvio E Inzucchi
- From the Department of Medicine, Division of Nephrology, Würzburg University Clinic, Würzburg (C.W.), and Boehringer Ingelheim Pharma, Ingelheim (M.E., M.M., H.J.W., U.C.B.) - both in Germany; the Section of Endocrinology, Yale University School of Medicine, New Haven, CT (S.E.I.); the Biostatistics Center, George Washington University, Rockville, MD (J.M.L.); the Divisions of Cardiology (D.F.) and Endocrinology (B.Z.), University of Toronto, and the Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital (B.Z.) - both in Toronto; and Boehringer Ingelheim Norway, Asker, Norway (O.E.J.)
| | - John M Lachin
- From the Department of Medicine, Division of Nephrology, Würzburg University Clinic, Würzburg (C.W.), and Boehringer Ingelheim Pharma, Ingelheim (M.E., M.M., H.J.W., U.C.B.) - both in Germany; the Section of Endocrinology, Yale University School of Medicine, New Haven, CT (S.E.I.); the Biostatistics Center, George Washington University, Rockville, MD (J.M.L.); the Divisions of Cardiology (D.F.) and Endocrinology (B.Z.), University of Toronto, and the Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital (B.Z.) - both in Toronto; and Boehringer Ingelheim Norway, Asker, Norway (O.E.J.)
| | - David Fitchett
- From the Department of Medicine, Division of Nephrology, Würzburg University Clinic, Würzburg (C.W.), and Boehringer Ingelheim Pharma, Ingelheim (M.E., M.M., H.J.W., U.C.B.) - both in Germany; the Section of Endocrinology, Yale University School of Medicine, New Haven, CT (S.E.I.); the Biostatistics Center, George Washington University, Rockville, MD (J.M.L.); the Divisions of Cardiology (D.F.) and Endocrinology (B.Z.), University of Toronto, and the Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital (B.Z.) - both in Toronto; and Boehringer Ingelheim Norway, Asker, Norway (O.E.J.)
| | - Maximilian von Eynatten
- From the Department of Medicine, Division of Nephrology, Würzburg University Clinic, Würzburg (C.W.), and Boehringer Ingelheim Pharma, Ingelheim (M.E., M.M., H.J.W., U.C.B.) - both in Germany; the Section of Endocrinology, Yale University School of Medicine, New Haven, CT (S.E.I.); the Biostatistics Center, George Washington University, Rockville, MD (J.M.L.); the Divisions of Cardiology (D.F.) and Endocrinology (B.Z.), University of Toronto, and the Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital (B.Z.) - both in Toronto; and Boehringer Ingelheim Norway, Asker, Norway (O.E.J.)
| | - Michaela Mattheus
- From the Department of Medicine, Division of Nephrology, Würzburg University Clinic, Würzburg (C.W.), and Boehringer Ingelheim Pharma, Ingelheim (M.E., M.M., H.J.W., U.C.B.) - both in Germany; the Section of Endocrinology, Yale University School of Medicine, New Haven, CT (S.E.I.); the Biostatistics Center, George Washington University, Rockville, MD (J.M.L.); the Divisions of Cardiology (D.F.) and Endocrinology (B.Z.), University of Toronto, and the Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital (B.Z.) - both in Toronto; and Boehringer Ingelheim Norway, Asker, Norway (O.E.J.)
| | - Odd Erik Johansen
- From the Department of Medicine, Division of Nephrology, Würzburg University Clinic, Würzburg (C.W.), and Boehringer Ingelheim Pharma, Ingelheim (M.E., M.M., H.J.W., U.C.B.) - both in Germany; the Section of Endocrinology, Yale University School of Medicine, New Haven, CT (S.E.I.); the Biostatistics Center, George Washington University, Rockville, MD (J.M.L.); the Divisions of Cardiology (D.F.) and Endocrinology (B.Z.), University of Toronto, and the Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital (B.Z.) - both in Toronto; and Boehringer Ingelheim Norway, Asker, Norway (O.E.J.)
