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Patil T, Ali S, Kaur A, Akridge M, Eppes D, Paarlberg J, Parashar A, Jarmukli N. Impact of Pharmacist-Led Heart Failure Clinic on Optimization of Guideline-Directed Medical Therapy (PHARM-HF). J Cardiovasc Transl Res 2022; 15:1424-1435. [PMID: 35501544 PMCID: PMC9060399 DOI: 10.1007/s12265-022-10262-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 11/14/2021] [Accepted: 04/20/2022] [Indexed: 12/16/2022]
Abstract
This prospective study included patients with heart failure (HF) with reduced ejection fraction (HFrEF) with LVEF < = 40% to evaluate the impact of pharmacist on guideline directed medical therapy (GDMT). The primary outcome was to compare proportion of triple GDMT achieved for Angiotensin-Converting-Enzyme-Inhibitors (ACEI)/Angiotensin-Receptor-Blockers (ARB)/Angiotensin-Receptor-Neprilysin-Inhibitors (ARNI), beta-blockers, aldosterone antagonists (AA), and quadruple GDMT which in additional to triple therapy, included Sodium glucose co-transporter 2 inhibitor (SGLT2i) at 90-day post-enrollment compared to baseline. Secondary endpoints included achieving target and/or maximally tolerated ACEI/ARB/ARNI and beta-blockers combined and individually as well as SGLT2i and AA GDMT at 90-day post-enrollment compared to baseline. We also compared combined and individual HF-related hospitalization/emergency room (ER) visits 90 days pre-/post-enrollment. Of the total 974 patients screened, 80 patients seen at least once in the heart failure medication titration clinic (HMTC) were included in the analysis. Median (IQR) age was 71 (57-69) years with majority white male. There was a significant improvement in the proportion of patients who achieved quadruple GDMT (p = 0.001) and triple GDMT (p-value = 0.020) at 90-day post-enrollment compared to baseline. The secondary GDMT outcomes were also significantly increased at 90 days post-enrollment compared to baseline. Significant difference in mean as well as proportion of combined HF-related hospitalization/ER-visits was found 90 days pre-/post-enrollment (p = 0.047). Our study found that pharmacist's intervention increased the proportion of patients who achieved GDMT at 90 days.
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Affiliation(s)
- Tanvi Patil
- Salem Veterans Affair Medical Center, 1970 Roanoke Blvd., Salem, VA 24153 USA
| | - Salihah Ali
- Salem Veterans Affair Medical Center, 1970 Roanoke Blvd., Salem, VA 24153 USA
| | - Alamdeep Kaur
- Salem Veterans Affair Medical Center, 1970 Roanoke Blvd., Salem, VA 24153 USA
| | - Meghan Akridge
- Salem Veterans Affair Medical Center, 1970 Roanoke Blvd., Salem, VA 24153 USA
| | - Davida Eppes
- Salem Veterans Affair Medical Center, 1970 Roanoke Blvd., Salem, VA 24153 USA
| | - James Paarlberg
- Salem Veterans Affair Medical Center, 1970 Roanoke Blvd., Salem, VA 24153 USA
| | - Amitabh Parashar
- Salem Veterans Affair Medical Center, 1970 Roanoke Blvd., Salem, VA 24153 USA
| | - Nabil Jarmukli
- Salem Veterans Affair Medical Center, 1970 Roanoke Blvd., Salem, VA 24153 USA
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Masunaga Y, Fujisawa Y, Muramatsu M, Ono H, Inoue T, Fukami M, Kagami M, Saitsu H, Ogata T. Insulin resistant diabetes mellitus in SHORT syndrome: case report and literature review. Endocr J 2021; 68:111-117. [PMID: 32879144 DOI: 10.1507/endocrj.ej20-0291] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 11/23/2022] Open
Abstract
SHORT syndrome is a rare developmental disorder frequently associated with growth failure and insulin resistant diabetes mellitus (IRDM). Since GH has a diabetogenic effect, GH therapy has been regarded as a contraindication. We observed a Brazilian girl with SHORT syndrome who received GH therapy from 4 6/12 years of age for SGA short stature. GH dosage was increased from 0.23 to 0.36 mg/kg/week, but statural response to GH therapy remained poor. Her blood HbA1c level, though it remained 5.5-6.0% in childhood, began to elevate with puberty and increased to 9.2% at 10 6/12 years of age, despite the discontinuation of GH therapy at 9 11/12 years of age. Laboratory studies indicated antibody-negative IRDM. She was treated with metformin and canagliflozin (a sodium glucose co-transporter 2 (SGLT2) inhibitor), which ameliorated overt diurnal hyperglycemia and mild nocturnal hypoglycemia and reduced her blood HbA1c around 7%. Whole exome sequencing revealed a de novo heterozygous pathogenic variant (c.1945C>T:p.(Arg649Trp)) in PIK3R1 known as the sole causative gene for SHORT syndrome. Subsequent literature review for patients with molecularly confirmed SHORT syndrome revealed the development of IRDM in 10 of 15 GH-untreated patients aged ≥12 years but in none of three GH-treated and six GH-untreated patients aged ≤10 years. These findings imply a critical role of pubertal development and/or advanced age rather than GH therapy in the development of IRDM, and a usefulness of SGLT2 inhibitor in the treatment of IRDM.
