1
|
Wada T, Mori‐Anai K, Kawaguchi Y, Katsumata H, Tsuda H, Iida M, Arakawa K, Jardine MJ. Renal, cardiovascular and safety outcomes of canagliflozin in patients with type 2 diabetes and nephropathy in East and South-East Asian countries: Results from the Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation Trial. J Diabetes Investig 2022; 13:54-64. [PMID: 34212533 PMCID: PMC8756319 DOI: 10.1111/jdi.13624] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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] [Received: 12/03/2020] [Revised: 06/23/2021] [Accepted: 06/27/2021] [Indexed: 11/28/2022] Open
Abstract
AIMS/INTRODUCTION The sodium-glucose cotransporter 2 inhibitor, canagliflozin, reduced kidney failure and cardiovascular events in the Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation (CREDENCE) trial. We carried out a post-hoc analysis to evaluate the efficacy and safety of canagliflozin in a subgroup of participants in East and South-East Asian (EA) countries who are at high risk of renal complications. MATERIALS AND METHODS Participants with an estimated glomerular filtration rate of 30 to <90 mL/min/1.73 m2 and urinary albumin-to-creatinine ratio of >300-5,000 mg/g were randomized to 100 mg of canagliflozin or a placebo. The effects of canagliflozin treatment on pre-specified efficacy and safety outcomes were examined using Cox proportional hazards regression between participants from EA countries (China, Japan, Malaysia, the Philippines, South Korea and Taiwan) and the remaining participants. RESULTS Of 4,401 participants, 604 (13.7%) were from EA countries; 301 and 303 were assigned to the canagliflozin and placebo groups, respectively. Canagliflozin lowered the risk of primary outcome (composite of end-stage kidney disease, doubling of serum creatinine level, or renal or cardiovascular death) in EA participants (hazard ratio 0.54, 95% confidence interval 0.35-0.84). The effects of canagliflozin on renal and cardiovascular outcomes in EA participants were generally similar to those of the remaining participants. Safety outcomes were similar between the EA and non-EA participants. CONCLUSIONS In the CREDENCE trial, the risk of renal and cardiovascular events was safely reduced in participants from EA countries at high risk of renal events.
Collapse
Affiliation(s)
- Takashi Wada
- Department of Nephrology and Laboratory Medicine, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Graduate School of Medical SciencesKanazawa UniversityKanazawaJapan
| | - Kazumi Mori‐Anai
- Ikuyaku. Integrated Value Development DivisionMitsubishi Tanabe Pharma CorporationTokyoJapan
| | - Yutaka Kawaguchi
- Ikuyaku. Integrated Value Development DivisionMitsubishi Tanabe Pharma CorporationTokyoJapan
| | - Hideyuki Katsumata
- Ikuyaku. Integrated Value Development DivisionMitsubishi Tanabe Pharma CorporationOsakaJapan
| | - Hidetaka Tsuda
- Ikuyaku. Integrated Value Development DivisionMitsubishi Tanabe Pharma CorporationTokyoJapan
| | - Mitsutaka Iida
- Ikuyaku. Integrated Value Development DivisionMitsubishi Tanabe Pharma CorporationTokyoJapan
| | - Kenji Arakawa
- Ikuyaku. Integrated Value Development DivisionMitsubishi Tanabe Pharma CorporationTokyoJapan
| | - Meg J Jardine
- The George Institute for Global Health, UNSWSydneyAustralia
- NHMRC Clinical Trials CenterUniversity of SydneySydneyAustralia
