1
|
Davies MJ, Drexel H, Jornayvaz FR, Pataky Z, Seferović PM, Wanner C. Cardiovascular outcomes trials: a paradigm shift in the current management of type 2 diabetes. Cardiovasc Diabetol 2022; 21:144. [PMID: 35927730 PMCID: PMC9351217 DOI: 10.1186/s12933-022-01575-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [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: 12/08/2021] [Accepted: 05/14/2022] [Indexed: 02/07/2023] Open
Abstract
Cardiovascular disease (CVD) is the leading cause of mortality and morbidity in patients with type 2 diabetes (T2D). Historical concerns about cardiovascular (CV) risks associated with certain glucose-lowering medications gave rise to the introduction of cardiovascular outcomes trials (CVOTs). Initially implemented to help monitor the CV safety of glucose-lowering drugs in patients with T2D, who either had established CVD or were at high risk of CVD, data that emerged from some of these trials started to show benefits. Alongside the anticipated CV safety of many of these agents, evidence for certain sodium-glucose transporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have revealed potential cardioprotective effects in patients with T2D who are at high risk of CVD events. Reductions in 3-point major adverse CV events (3P-MACE) and CV death have been noted in some of these CVOTs, with additional benefits including reduced risks of hospitalisation for heart failure, progression of renal disease, and all-cause mortality. These new data are leading to a paradigm shift in the current management of T2D, with international guidelines now prioritising SGLT2 inhibitors and/or GLP-1 RAs in certain patient populations. However, clinicians are faced with a large volume of CVOT data when seeking to use this evidence base to bring opportunities to improve CV, heart failure and renal outcomes, and even reduce mortality, in their patients with T2D. The aim of this review is to provide an in-depth summary of CVOT data-crystallising the key findings, from safety to efficacy-and to offer a practical perspective for physicians. Finally, we discuss the next steps for the post-CVOT era, with ongoing studies that may further transform clinical practice and improve outcomes for people with T2D, heart failure or renal disease.
Collapse
Affiliation(s)
- Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester, UK
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Heinz Drexel
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Landeskrankenhaus Feldkirch, Feldkirch, Austria
| | - François R Jornayvaz
- Service of Endocrinology, Diabetes, Nutrition and Therapeutic Patient Education, WHO Collaborating Centre, Geneva University Hospital/Geneva University, Geneva, Switzerland
| | - Zoltan Pataky
- Service of Endocrinology, Diabetes, Nutrition and Therapeutic Patient Education, WHO Collaborating Centre, Geneva University Hospital/Geneva University, Geneva, Switzerland
| | - Petar M Seferović
- University of Belgrade, Faculty of Medicine, Belgrade, Serbia.
- Serbian Academy of Sciences and Arts, Belgrade, Serbia.
| | | |
Collapse
|
2
|
Janez A, Muzurovic E, Stoian AP, Haluzik M, Guja C, Czupryniak L, Duvnjak L, Lalic N, Tankova T, Bogdanski P, Papanas N, Nunes JS, Kempler P, Fras Z, Rizzo M. Translating results from the cardiovascular outcomes trials with glucagon-like peptide-1 receptor agonists into clinical practice: Recommendations from a Eastern and Southern Europe diabetes expert group. Int J Cardiol 2022; 365:8-18. [PMID: 35905827 DOI: 10.1016/j.ijcard.2022.07.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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] [Received: 05/29/2022] [Revised: 07/05/2022] [Accepted: 07/12/2022] [Indexed: 02/06/2023]
Abstract
Glucagon-like peptide-1 (GLP-1) receptor agonists mimic the action of the endogenous GLP-1 incretin hormone, improving glycaemic control in type 2 diabetes mellitus (T2DM) by increasing insulin secretion and decreasing glucagon secretion in a glucose-dependent manner. However, as cardiovascular (CV) morbidity and mortality is common in patients with T2DM, several trials with the use of GLP-1 receptor agonists (RAs) have been performed focusing on endpoints related to cardiovascular disease rather than metabolic control of T2DM. Following the positive cardiovascular effects of liraglutide, dulaglutide and semaglutide observed in these trials, major changes in T2DM management guidelines have occurred. This document from a Eastern and Southern European Diabetes Expert Group discusses the results of GLP-1 RA CV outcomes trials, their impact on recent clinical guidelines for the management of T2DM, and some selected combination regimens utilising GLP-1 RAs. We also propose an algorithm for guiding GLP-1 RA-based treatment according to patients' characteristics, which can be easily applied in every day clinical practice.