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Affiliation(s)
- Yohei Masunaga
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
| | - Yasuko Fujisawa
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
| | - Mayumi Muramatsu
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
| | - Hiroyuki Ono
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
| | - Takanobu Inoue
- Department of Molecular Endocrinology, National Research Institute for Child Health and Development, Tokyo 157-8535, Japan
| | - Maki Fukami
- Department of Molecular Endocrinology, National Research Institute for Child Health and Development, Tokyo 157-8535, Japan
| | - Masayo Kagami
- Department of Molecular Endocrinology, National Research Institute for Child Health and Development, Tokyo 157-8535, Japan
| | - Hirotomo Saitsu
- Department of Biochemistry, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
| | - Tsutomu Ogata
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
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Ishibashi R, Baba Y, Kakinuma K, Takasaki A, Hiraga C, Harama T, Yamamoto T, Nakamura S, Koshizaka M, Maezawa Y, Uchida D, Okajima F. Assessing Patient Satisfaction Following Sodium Glucose Co-Transporter 2 Inhibitor Treatment for Type 1 Diabetes Mellitus: A Prospective Study in Japan. Diabetes Ther 2021; 12:453-460. [PMID: 33237553 PMCID: PMC7843726 DOI: 10.1007/s13300-020-00971-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 10/16/2020] [Accepted: 11/13/2020] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION In Japan, several sodium glucose co-transporter 2 (SGLT2) inhibitors have been used for type 1 diabetes mellitus as an adjuvant therapy to insulin therapy; however, there are no clinical reports regarding the satisfaction of its use. Therefore, we conducted a survey among patients with type 1 diabetes undergoing treatment using an SGLT2 inhibitor. METHODS This is a single-arm open-label prospective study including 24 patients with type 1 diabetes who were to be initiated on ipragliflozin treatment between March and August 2019. All participants provided written informed consent. They completed the Diabetes Treatment Satisfaction Questionnaire (DTSQ) for the survey and 3 months of observation after the administration of an SGLT2 inhibitor (50 mg of ipragliflozin), and changes from baseline diabetes treatment satisfaction were evaluated using modified DTSQ scores (five-step evaluation) and were analyzed. RESULTS The average score for each question on DTSQ significantly increased [mean (standard deviation); 0.25 (0.25) vs 0.83 (0.77), P = 0.004]. Approximately 75% of the patients perceived an improvement in glycemic control over short periods of time. Finally, 54.2% of patients were highly satisfied and would recommend the SGLT2 inhibitor treatment [0.0 (0.0) vs. 0.92 (1.32), P < 0.001]. After the administration of ipragliflozin, reductions in body weight [24.0 (2.9) vs. 23.4 (2.9) kg/m2, P = 0.002], total insulin [39.1 (12.9) vs. 34.3 (12.5) units, P = 0.013], and glycated hemoglobin [7.77 (0.97) vs. 7.40 (0.86) %, P = 0.013] were observed, without any severe side effects. Improvements in glycemic variability indexes were observed through flash glucose monitoring. CONCLUSIONS SGLT2 inhibitors may improve clinical treatment satisfaction by improving glycemic variability in patients with type 1 diabetes mellitus, while not inducing severe side effects with careful use. TRIAL REGISTRATION This study is registered with the University Hospital Medical Information Network Clinical Trial Registry (UMIN000040487).
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Affiliation(s)
- Ryoichi Ishibashi
- Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, Kimitsu Chuo Hospital, Kisarazu, Chiba, Japan.
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan.