- Concord Repatriation General HospitalSydneyAustralia
| |
Collapse
|
2
|
Agarwal R, Anker SD, Filippatos G, Pitt B, Rossing P, Ruilope LM, Boletis J, Toto R, Umpierrez GE, Wanner C, Wada T, Scott C, Joseph A, Ogbaa I, Roberts L, Scheerer MF, Bakris GL. Effects of canagliflozin versus finerenone on cardiorenal outcomes: exploratory post-hoc analyses from FIDELIO-DKD compared to reported CREDENCE results. Nephrol Dial Transplant 2021; 37:1261-1269. [PMID: 34850173 PMCID: PMC9217637 DOI: 10.1093/ndt/gfab336] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Indexed: 11/12/2022] Open
Abstract
Background The nonsteroidal mineralocorticoid receptor antagonist finerenone and the sodium–glucose cotransporter-2 inhibitor (SGLT-2i) canagliflozin reduce cardiorenal risk in albuminuric patients with chronic kidney disease (CKD) and type 2 diabetes (T2D). At first glance, the results of Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease (FIDELIO-DKD) (ClinicalTrials.gov, NCT02540993) and Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation (CREDENCE) appear disparate. In FIDELIO-DKD, the primary endpoint had an 18% [95% confidence interval (CI) 7–27] relative risk reduction; in CREDENCE, the primary endpoint had a 30% (95% CI 18–41) relative risk reduction. Unlike CREDENCE, the FIDELIO-DKD trial included patients with high albuminuria but excluded patients with symptomatic heart failure with reduced ejection fraction. The primary endpoint in the FIDELIO-DKD trial was kidney specific and included a sustained decline in the estimated glomerular filtration rate (eGFR) of ≥40% from baseline. In contrast, the primary endpoint in the CREDENCE trial included a sustained decline in eGFR of ≥57% from baseline and cardiovascular (CV) death. This post hoc exploratory analysis investigated how differences in trial design—inclusion/exclusion criteria and definition of primary outcomes—influenced observed treatment effects. Methods Patients from FIDELIO-DKD who met the CKD inclusion criteria of the CREDENCE study (urine albumin: creatinine ratio >300–5000 mg/g and an eGFR of 30–<90 mL/min/1.73 m2 at screening) were included in this analysis. The primary endpoint was a cardiorenal composite (CV death, kidney failure, eGFR decrease of ≥57% sustained for ≥4 weeks or renal death). Patients with symptomatic heart failure with reduced ejection fraction were excluded from FIDELIO-DKD. Therefore, in a sensitivity analysis, we further adjusted for the baseline prevalence of heart failure. Results Of 4619/5674 (81.4%) patients who met the subgroup inclusion criteria, 49.6% were treated with finerenone and 50.4% received placebo. The rate of the cardiorenal composite endpoint was 43.9/1000 patient-years with finerenone compared with 59.5/1000 patient-years with placebo. The relative risk was significantly reduced by 26% with finerenone versus placebo [hazard ratio (HR) 0.74 (95% CI 0.63–0.87)]. In CREDENCE, the rate of the cardiorenal composite endpoint was 43.2/1000 patient-years with canagliflozin compared with 61.2/1000 patient-years with placebo; a 30% risk reduction was observed with canagliflozin [HR 0.70 (95% CI 0.59–0.82)]. Conclusions This analysis highlights the pitfalls of direct comparisons between trials. When key differences in trial design are considered, FIDELIO-DKD and CREDENCE demonstrate cardiorenal benefits of a similar magnitude.