| | - Hans J Woerle
- From the Department of Medicine, Division of Nephrology, Würzburg University Clinic, Würzburg (C.W.), and Boehringer Ingelheim Pharma, Ingelheim (M.E., M.M., H.J.W., U.C.B.) - both in Germany; the Section of Endocrinology, Yale University School of Medicine, New Haven, CT (S.E.I.); the Biostatistics Center, George Washington University, Rockville, MD (J.M.L.); the Divisions of Cardiology (D.F.) and Endocrinology (B.Z.), University of Toronto, and the Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital (B.Z.) - both in Toronto; and Boehringer Ingelheim Norway, Asker, Norway (O.E.J.)
| | - Uli C Broedl
- From the Department of Medicine, Division of Nephrology, Würzburg University Clinic, Würzburg (C.W.), and Boehringer Ingelheim Pharma, Ingelheim (M.E., M.M., H.J.W., U.C.B.) - both in Germany; the Section of Endocrinology, Yale University School of Medicine, New Haven, CT (S.E.I.); the Biostatistics Center, George Washington University, Rockville, MD (J.M.L.); the Divisions of Cardiology (D.F.) and Endocrinology (B.Z.), University of Toronto, and the Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital (B.Z.) - both in Toronto; and Boehringer Ingelheim Norway, Asker, Norway (O.E.J.)
| | - Bernard Zinman
- From the Department of Medicine, Division of Nephrology, Würzburg University Clinic, Würzburg (C.W.), and Boehringer Ingelheim Pharma, Ingelheim (M.E., M.M., H.J.W., U.C.B.) - both in Germany; the Section of Endocrinology, Yale University School of Medicine, New Haven, CT (S.E.I.); the Biostatistics Center, George Washington University, Rockville, MD (J.M.L.); the Divisions of Cardiology (D.F.) and Endocrinology (B.Z.), University of Toronto, and the Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital (B.Z.) - both in Toronto; and Boehringer Ingelheim Norway, Asker, Norway (O.E.J.)
| |
Collapse
|
43
|
Groop PH, Cooper ME, Perkovic V, Sharma K, Schernthaner G, Haneda M, Hocher B, Gordat M, Cescutti J, Woerle HJ, von Eynatten M. Dipeptidyl peptidase-4 inhibition with linagliptin and effects on hyperglycaemia and albuminuria in patients with type 2 diabetes and renal dysfunction: Rationale and design of the MARLINA-T2D™ trial. Diab Vasc Dis Res 2015. [PMID: 26224765 DOI: 10.1177/1479164115579002] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Efficacy, Safety & Modification of Albuminuria in Type 2 Diabetes Subjects with Renal Disease with LINAgliptin (MARLINA-T2D™), a multicentre, multinational, randomized, double-blind, placebo-controlled, parallel-group, phase 3b clinical trial, aims to further define the potential renal effects of dipeptidyl peptidase-4 inhibition beyond glycaemic control. A total of 350 eligible individuals with inadequately controlled type 2 diabetes and evidence of renal disease are planned to be randomized in a 1:1 ratio to receive either linagliptin 5 mg or placebo in addition to their stable glucose-lowering background therapy for 24 weeks. Two predefined main endpoints will be tested in a hierarchical manner: (1) change from baseline in glycated haemoglobin and (2) time-weighted average of percentage change from baseline in urinary albumin-to-creatinine ratio. Both endpoints are sufficiently powered to test for superiority versus placebo after 24 weeks with α = 0.05. MARLINA-T2D™ is the first of its class to prospectively explore both the glucose- and albuminuria-lowering potential of a dipeptidyl peptidase-4 inhibitor in patients with type 2 diabetes and evidence of renal disease.