| | - Yusuke Baba
- Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, Kimitsu Chuo Hospital, Kisarazu, Chiba, Japan
| | - Kyoka Kakinuma
- Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, Kimitsu Chuo Hospital, Kisarazu, Chiba, Japan
| | - Atsushi Takasaki
- Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, Kimitsu Chuo Hospital, Kisarazu, Chiba, Japan
| | - Chihiro Hiraga
- Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, Kimitsu Chuo Hospital, Kisarazu, Chiba, Japan
| | - Tomomi Harama
- Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, Kimitsu Chuo Hospital, Kisarazu, Chiba, Japan
| | - Tetsuya Yamamoto
- Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, Kimitsu Chuo Hospital, Kisarazu, Chiba, Japan
| | - Susumu Nakamura
- Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, Kimitsu Chuo Hospital, Kisarazu, Chiba, Japan
| | - Masaya Koshizaka
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
- Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Chiba, Japan
| | - Yoshiro Maezawa
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
- Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Chiba, Japan
| | - Daigaku Uchida
- Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, Kimitsu Chuo Hospital, Kisarazu, Chiba, Japan
| | - Fumitaka Okajima
- Department of Diabetes, Endocrinology and Metabolism, Nippon Medical School, Chiba Hokusoh Hospital, Inzai, Chiba, Japan
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Abstract
Sodium–glucose cotransporter 2 (SGLT2) inhibitors are increasingly prescribed for the treatment of patients with type 2 diabetes to reduce the risk of cardiovascular events, including heart failure (HF). The mechanisms by which SGLT2 inhibitors reduce such risk are likely to be independent of diabetes status and improvement of glycemic control. In this commentary, based on recent mediation analyses of cardiovascular outcome trials with SGLT2 inhibitors, we discuss the prognostic role of a well-known HF-related biomarker, amino-terminal pro-B-type natriuretic peptide (NT-proBNP), in patients receiving SGLT2 inhibitors. Interestingly, the NT-proBNP concentration had a relatively small impact on the SGLT2 inhibitor-associated benefit on HF events, suggesting a limited value in measuring NT-proBNP concentrations to monitor effects on cardiovascular outcomes after initiation of SGLT2 inhibitor therapy. Instead, clinical factors, such as body weight and volume status, were prognostic for cardiovascular outcomes. As shown in some biomarker studies, short-term SGLT2 inhibitor treatment significantly improved volume and HF-related health status, despite the absence of a significant change in NT-proBNP concentration. Given the early and continuous risk reduction in HF events seen in the cardiovascular outcome trials with SGLT2 inhibitors, changes in these fundamental clinical parameters after initiation of SGLT2 inhibitor therapy, independent of NT-proBNP, could be more prognostic and could represent key determinants to identify responders or non-responders to SGLT2 inhibitors for cardiovascular outcomes. Thus, this commentary highlights the clinical importance of establishing how clinicians should monitor patients initiating SGLT2 inhibitor therapy to predict the expected cardiovascular benefit. Further detailed investigations and discussion to better understand this ‘‘black box’’ are urgently warranted.
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Affiliation(s)
- Atsushi Tanaka
- Department of Cardiovascular Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan.
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
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Tanaka A, Node K. Clinical application of sodium-glucose cotransporter 2 inhibitor into a real-world setting of heart failure care. Cardiovasc Diabetol 2020; 19:132. [PMID: 32878601 PMCID: PMC7469307 DOI: 10.1186/s12933-020-01113-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 08/29/2020] [Indexed: 01/10/2023] Open
Abstract
For years there have been concerns whether the results of large-scale clinical trials that include limited specific patient populations can be applied to patients in real-world clinical practice. Therefore, it is crucially important to verify whether emerging evidences obtained from large-scale clinical trials on limited specific patient populations can be applied to patients at real-world clinical settings. Recent cardiovascular outcome trials with sodium-glucose cotransporter 2 (SGLT2) inhibitors showed a consistent risk reduction of approximately 30% for hospitalization for heart failure (HF), and the SGLT2 inhibitors had a great potential to be effective for prevention of HF in a wide variety of type 2 diabetes (T2D) patients independent of their history of HF or cardiovascular disease (CVD). Furthermore, the DAPA-HF trial also demonstrated that dapagliflozin proved clinically effective in patients with HF with reduced ejection fraction regardless of diabetes, suggesting its robust benefits in some specific patients with HF. According to these evidences, SGLT2 inhibitor is increasingly recognized as an emerging and promising option to reduce the risk of HF in patient with T2D. To use appropriately SGLT2 inhibitors for HF prevention in the real-world setting, it would be required to determine the optimal patient population who can receive better clinical benefits from SGLT2 inhibitors. In this commentary, based on the current understandings and lessons learned from the most recent studies, we discussed the importance of future research on the safety and efficacy of SGLT2 inhibitor in clinical situations of HF other than those examined in previous cardiovascular outcome trials.
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Affiliation(s)
- Atsushi Tanaka
- Department of Cardiovascular Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan.