Collapse
Affiliation(s)
- Rajiv Agarwal
- Richard L. Roudebush VA Medical Center and Indiana University, Indianapolis, Indiana, USA
| | - Stefan D Anker
- Department of Cardiology (CVK) and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens, Greece
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, MI
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Luis M Ruilope
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12, Madrid, Spain.,CIBER-CV, Hospital Universitario 12 de Octubre, Madrid, Spain.,Faculty of Sport Sciences, European University of Madrid, Madrid, Spain
| | - John Boletis
- Faculty of Medicine, Laiko General Hospital, University of Athens, Greece
| | - Robert Toto
- Department of Internal Medicine, UT Southwestern, Dallas, Texas, USA
| | - Guillermo E Umpierrez
- Division of Endocrinology, Metabolism, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christoph Wanner
- Medizinische Klinik und Poliklinik 1, Schwerpunkt Nephrologie, Universitätsklinik Würzburg, Germany
| | - Takashi Wada
- Department of Nephrology, Kanazawa Medical University, Ishikawa, Japan
| | | | - Amer Joseph
- Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany
| | - Ike Ogbaa
- US Medical Affairs - Cardiovascular and Renal, Bayer U.S. LLC
| | | | - Markus F Scheerer
- Global Medical Affairs & Pharmacovigilance, Pharmaceuticals, Bayer AG, Berlin, Germany
| | - George L Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| |
Collapse
|
3
|
Ciardullo S, Trevisan R, Perseghin G. Sodium-glucose transporter 2 inhibitors for renal and cardiovascular protection in US adults with type 2 diabetes: Impact of the 2020 KDIGO clinical practice guidelines. Pharmacol Res 2021; 166:105530. [PMID: 33675963 DOI: 10.1016/j.phrs.2021.105530] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 01/12/2021] [Revised: 03/01/2021] [Accepted: 03/01/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Sodium glucose transporter 2 inhibitors (SGLT2-i) reduce renal and cardiovascular events in patients with type 2 diabetes (T2D) and their use is recommended by the 2020 KDIGO guidelines in patients with T2D and chronic kidney disease (CKD). The aim of this study is to estimate the proportion of patients with T2D and CKD in the US that should be treated with these agents for renal and cardiovascular protection. METHODS We conducted a retrospective analysis of 2005-2018 National Health and Nutrition Examination Survey (NHANES) data. We focused on participants with a prior diagnosis of diabetes or that met diagnostic criteria for diabetes during the survey, with the exclusion of probable type 1 diabetic patients. Inclusion criteria for completed and ongoing renal and cardiovascular outcome trials in patients with CKD were applied. RESULTS We estimated that 35.3% of patients with T2D in the US (projected to 8.96 million) should be treated with SGLT2-i according to the 2020 KDIGO guidelines. Moreover, 2.9-10.1% (projected to 0.75-2.55 million) met the inclusion criteria for dedicated kidney outcome trials, which were focused on a population of individuals with proteinuria. CONCLUSIONS About a third of patients with T2D in the US should be treated with an SGLT2-i. While compelling evidence of renal protection is present for patients with proteinuria, all patients with CKD obtain a cardiovascular benefit with this class of drugs.
Collapse
Affiliation(s)
- Stefano Ciardullo
- Department of Medicine and Rehabilitation, Policlinico di Monza, Monza, Italy; Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
| | - Roberto Trevisan
- Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy; Endocrinology and Diabetes Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Gianluca Perseghin
- Department of Medicine and Rehabilitation, Policlinico di Monza, Monza, Italy; Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy.
| |
Collapse
|
4
|
Abstract
Patients with Type 2 Diabetes (T2D) are at risk of developing macrovascular (cardiac, cerebrovascular, peripheral arterial disease) and microvascular (nephropathy, neuropathy, retinopathy) complications. Glycemic control improves only microvascular outcomes. However, some SGLT-2 inhibitors and GLP1-R agonists have proven beneficial in macrovascular conditions. Canagliflozin is an SGLT2 inhibitor that provides sustained reductions in HbA1c, blood pressure and weight. Remarkably, as CANVAS program and CREDENCE trial demonstrated, canagliflozin promotes significant reductions in the frequency of atherosclerotic cardiovascular events, hospitalizations for heart failure and renal outcomes. In addition, real-world studies have confirmed the results of clinical trials in clinical practice. Therefore, canagliflozin should be considered a first-line therapy in the management of T2D patients in order to reduce both micro- and macrovascular complications.