Collapse
Affiliation(s)
- Andrej Janez
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Center Ljubljana, Slovenia.
| | - Emir Muzurovic
- Faculty of Medicine, University of Montenegro, Department of Internal Medicine, Endocrinology Section, Clinical Centre of Montenegro, Podgorica, Montenegro
| | - Anca Pantea Stoian
- Diabetes, Nutrition and Metabolic Diseases Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Martin Haluzik
- Diabetes Centre and Centre for Experimental Medicine, Institute for Clinical and Experimental Medicine and Institute of Endocrinology, Prague, Czech Republic
| | - Cristian Guja
- Department of Diabetes, Nutrition and Metabolic Diseases, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Leszek Czupryniak
- Department of Diabetology and Internal Medicine, Medical University of Warsaw, Poland
| | - Lea Duvnjak
- School of Medicine University of Zagreb, Vuk Vrhovac University Clinic, Zagreb, Croatia
| | - Nebojsa Lalic
- Faculty of Medicine University of Belgrade, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Belgrade, Serbia
| | | | - Pawel Bogdanski
- Department of Treatment of Obesity, Metabolic Disorders and Clinical Dietetics, University of Medical Sciences, Poznan, Poland
| | - Nikolaos Papanas
- Diabetes Centre, Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Josè Silva Nunes
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Peter Kempler
- First Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Zlatko Fras
- Preventive Cardiology Unit, Division of Medicine, University Medical Centre Ljubljana and Chair of Internal Medicine, Medical Faculty, University of Ljubljana, Slovenia
| | - Manfredi Rizzo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (Promise), School of Medicine, University of Palermo, Italy
| |
Collapse
|
3
|
Lavalle-Cobo A, Masson W, Lobo M, Masson G, Molinero G. Glucagon-like Peptide-1 Receptor Agonists and Cardioprotective Benefit in Patients with Type 2 Diabetes Without Baseline Metformin: A Systematic Review and Update Meta-analysis. High Blood Press Cardiovasc Prev 2021; 28:605-612. [PMID: 34705249 DOI: 10.1007/s40292-021-00479-1] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 10/12/2021] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Sodium Glucose Co-transporter 2 inhibitors and glucagon-like peptide 1 receptor agonists (GLP-1RAs) were associated with a reduction in cardiovascular disease events in cardiovascular outcomes trials (CVOTs) in type 2 diabetes. Most of the patients included in these trials received metformin as background therapy. AIM To evaluate the effect of glucagon-like peptide 1 receptor agonists on major cardiovascular events (MACE) and mortality in metformin-naïve patients with type 2 diabetes. METHODS A systematic review and meta-analysis of randomized controlled clinical trials of GLP-1RAs on type 2 diabetes population was performed, after searching the PubMed/MEDLINE, Embase, Scielo, Google Scholar and Cochrane Controlled Trials databases. The primary endpoint was MACE. The secondary endpoints were cardiovascular death and all-cause mortality. A meta-analysis of time-to-event outcomes was performed. This meta-analysis was registered in PROSPERO (CRD42021260040) RESULTS: Seven trials, including 11510 patients, were identified and considered eligible for the analyses. GLP-1RAs were associated with a significant reduction in MACE incidence (HR: 0.86, 95% confidence interval: 0.79-0.94; I2: 0%). The secondary endpoints analysis showed a non-significant reduction in all-cause mortality (HR: 0.86, 95% confidence interval: 0.73-1.00 I2: 0%) and cardiovascular mortality (HR: 0.81, 95% confidence interval: 0.63-1.05; I2: 0%). CONCLUSIONS In this meta-analysis, GLP-1RAs reduced the incidence of MACE in patients with type 2 diabetes without metformin at baseline, without significant reduction in all-cause mortality and cardiovascular mortality. These results support the fact that when a GLP-1RAs is administered, the benefit on cardiovascular outcomes is independent of the use of metformin.