Collapse
Affiliation(s)
- Per-Henrik Groop
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Biomedicum Helsinki, Helsinki, Finland Division of Nephrology, Department of Medicine, Helsinki University Central Hospital, Helsinki, Finland Baker IDI Heart & Diabetes Institute, Melbourne, VIC, Australia
| | - Mark E Cooper
- Baker IDI Heart & Diabetes Institute, Melbourne, VIC, Australia
| | - Vlado Perkovic
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
| | - Kumar Sharma
- Research Service and Division of Nephrology-Hypertension, Veterans Affairs San Diego Healthcare System, Veterans Medical Research Foundation, San Diego, CA, USA Center for Renal Translational Medicine, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | | | - Masakazu Haneda
- Division of Metabolism and Biosystemic Science, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Berthold Hocher
- Institute of Nutritional Science, University of Potsdam, Potsdam, Germany
| | | | | | | | | |
Collapse
|
44
|
Cooper ME, Perkovic V, McGill JB, Groop PH, Wanner C, Rosenstock J, Hehnke U, Woerle HJ, von Eynatten M. Kidney Disease End Points in a Pooled Analysis of Individual Patient–Level Data From a Large Clinical Trials Program of the Dipeptidyl Peptidase 4 Inhibitor Linagliptin in Type 2 Diabetes. Am J Kidney Dis 2015; 66:441-9. [DOI: 10.1053/j.ajkd.2015.03.024] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 03/05/2015] [Indexed: 11/11/2022]
|
45
|
McGill JB, Yki-Järvinen H, Crowe S, Woerle HJ, von Eynatten M. Combination of the dipeptidyl peptidase-4 inhibitor linagliptin with insulin-based regimens in type 2 diabetes and chronic kidney disease. Diab Vasc Dis Res 2015; 12:249-57. [PMID: 25941160 DOI: 10.1177/1479164115579001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Glucose-lowering treatment options for type 2 diabetes mellitus patients with chronic kidney disease are limited. We evaluated the potential for linagliptin in combination with insulin in type 2 diabetes mellitus patients with mild-to-severe renal impairment. Data for participants in two phase 3 trials with linagliptin who were receiving insulin were analysed separately (n = 811). Placebo-adjusted mean HbA1c changes from baseline were -0.59% (mild renal impairment) and -0.69% (moderate renal impairment) after 24 weeks and -0.43% (severe renal impairment) after 12 weeks. Drug-related adverse events with linagliptin were similar to placebo (mild renal impairment: 19.9% vs. 26.5%; moderate renal impairment: 22.0% vs. 25.0%; severe renal impairment: 46.3% vs. 43.6%, respectively). Frequencies of hypoglycaemia in patients with mild, moderate and severe renal impairment were 34.9%, 35.6% and 66.7% with linagliptin and 37.5%, 39.7% and 49.1% with placebo, respectively. Episodes of severe hypoglycaemia were low (⩽5.6%). Adding linagliptin to insulin in type 2 diabetes mellitus patients with chronic kidney disease improved glucose control and was well tolerated.
Collapse
Affiliation(s)
- Janet B McGill
- Washington University School of Medicine in St Louis, St Louis, MO, USA
| | | | - Susanne Crowe
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | | | | |
Collapse
|
46
|
Thrasher J, Kountz DS, Crowe S, Woerle HJ, von Eynatten M. Efficacy and safety of the dipeptidyl peptidase-4 inhibitor linagliptin in black/African American patients with type 2 diabetes: Pooled analysis from eight Phase III trials. Postgrad Med 2015; 127:419-28. [PMID: 25840727 DOI: 10.1080/00325481.2015.1027132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The prevalence of type 2 diabetes in black/African Americans from North and South America is high; yet data evaluating antidiabetic agents in this population is scarce. To address this gap, we pooled data from the clinical development program for linagliptin. METHODS A retrospective pooled analysis of eight completed randomized, placebo-controlled Phase III trials of linagliptin identified 336 patients with type 2 diabetes who self-identified their ethnicity as black or African American. Participants received linagliptin (n = 173, 5 mg/day) or placebo (n = 163) as monotherapy, or as add-on to other antidiabetic agents, including insulin. The primary end point was the change in glycated hemoglobin (HbA1c) from baseline to week 18 or 24. RESULTS The placebo-adjusted mean change (95% confidence interval [CI]) in HbA1c from baseline was -0.69% (-0.92 to -0.46; p < 0.0001) at week 18 (eight trials), and -0.64% (-0.90 to -0.39; p < 0.0001) at week 24 (six trials). The placebo-adjusted mean change (95% CI) in fasting plasma glucose from baseline was -11.7 mg/dL (-23.1 to -0.3; p = 0.0446) at week 18 and -14.7 mg/dL (-25.7 to -3.8; p = 0.0087) at week 24. Incidence of investigator-defined hypoglycemia was similar between the two groups (linagliptin, 12.1%; placebo, 11.7%). Overall, the safety profile of linagliptin in this patient group was comparable to that of placebo, with comparable incidence of adverse events; linagliptin was weight-neutral in this patient population. CONCLUSION Linagliptin provided clinically significant improvements in glycemic control without increased risk of hypoglycemia and without weight gain, representing a useful type 2 diabetes therapy option for the black/African American population.