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
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Weir MR, McCullough PA, Buse JB, Anderson J. Renal and Cardiovascular Effects of Sodium Glucose Co-Transporter 2 Inhibitors in Patients with Type 2 Diabetes and Chronic Kidney Disease: Perspectives on the Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation Trial Results. Am J Nephrol 2020; 51:276-288. [PMID: 32172239 DOI: 10.1159/000506533] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 02/17/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) risk is elevated in patients with type 2 diabetes mellitus (T2DM). Disease management in these patients has been generally focused on glycemic control and controlling other renal and cardiac risk factors as, historically, few protective therapies have been available. The Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation -(CREDENCE) trial of canagliflozin was the first study to demonstrate renal protection with a sodium glucose co-transporter 2 inhibitor in patients with T2DM and CKD, and these results could have important implications for clinical practice. SUMMARY In CREDENCE, participants with T2DM and estimated glomerular filtration rate 30-<90 mL/min/1.73 m2 and urinary albumin-creatinine ratio >300-5,000 mg/g who were treated with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker for ≥4 weeks prior to randomization at either the maximum labeled or tolerated dose were randomized to receive either canagliflozin 100 mg or placebo. Canagliflozin significantly reduced the risk of the primary composite outcome of doubling of serum creatinine, end-stage kidney disease, or renal or cardiovascular (CV) death compared with placebo (hazard ratio 0.70, 95% CI 0.59-0.82; p = 0.00001). Canagliflozin also reduced the risk of secondary renal and CV outcomes. The safety profile of canagliflozin in CREDENCE was generally similar to previous studies of canagliflozin. No imbalances were observed between canagliflozin and placebo in the risk of amputation or fracture in the CREDENCE population. Key Messages: The positive renal and CV effects of canagliflozin observed in the -CREDENCE trial could have a substantial impact on improving outcomes for patients with T2DM and CKD.
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Affiliation(s)
- Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA,
| | - Peter A McCullough
- Baylor University Medical Center, Baylor Heart and Vascular Hospital, Baylor Heart and Vascular Institute, Dallas, Texas, USA
| | - John B Buse
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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Carbone S, Dixon DL. The CANVAS Program: implications of canagliflozin on reducing cardiovascular risk in patients with type 2 diabetes mellitus. Cardiovasc Diabetol 2019; 18:64. [PMID: 31138195 PMCID: PMC6540565 DOI: 10.1186/s12933-019-0869-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [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: 03/22/2019] [Accepted: 05/10/2019] [Indexed: 12/18/2022] Open
Abstract
Canagliflozin is a sodium glucose co-transporter 2 (SGLT2) inhibitor that reduces blood glucose, as well as blood pressure, body weight, and albuminuria in patients with type 2 diabetes mellitus (T2DM). In the CANagliflozin cardioVascular Assessment Study (CANVAS) Program, patients with T2DM and high cardiovascular risk treated with canagliflozin had a significantly lower risk of the composite outcome of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke; hospitalization for heart failure; and renal outcomes, but also a greater risk of lower-limb amputation. Cardiovascular outcomes trials of some other T2DM agents (i.e., empagliflozin, dapagliflozin, liraglutide, semaglutide, albiglutide) have also shown potential cardiovascular and renal benefits. As a result, diabetes treatment guidelines have begun to incorporate consideration of cardiovascular and renal benefits into their treatment recommendations. Antihyperglycemic agents with proven beneficial cardiovascular effects represent a new opportunity for the diabetologist and cardiologist, in the setting of a multidisciplinary approach, to concomitantly improve glycemic control and reduce the risk of cardiovascular events in patients with T2DM. This review briefly discusses the pharmacology of canagliflozin, including clinical and preclinical data; it also describes the effects of canagliflozin on cardiovascular outcomes and side-effects, and compares these effects with other glucose-lowering agents with proven cardiovascular benefits.
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Affiliation(s)
- Salvatore Carbone
- Department of Internal Medicine, Pauley Heart Center, Virginia Commonwealth University, West Hospital, Room 529b, 1200 E Broad Street, Richmond, VA, 23298, USA.
| | - Dave L Dixon
- Department of Pharmacotherapy and Outcome Sciences, School of Pharmacy, Virginia Commonwealth University, 410 N. 12th Street, Richmond, VA, 23298, USA
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Lee TI, Chen YC, Lin YK, Chung CC, Lu YY, Kao YH, Chen YJ. Empagliflozin Attenuates Myocardial Sodium and Calcium Dysregulation and Reverses Cardiac Remodeling in Streptozotocin-Induced Diabetic Rats. Int J Mol Sci. 2019;20. [PMID: 30987285 PMCID: PMC6479313 DOI: 10.3390/ijms20071680] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 03/30/2019] [Accepted: 04/02/2019] [Indexed: 12/18/2022] Open
Abstract
Diabetes mellitus (DM) has significant effects on cardiac calcium (Ca2+) and sodium (Na+) regulation. Clinical studies have shown that empagliflozin (Jardiance™) has cardiovascular benefits, however the mechanisms have not been fully elucidated. This study aimed to investigate whether empagliflozin modulates cardiac electrical activity as well as Ca2+/Na+ homeostasis in DM cardiomyopathy. Electrocardiography, echocardiography, whole-cell patch-clamp, confocal microscopic examinations, and Western blot, were performed in the ventricular myocytes of control and streptozotocin-induced DM rats, with or without empagliflozin (10 mg/kg for 4 weeks). The results showed that the control and empagliflozin-treated DM rats had smaller left ventricular end-diastolic diameters and shorter QT intervals than the DM rats. In addition, the prolonged action potential duration in the DM rats was attenuated in the empagliflozin-treated DM rats. Moreover, the DM rats had smaller sarcoplasmic reticular Ca2+ contents, intracellular Ca2+ transients, L-type Ca2+, reverse mode Na+-Ca2+exchanger currents, lower protein expressions of sarcoplasmic reticulum ATPase, ryanodine receptor 2 (RyR2), but higher protein expressions of phosphorylated RyR2 at serine 2808 than the control and empagliflozin-treated DM rats. The incidence and frequency of Ca2+ sparks, cytosolic and mitochondrial reactive oxygen species, and late Na+ current and Na+/hydrogen-exchanger currents were greater in the DM rats than in the control and empagliflozin-treated DM rats. Empagliflozin significantly changed Ca2+ regulation, late Na+ and Na+/hydrogen-exchanger currents and electrophysiological characteristics in DM cardiomyopathy, which may contribute to its cardioprotective benefits in DM patients.