Collapse
Affiliation(s)
- Augusto Lavalle-Cobo
- Council of Epidemiology and Cardiovascular Prevention, Argentine Society of Cardiology, Azcuenaga 980, Buenos Aires, Argentina. .,Cardiology Department, Sanatorio Finochietto, Av. Córdoba 2678, Buenos Aires, Argentina. .,, 926 7B, Ayacucho, Argentina.
| | - Walter Masson
- Council of Epidemiology and Cardiovascular Prevention, Argentine Society of Cardiology, Azcuenaga 980, Buenos Aires, Argentina.,Cardiology Department, Sanatorio Finochietto, Av. Córdoba 2678, Buenos Aires, Argentina.,Cardiology Department, Hospital Italiano de Buenos Aires. Tte. Gral, Juan Domingo Perón 4190, Buenos Aires, Argentina
| | - Martín Lobo
- Council of Epidemiology and Cardiovascular Prevention, Argentine Society of Cardiology, Azcuenaga 980, Buenos Aires, Argentina.,Cardiology Department, Sanatorio Finochietto, Av. Córdoba 2678, Buenos Aires, Argentina.,Cardiology Department, Hospital Italiano de Buenos Aires. Tte. Gral, Juan Domingo Perón 4190, Buenos Aires, Argentina.,Cardiology Department, Hospital Militar Campo de Mayo. Tte. Gral. Ricchieri S/N, Buenos Aires, Argentina
| | - Gerardo Masson
- Council of Epidemiology and Cardiovascular Prevention, Argentine Society of Cardiology, Azcuenaga 980, Buenos Aires, Argentina.,Cardiology Department, Sanatorio Finochietto, Av. Córdoba 2678, Buenos Aires, Argentina.,Cardiology Department, Hospital Italiano de Buenos Aires. Tte. Gral, Juan Domingo Perón 4190, Buenos Aires, Argentina.,Cardiology Department, Hospital Militar Campo de Mayo. Tte. Gral. Ricchieri S/N, Buenos Aires, Argentina.,Cardiology Department, Instituto Cardiovascular San Isidro-Sanatorio Las Lomas, Von Wernicke 3031, San Isidro, Argentina
| | - Graciela Molinero
- Council of Epidemiology and Cardiovascular Prevention, Argentine Society of Cardiology, Azcuenaga 980, Buenos Aires, Argentina
| |
Collapse
|
4
|
Brito D, Bettencourt P, Carvalho D, Ferreira J, Fontes-Carvalho R, Franco F, Moura B, Silva-Cardoso JC, de Melo RT, Fonseca C. Sodium-Glucose Co-transporter 2 Inhibitors in the Failing Heart: a Growing Potential. Cardiovasc Drugs Ther 2020; 34:419-436. [PMID: 32350793 PMCID: PMC7242490 DOI: 10.1007/s10557-020-06973-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 12/17/2022]
Abstract
Sodium-glucose co-transporter 2 inhibitors (SGLT2i) are a new drug class designed to treat patients with type 2 diabetes (T2D). However, cardiovascular outcome trials showed that SGLT2i also offer protection against heart failure (HF)-related events and cardiovascular mortality. These benefits appear to be independent of glycaemic control and have recently been demonstrated in the HF population with reduced ejection fraction (HFrEF), with or without T2D. This comprehensive, evidence-based review focuses on the published studies concerning HF outcomes with SGLT2i, discussing issues that may underlie the different results, along with the impact of these new drugs in clinical practice. The potential translational mechanisms behind SGLT2i cardio-renal benefits and the information that ongoing studies may add to the already existing body of evidence are also reviewed. Finally, we focus on practical management issues regarding SGLT2i use in association with other T2D and HFrEF common pharmacological therapies. Safety considerations are also highlighted. Considering the paradigm shift in T2D management, from a focus on glycaemic control to a broader approach on cardiovascular protection and event reduction, including the potential for wide SGLT2i implementation in HF patients, with or without T2D, we are facing a promising time for major changes in the global management of cardiovascular disease.
Collapse
Affiliation(s)
- Dulce Brito
- Department of Cardiology, Centro Hospitalar Universitário Lisboa Norte, Av. Prof. Egas Moniz, 1649-035, Lisboa, Portugal. .,CCUL, Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, 1649-035, Lisboa, Portugal.