Collapse
|
47
|
Jax TW, von Eynatten M, Stirban A, Terjung A, Esmaeili H, Berk A, Thiemann S, Chilton R, Marx N. A RANDOMIZED, ACTIVE- AND PLACEBO-CONTROLLED, THREE-PERIOD CROSSOVER TRIAL TO INVESTIGATE SHORT-TERM EFFECTS OF THE DIPEPTIDYL PEPTIDASE-4 INHIBITOR LINAGLIPTIN ON ENDOTHELIAL FUNCTION IN TYPE 2 DIABETES. J Am Coll Cardiol 2015. [DOI: 10.1016/s0735-1097(15)62080-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
48
|
Laakso M, Rosenstock J, Groop PH, Barnett AH, Gallwitz B, Hehnke U, Tamminen I, Patel S, von Eynatten M, Woerle HJ. Treatment with the dipeptidyl peptidase-4 inhibitor linagliptin or placebo followed by glimepiride in patients with type 2 diabetes with moderate to severe renal impairment: a 52-week, randomized, double-blind clinical trial. Diabetes Care 2015; 38:e15-7. [PMID: 25614693 DOI: 10.2337/dc14-1684] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Markku Laakso
- Department of Medicine, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
| | - Julio Rosenstock
- Dallas Diabetes and Endocrine Center at Medical City, Dallas, TX
| | - Per-Henrik Groop
- Department of Medicine, Division of Nephrology, Helsinki University Central Hospital, Helsinki, Finland; Folkhälsan Institute of Genetics, Folkhälsan Research Center, Biomedicum Helsinki, Helsinki, Finland; and Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Anthony H Barnett
- Diabetes and Endocrinology Centre, Heart of England National Health Service Foundation Trust, and University of Birmingham, Birmingham, U.K
| | - Baptist Gallwitz
- Department of Medicine IV, Universitäts-Klinikum Tübingen, Tübingen, Germany
| | - Uwe Hehnke
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | | | | | | | | |
Collapse
|
49
|
Skrtić M, Yang GK, Perkins BA, Soleymanlou N, Lytvyn Y, von Eynatten M, Woerle HJ, Johansen OE, Broedl UC, Hach T, Silverman M, Cherney DZI. Characterisation of glomerular haemodynamic responses to SGLT2 inhibition in patients with type 1 diabetes and renal hyperfiltration. Diabetologia 2014; 57:2599-602. [PMID: 25280671 DOI: 10.1007/s00125-014-3396-4] [Citation(s) in RCA: 107] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Accepted: 09/10/2014] [Indexed: 01/13/2023]
Affiliation(s)
- Marko Skrtić
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, 585 University Ave, 8N-845, Toronto, ON, Canada, M5G 2N2
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Graefe-Mody U, Friedrich C, von Eynatten M, Thiemann S, Heise T, Woerle HJ. Letter to the editor regarding: “Pharmacokinetics of teneligliptin in subjects with renal impairment.” Halabi et al., Clinical Pharmacology in Drug Development2013;2:246-254. Clin Pharmacol Drug Dev 2014; 3:417-8. [DOI: 10.1002/cpdd.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 01/08/2014] [Indexed: 11/06/2022]
Affiliation(s)
| | - Christian Friedrich
- Boehringer Ingelheim; Biberach Germany (current address: Bayer Healthcare, Berlin, Germany)
| | | | | | | | | |
Collapse
|