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Willis M, Asseburg C, Neslusan C. Conducting and interpreting results of network meta-analyses in type 2 diabetes mellitus: A review of network meta-analyses that include sodium glucose co-transporter 2 inhibitors. Diabetes Res Clin Pract 2019; 148:222-233. [PMID: 30641163 DOI: 10.1016/j.diabres.2019.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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] [Received: 07/31/2018] [Revised: 12/04/2018] [Accepted: 01/04/2019] [Indexed: 11/27/2022]
Abstract
AIMS Network meta-analyses (NMAs) are valuable ways to generate comparative effectiveness data for therapies available to treat type 2 diabetes mellitus (T2DM). This review assesses NMAs that evaluate sodium glucose co-transporter 2 (SGLT2) inhibitors for treatment of T2DM and discusses potential issues in conducting and interpreting NMAs. METHODS A systematic literature search was conducted on September 13, 2018 using the search terms "network meta-analysis," "SGLT2," variations of these terms, and individual SGLT2 inhibitor names. Extracted data included NMA objectives, methods, target populations, treatments, study endpoints, length of follow-up, and funding. Differences between NMAs were investigated. RESULTS Thirty-five full-length publications met criteria for inclusion. In most NMAs, the target population was defined by therapeutic regimen (e.g., combination with metformin). Follow-up intervals permitted in NMAs varied considerably (range, 4-208 weeks). Twenty-nine NMAs included dapagliflozin, 28 evaluated canagliflozin, and 27 evaluated empagliflozin. Nine NMAs used frequentist methods; 16 used Bayesian methods. Six NMAs were funded by pharmaceutical manufacturers. Heterogeneity across NMAs was seen in scope, time frame, and other aspects of analytic design. CONCLUSIONS Although this review indicates that methodological guidelines for reporting NMAs were generally followed, it also emphasizes the need for T2DM-specific guidance requiring clear reporting of NMA scope and objectives to aid appropriate interpretation and use of NMA results.
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Affiliation(s)
- Michael Willis
- The Swedish Institute for Health Economics, Box 2127, Lund 220 02, Sweden.
| | - Christian Asseburg
- The Swedish Institute for Health Economics, Box 2127, Lund 220 02, Sweden.
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Neslusan C, Teschemaker A, Willis M, Johansen P, Vo L. Cost-Effectiveness Analysis of Canagliflozin 300 mg Versus Dapagliflozin 10 mg Added to Metformin in Patients with Type 2 Diabetes in the United States. Diabetes Ther 2018; 9:565-581. [PMID: 29411292 PMCID: PMC6104269 DOI: 10.1007/s13300-018-0371-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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: 12/05/2017] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Agents that inhibit sodium glucose co-transporter 2 (SGLT2), including canagliflozin and dapagliflozin, are approved in the United States for the treatment of adults with type 2 diabetes mellitus (T2DM). SGLT2 inhibition lowers blood glucose by increasing urinary glucose excretion, which leads to a mild osmotic diuresis and a net loss of calories that are associated with reductions in body weight and blood pressure. This analysis evaluated the cost-effectiveness of canagliflozin 300 mg versus dapagliflozin 10 mg in patients with T2DM inadequately controlled with metformin in the United States. METHODS A 30-year cost-effectiveness analysis was performed using the validated Economic and Health Outcomes Model of T2DM (ECHO-T2DM) from the perspective of the third-party health care system in the United States. Patient demographics, biomarker values, and treatment effects for the ECHO-T2DM model were sourced primarily from a network meta-analysis (NMA) that included studies of canagliflozin and dapagliflozin in patients with T2DM on background metformin. Costs were derived from sources specific to the United States. Outcomes and costs were discounted at 3%. Sensitivity analyses that varied key model parameters were conducted. RESULTS Canagliflozin 300 mg dominated dapagliflozin 10 mg as an add-on to metformin over 30 years, with an estimated cost offset of $13,991 and a quality-adjusted life-year gain of 0.08 versus dapagliflozin 10 mg. Results were driven by the better HbA1c lowering achieved with canagliflozin, which translated to less need for insulin rescue therapy. Findings from sensitivity analyses were consistent with the base case. CONCLUSION These results suggest that canagliflozin 300 mg is likely to provide better health outcomes at a lower overall cost than dapagliflozin 10 mg in patients with T2DM inadequately controlled with metformin from the perspective of the United States health care system. FUNDING Janssen Scientific Affairs, LLC and Janssen Global Services, LLC.