Collapse
Affiliation(s)
- Vivencio Barrios
- Cardiology Department, University Hospital Ramón y Cajal. Alcalá University, Madrid, Spain
| | - Carlos Escobar
- Cardiology Department, University Hospital La Paz, Madrid, Spain
| |
Collapse
|
5
|
Willis M, Nilsson A, Kellerborg K, Ball P, Roe R, Traina S, Beale R, Newell I. Cost-Effectiveness of Canagliflozin Added to Standard of Care for Treating Diabetic Kidney Disease (DKD) in Patients with Type 2 Diabetes Mellitus (T2DM) in England: Estimates Using the CREDEM-DKD Model. Diabetes Ther 2021; 12:313-328. [PMID: 33263893 PMCID: PMC7843731 DOI: 10.1007/s13300-020-00968-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [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: 10/08/2020] [Accepted: 11/06/2020] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION On the basis of reductions in diabetic kidney disease (DKD) progression and major adverse cardiovascular events observed in the landmark CREDENCE trial, canagliflozin 100 mg received an extension to its EU marketing authorisation in July 2020 to include the treatment of DKD in people with type 2 diabetes mellitus (T2DM) making it the first pharmacological therapy to receive regulatory authorisation for treatment of DKD since the RENAAL and IDNT trials in nearly 20 years. Efficient allocation of limited healthcare resources requires evaluation not only of clinical safety and efficacy but also economic consequences. The study aim was to estimate the cost-effectiveness of canagliflozin when added to current standard of care (SoC) versus SoC alone from the perspective of the NHS in England. METHODS A microsimulation model was developed using patient-level data from CREDENCE, including risk equations for the key clinical outcomes of start of dialysis, hospitalisation for heart failure, nonfatal myocardial infarction, nonfatal stroke, and all-cause mortality. DKD progression was modelled using estimated glomerular filtration rate and urinary albumin-to-creatinine ratio evolution equations. Risk for kidney transplant was sourced from UK-specific sources given the near absence of events in CREDENCE. Patient characteristics and treatment effects were sourced from CREDENCE. Unit costs (£2019) and disutility weights were sourced from the literature and discounted at 3.5% annually. The time horizon was 10 years in the base case, and sensitivity analysis was performed. RESULTS Canagliflozin was associated with sizable gains in life-years and quality-adjusted life-year (QALYs) over 10 years, with gains increasing with simulation duration. Cost offsets associated with reductions in cardiovascular and renal complications were sufficient to achieve overall net cost savings. The findings were generally confirmed in the sensitivity analyses. CONCLUSION Model results suggest that adding canagliflozin 100 mg to SoC can improve patient outcomes while reducing overall net costs from the NHS perspective in England. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT02065791.
Collapse
Affiliation(s)
- Michael Willis
- The Swedish Institute for Health Economics, Lund, Sweden.
| | | | | | | | - Rupert Roe
- Napp Pharmaceuticals Limited, Cambridge, UK
| | | | | | | |
Collapse
|
6
|
Schnell O, Standl E, Cos X, Heerspink HJ, Itzhak B, Lalic N, Nauck M, Ceriello A. Report from the 5th cardiovascular outcome trial (CVOT) summit. Cardiovasc Diabetol 2020; 19:47. [PMID: 32303223 DOI: 10.1186/s12933-020-01022-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 03/27/2020] [Indexed: 02/08/2023] Open
Abstract
The 5th Cardiovascular Outcome Trial (CVOT) Summit was held in Munich on October 24th-25th, 2019. As in previous years, this summit served as a reference meeting for in-depth discussions on the topic of recently completed and presented CVOTs. This year, focus was placed on the CVOTs CAROLINA, CREDENCE, DAPA-HF, REWIND, and PIONEER-6. Trial implications for diabetes management and the impact on new treatment algorithms were highlighted for diabetologists, cardiologists, endocrinologists, nephrologists, and general practitioners. Discussions evolved from CVOTs to additional therapy options for heart failure (ARNI), knowledge gained for the treatment and prevention of heart failure and diabetic kidney disease in populations with and without diabetes, particularly using SGLT-2 inhibitors and GLP-1 receptor agonists. Furthermore, the ever increasing impact of CVOTs and substances tested for primary prevention and primary care was discussed. The 6th Cardiovascular Outcome Trial Summit will be held in Munich on October 29th-30th, 2020 (https://www.cvot.org).