| | - Paulo Bettencourt
- Department of Internal Medicine, Hospital CUF Porto, Porto, Portugal.,Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Davide Carvalho
- Faculdade de Medicina, Universidade do Porto, Porto, Portugal.,Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar, Universitário de São João, Porto, Portugal.,Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
| | - Jorge Ferreira
- Department of Cardiology, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Ricardo Fontes-Carvalho
- Department of Cardiology, Centro Hospitalar Vila Nova de Gaia/Espinho, Espinho, Portugal.,Department of Surgery and Physiology, Cardiovascular Investigation Unit, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Fátima Franco
- Department of Cardiology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Brenda Moura
- Faculdade de Medicina, Universidade do Porto, Porto, Portugal.,Department of Cardiology, Hospital das Forças Armadas-Pólo do Porto, Porto, Portugal.,CINTESIS-Cardiocare, Center for Health Technology and Services Research, Porto, Portugal
| | - José Carlos Silva-Cardoso
- Faculdade de Medicina, Universidade do Porto, Porto, Portugal.,CINTESIS-Cardiocare, Center for Health Technology and Services Research, Porto, Portugal.,Department of Cardiology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | | | - Cândida Fonseca
- Heart Failure Clinic, Hospital São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal.,NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal
| |
Collapse
|
5
|
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a novel class of medications that reduce plasma glucose concentrations through an insulin-independent mechanism of increased urinary glucose excretion, with concomitant natriuresis and diuresis. Clinical outcomes trials with SGLT2 inhibitors revealed a cardioprotective benefit among patients with diabetes mellitus, with a consistent reduction in hospitalization for heart failure. As such, the 2018 updated US and European treatment guidelines for diabetes mellitus incorporated SGLT2 inhibitors as second-line glucose-lowering agents after metformin. Although well tolerated, there are known adverse effects with SGLT2 inhibitors that require clinical monitoring, such as genital mycotic infections, diabetic ketoacidosis, volume depletion particularly in the setting of concomitant diuretic use, and lower limb amputations with canagliflozin. Ongoing clinical trials will uncover the potential benefit of SGLT2 inhibitors in patients with prevalent heart failure with or without diabetes mellitus.
Collapse
Affiliation(s)
- Orly Vardeny
- Minneapolis VA Center for Care Delivery and Outcomes Research, Minneapolis, Minn; Associate Professor of Medicine, University of Minnesota, Minneapolis.
| |
Collapse
|
6
|
Harrington JL, de Albuquerque Rocha N, Patel KV, Verma S, McGuire DK. Should Metformin Remain First-Line Medical Therapy for Patients with Type 2 Diabetes Mellitus and Atherosclerotic Cardiovascular Disease? An Alternative Approach. Curr Diab Rep 2018; 18:64. [PMID: 30008022 DOI: 10.1007/s11892-018-1035-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [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] [Indexed: 01/07/2023]
Abstract
PURPOSE OF REVIEW With recent cardiovascular outcome trial (CVOT) results for antihyperglycemic medications, the treatment algorithm for patients with type 2 diabetes (T2DM) and atherosclerotic vascular disease (ASCVD) requires revision. RECENT FINDINGS All completed CVOTs have demonstrated CV safety of the tested medications, with some trials demonstrating CV efficacy. While metformin remains the first-line recommended medication for T2DM, 18-37% of the patients enrolled in the completed CVOTs were not treated with metformin, providing substantial power to assess CV outcomes independent of metformin. The safety and tolerability of metformin are indisputable, but there are no robust data proving its efficacy for either macro or microvascular disease outcomes. We should reconsider the primacy of metformin in the management of T2DM in patients with ASCVD. This article will review the evidence for CV effects of antihyperglycemic agents (AHAs), and propose an evidence-based treatment algorithm for patients with T2DM and ASCVD.
Collapse
Affiliation(s)
- Josephine L Harrington
- Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-8830, USA
| | - Natalia de Albuquerque Rocha
- Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-8830, USA
- Division of Cardiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-8830, USA
| | - Kershaw V Patel
- Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-8830, USA
- Division of Cardiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-8830, USA
| | - Subodh Verma
- Division of Cardiac Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Darren K McGuire
- Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-8830, USA.
- Division of Cardiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-8830, USA.
- Department of Clinical Science, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| |
Collapse
|
7
|
Abstract
Hypoglycemia is the limiting factor in controlling glucose levels in Diabetes. Rather than being a side effect, hypoglycemia is the mechanism of action for insulin therapy, with a very narrow therapeutic window. Until recently, regulatory bodies listed hypoglycemia only as an adverse effect of therapy; however, one insulin preparation is now recognized and labelled as reducing the risk of severe hypoglycemia. This paper describes internationally agreed upon definitions for hypoglycemia and proposed regulatory approaches for recognition and labeling of diabetes therapies to facilitate personalized care.
Collapse
|