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Affiliation(s)
| | | | - Michael Willis
- The Swedish Institute for Health Economics, Lund, Sweden
| | | | - Lien Vo
- Janssen Scientific Affairs, LLC, Titusville, NJ, USA
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Iemitsu K, Kawata T, Iizuka T, Takihata M, Takai M, Nakajima S, Minami N, Umezawa S, Kanamori A, Takeda H, Ito S, Kikuchi T, Amemiya H, Kaneshiro M, Mokubo A, Takuma T, Machimura H, Tanaka K, Asakura T, Kubota A, Aoyanagi S, Hoshino K, Ishikawa M, Matsuzawa Y, Obana M, Sasai N, Kaneshige H, Minagawa F, Saito T, Shinoda K, Miyakawa M, Tanaka Y, Terauchi Y, Matsuba I. Effectiveness of Ipragliflozin for Reducing Hemoglobin A1c in Patients With a Shorter Type 2 Diabetes Duration: Interim Report of the ASSIGN-K Study. J Clin Med Res 2017; 9:793-801. [PMID: 28811858 PMCID: PMC5544486 DOI: 10.14740/jocmr3116w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 05/25/2017] [Accepted: 06/13/2017] [Indexed: 01/01/2023] Open
Abstract
Background Ipragliflozin is a selective sodium glucose co-transporter 2 inhibitor. The ASSIGN-K study is investigating the efficacy and safety of ipragliflozin for type 2 diabetes mellitus (T2DM) in the real-world clinical setting. Methods Japanese T2DM patients with inadequate glycemic control despite diet and exercise with/without pharmacotherapy were enrolled in an investigator-driven, multicenter, prospective, observational study examining the efficacy and safety of ipragliflozin treatment (50 mg/day for 52 weeks). We performed interim analysis after 24 weeks. Results In 367 patients completing 24-week ipragliflozin therapy, hemoglobin A1c (HbA1c) decreased significantly from 8.07% at baseline to 7.26% in week 24 (P < 0.001). The change in HbA1c from treatment initiation to week 24 was -0.88% in patients < 65 years old versus -0.55% in those ≥ 65 years and -0.92% in men versus -0.70% in women (all P < 0.001). When baseline HbA1c was < 7%, 7% to < 8%, and ≥ 8%, the change was -0.18%, -0.45%, and -1.48%, respectively (P = 0.5352, P < 0.001, and P < 0.001, respectively). When baseline body mass index (BMI) was < 25, 25 to < 30, and ≥ 30, the change was -1.05%, -0.65%, and -0.87%, respectively (all P < 0.001). Multiple regression analysis showed that HbA1c decreased more in patients with a higher baseline HbA1c or shorter duration of diabetes. An HbA1c < 7% was achieved in 33.3% of the patients, and their baseline HbA1c was significantly lower than that of patients failing to achieve it (P < 0.001). Adverse events (AEs) occurred in 106/451 patients (23.5%), including 29.1% of patients aged 65 or older. Common AEs were vulvovaginal candidiasis (3.1%) and genital pruritus (1.8%). Serious AEs included urinary tract infection, unstable angina, and ketosis, which occurred in patients who did not suspend medication during acute illness. Conclusions Ipragliflozin significantly improved HbA1c in T2DM patients with inadequate glycemic control. Improvement in HbA1c was significant irrespective of age, sex, baseline HbA1c, or BMI, but efficacy was greater with a higher baseline HbA1c and shorter duration of diabetes. For safe continuation of treatment, patients should be advised to suspend medication during acute illness.