Collapse
|
7
|
Kluger AY, Tecson KM, Lee AY, Lerma EV, Rangaswami J, Lepor NE, Cobble ME, McCullough PA. Class effects of SGLT2 inhibitors on cardiorenal outcomes. Cardiovasc Diabetol 2019; 18:99. [PMID: 31382965 PMCID: PMC6683461 DOI: 10.1186/s12933-019-0903-4] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [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: 06/26/2019] [Accepted: 07/26/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND To summarize the four recent sodium-glucose cotransporter 2 inhibitor (SGLT2i) trials: Dapagliflozin Effect on CardiovascuLAR Events (DECLARE-TIMI 58), CANagliflozin CardioVascular Assessment Study (CANVAS) Program, Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients-Removing Excess Glucose (EMPA-REG OUTCOME), Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation (CREDENCE), and explore the potential determinants for their cardiovascular, renal, and safety outcomes. RESULTS The composite renal outcome event rates per 1000 patient-years for drug and placebo, as well as the corresponding relative risk reductions, were 3.7, 7.0, 47%; 5.5, 9.0, 40%; 6.3, 11.5, 46%; 43.2, 61.2, 30% for DECLARE-TIMI 58, CANVAS, EMPA-REG OUTCOME, and CREDENCE, respectively (event definitions varied across trials). The major adverse cardiovascular (CV) event rates per 1000 patient-years for drug and placebo, as well as the corresponding relative risk reductions, were 22.6, 24.2, 7%; 26.9, 31.5, 14%; 37.4, 43.9, 14%; 38.7, 48.7, 20% for DECLARE-TIMI 58, CANVAS, EMPA-REG OUTCOME, and CREDENCE, respectively. DECLARE-TIMI 58 had the fewest cardiorenal events and CREDENCE the most. These differences were presumably due to varying inclusion criteria resulting in DECLARE-TIMI 58 having the best baseline renal filtration function and CREDENCE the worst (mean estimated glomerular filtration rate 85.2, 76.5, 74, 56.2 mL/min/1.73 m2 for DECLARE-TIMI 58, CANVAS, EMPA-REG OUTCOME, and CREDENCE, respectively). Additionally, CREDENCE had considerably higher rates of albuminuria (median urinary albumin-creatinine ratios (UACR) were 927, 12.3, and 13.1 mg/g for CREDENCE, CANVAS, and DECLARE-TIMI 58, respectively; EMPA-REG OUTCOME had 59.4% UACR < 30, 28.6% UACR > 30-300, 11.0% UACR > 300 mg/g). CONCLUSIONS Dapagliflozin, empagliflozin, and canagliflozin have internally and externally consistent and biologically plausible class effects on cardiorenal outcomes. Baseline renal filtration function and degree of albuminuria are the most significant indicators of risk for both CV and renal events. Thus, these two factors also anticipate the greatest clinical benefit for SGLT2i.
Collapse
Affiliation(s)
- Aaron Y Kluger
- Baylor Heart and Vascular Institute, 621 N. Hall #H030, Dallas, TX, 75226, USA. .,Baylor Scott & White Research Institute, Dallas, TX, USA.
| | - Kristen M Tecson
- Baylor Heart and Vascular Institute, 621 N. Hall #H030, Dallas, TX, 75226, USA.,Baylor Scott & White Research Institute, Dallas, TX, USA.,Texas A&M College of Medicine Health Science Center, Dallas, TX, USA
| | - Andy Y Lee
- Baylor University Medical Center, Dallas, TX, USA.,Baylor Heart and Vascular Hospital, Dallas, TX, USA
| | - Edgar V Lerma
- UIC/Advocate Christ Medical Center, Oak Lawn, IL, USA
| | - Janani Rangaswami
- Einstein Medical Center, Philadelphia, PA, USA.,Sidney Kimmel College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Norman E Lepor
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Peter A McCullough
- Baylor Heart and Vascular Institute, 621 N. Hall #H030, Dallas, TX, 75226, USA.,Texas A&M College of Medicine Health Science Center, Dallas, TX, USA.,Baylor University Medical Center, Dallas, TX, USA.,Baylor Heart and Vascular Hospital, Dallas, TX, USA
| |
Collapse
|