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Affiliation(s)
- Kotaro Iemitsu
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Takehiro Kawata
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Takashi Iizuka
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Masahiro Takihata
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Masahiko Takai
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Shigeru Nakajima
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Nobuaki Minami
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Shinichi Umezawa
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Akira Kanamori
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Hiroshi Takeda
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Shogo Ito
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Taisuke Kikuchi
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Hikaru Amemiya
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Mizuki Kaneshiro
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Atsuko Mokubo
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Tetsuo Takuma
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Hideo Machimura
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Keiji Tanaka
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Taro Asakura
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Akira Kubota
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Sachio Aoyanagi
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Kazuhiko Hoshino
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Masashi Ishikawa
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Yoko Matsuzawa
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Mitsuo Obana
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Nobuo Sasai
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Hideaki Kaneshige
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Fuyuki Minagawa
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Tatsuya Saito
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Kazuaki Shinoda
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Masaaki Miyakawa
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
| | - Yasushi Tanaka
- Department of Internal Medicine, Division of Metabolism and Endocrinology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki-shi, Kanagawa 216-8511, Japan
| | - Yasuo Terauchi
- Department of Molecular Endocrinology and Diabetes Internal Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama-shi, Kanagawa 236-0004, Japan
| | - Ikuro Matsuba
- Diabetes Committee, Kanagawa Physicians Association, 3-1 Fujimi-cho, Naka-ku, Yokohama-shi, Kanagawa 231-0037, Japan
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Qiu R, Balis D, Capuano G, Xie J, Meininger G. Canagliflozin: Efficacy and Safety in Combination with Metformin Alone or with Other Antihyperglycemic Agents in Type 2 Diabetes. Diabetes Ther 2016; 7:659-678. [PMID: 27734320 PMCID: PMC5118239 DOI: 10.1007/s13300-016-0201-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [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: 08/01/2016] [Indexed: 12/21/2022] Open
Abstract
Metformin is typically the first pharmacologic treatment recommended for type 2 diabetes mellitus (T2DM), but many patients do not achieve glycemic control with metformin alone and eventually require combination therapy with other agents. Canagliflozin, a sodium glucose co-transporter 2 (SGLT2) inhibitor, was assessed in a comprehensive Phase 3 clinical development program consisting of ~10,000 participants, of which ~80% were on background therapy that consisted of metformin alone or in combination with other antihyperglycemic agents (AHAs; e.g., pioglitazone, sulfonylurea, and insulin). In addition, the efficacy and safety of canagliflozin and metformin as the initial combination therapy and canagliflozin monotherapy were assessed versus metformin in treatment-naïve patients with T2DM. Across studies in patients with T2DM who were on metformin alone or in combination with other AHAs, canagliflozin 100 and 300 mg provided improvements in glycated hemoglobin for up to 104 weeks. Canagliflozin was also associated with reductions in body weight and systolic blood pressure when added to background therapy consisting of metformin alone or with other AHAs. Canagliflozin was generally well tolerated, with increased incidence of adverse events (AEs) related to the mechanism of SGLT2 inhibition (i.e., genital mycotic infections, urinary tract infections, and osmotic diuresis-related AEs). Consistent with its insulin-independent mechanism of action, canagliflozin was associated with low rates of hypoglycemia when background therapy did not include sulfonylurea or insulin. Due to its favorable efficacy and safety profile, these results suggest that adding canagliflozin to a background regimen consisting of metformin or implementing treatment with a fixed-dose regimen of canagliflozin and metformin would provide an effective and safe treatment regimen for T2DM management. FUNDING Janssen Global Services, LLC.
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Affiliation(s)
- Rong Qiu
- Janssen Research & Development, LLC, 920 Route 202 South, Raritan, NJ, 08869, USA.
| | - Dainius Balis
- Janssen Research & Development, LLC, 920 Route 202 South, Raritan, NJ, 08869, USA
| | - George Capuano
- Janssen Research & Development, LLC, 920 Route 202 South, Raritan, NJ, 08869, USA
| | - John Xie
- Janssen Research & Development, LLC, 920 Route 202 South, Raritan, NJ, 08869, USA
| | - Gary Meininger
- Janssen Research & Development, LLC, 920 Route 202 South, Raritan, NJ, 08869, USA
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13
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Yavin Y, Mansfield TA, Ptaszynska A, Johnsson K, Parikh S, Johnsson E. Effect of the SGLT2 Inhibitor Dapagliflozin on Potassium Levels in Patients with Type 2 Diabetes Mellitus: A Pooled Analysis. Diabetes Ther 2016; 7:125-37. [PMID: 26758563 PMCID: PMC4801817 DOI: 10.1007/s13300-015-0150-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [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: 11/18/2015] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Hyperkalemia risk is increased in diabetes, particularly in patients with renal impairment or those receiving angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs) or potassium-sparing diuretics. Conversely, other diuretics can increase hypokalemia risk. We assessed the effects of the sodium glucose co-transporter 2 (SGLT2) inhibitor dapagliflozin on serum potassium levels in a pooled analysis of clinical trials in patients with type 2 diabetes mellitus (T2DM). METHODS Fourteen randomized, placebo-controlled, double-blind T2DM studies were analyzed: pooled data from 13 studies of ≤24 weeks' duration (dapagliflozin 10 mg, N = 2360; placebo, N = 2295); and one 52-week moderate renal impairment study in patients with baseline eGFR ≥30 to <60 mL/min/1.73 m(2) (dapagliflozin 10 mg, N = 85; placebo, N = 84). Central laboratory serum potassium levels were determined at each study visit. RESULTS No clinically relevant mean changes from baseline in serum potassium ≤24 weeks were reported for dapagliflozin 10 mg [-0.05 mmol/L; 95% confidence interval (CI) -0.07, -0.03] versus placebo (-0.02 mmol/L; 95% CI -0.04, 0.00) in the pooled population or in the renal impairment study (-0.03 mmol/L; 95% CI -0.14, 0.08 vs. -0.02 mmol/L; 95% CI -0.13, 0.09, respectively). The incidence rate ratio for serum potassium ≥5.5 mmol/L over 24 weeks for dapagliflozin 10 mg versus placebo was 0.90 (95% CI 0.74, 1.10) in the pooled population; with no increased risk in patients receiving ARBs/ACE inhibitors, or potassium-sparing diuretics, or in those with moderate renal impairment. Slightly more patients receiving dapagliflozin 10 mg had serum potassium ≤3.5 mmol/L versus placebo (5.2% vs. 3.6%); however, no instances of serum potassium ≤2.5 mmol/L were reported. CONCLUSION Dapagliflozin is not associated with an increased risk of hyperkalemia or severe hypokalemia in patients with T2DM. FUNDING Bristol-Myers Squibb and AstraZeneca.
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Neeland IJ, McGuire DK, Eliasson B, Ridderstråle M, Zeller C, Woerle HJ, Broedl UC, Johansen OE. Comparison of Adipose Distribution Indices with Gold Standard Body Composition Assessments in the EMPA-REG H2H SU Trial: A Body Composition Sub-Study. Diabetes Ther 2015; 6:635-642. [PMID: 26608511 PMCID: PMC4674478 DOI: 10.1007/s13300-015-0146-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [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: 10/13/2015] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Excess adiposity contributes to cardiometabolic disease. Although adipose depots can be measured using imaging, implementation remains limited in practice. Data comparing surrogate indices of total and visceral adiposity with gold standard measurements in the context of a clinical trial population are lacking. We explored the relationships between adipose distribution indices and imaging assessments of body composition using baseline data from the EMPA-REG H2H SU™ trial. METHODS 118 participants from the Phase III trial of empagliflozin 25 mg vs. glimepiride 1-4 mg enrolled in a dedicated sub-study underwent assessment of total fat and fat-free mass by dual x-ray absorptiometry (n = 93) and abdominal visceral (VAT) and subcutaneous adipose tissue by magnetic resonance imaging (n = 99). Correlations with waist circumference (WC), estimated total body fat (eTBF), index of central obesity (ICO), and visceral adiposity index (VAI) were assessed. RESULTS eTBF was highly representative of total body fat (Spearman's ρ = 0.73, P < 0.001) but not associated with VAT. WC and ICO were strongly, and VAI to a lesser degree, correlated with VAT (ρ = 0.66, P < 0.001; ρ = 0.52, P < 0.001; ρ = 0.24, P = 0.02, respectively). CONCLUSION These findings support the use of eTBF and WC or ICO as surrogate indices for total body fat and VAT, respectively, in the absence of gold standard imaging methodology.
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Affiliation(s)
- Ian J Neeland
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Darren K McGuire
- Department of Internal Medicine, Division of Cardiology and Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | - Cordula Zeller
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Hans J Woerle
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Uli C Broedl
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
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15
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Leiter LA, Forst T, Polidori D, Balis DA, Xie J, Sha S. Effect of canagliflozin on liver function tests in patients with type 2 diabetes. Diabetes Metab. 2016;42:25-32. [PMID: 26575250 DOI: 10.1016/j.diabet.2015.10.003] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 09/24/2015] [Accepted: 10/05/2015] [Indexed: 12/29/2022]
Abstract
AIMS To report changes in liver function tests observed with canagliflozin, a sodium glucose co-transporter 2 inhibitor, across phase 3 studies in patients with type 2 diabetes, and to examine the relationship between changes in liver function tests and the weight loss and glycaemic improvements observed with canagliflozin. METHODS Data were pooled from four 26-week, placebo-controlled studies of canagliflozin 100 and 300mg (n=2313) and two 52-week, active-controlled studies of canagliflozin 300mg versus sitagliptin 100mg (n=1488). Analysis of covariance was performed to determine the contribution of changes in body weight and HbA1c to the changes in liver function tests. RESULTS Reductions in alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase and gamma-glutamyl transferase, and increases in bilirubin were seen with canagliflozin 100 and 300mg versus placebo (nominal P<0.001 for alanine aminotransferase, aspartate aminotransferase and gamma-glutamyl transferase [both doses]; P<0.001 for alkaline phosphatase and P=0.015 for bilirubin [canagliflozin 300mg only]) at week 26 and with canagliflozin 300mg versus sitagliptin 100mg (nominal P<0.001 for alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transferase and bilirubin, and P<0.01 for alkaline phosphatase) at week 52. Few patients met predefined limits of change criteria for liver function tests, and none met Hy's law criteria. In both populations, alanine aminotransferase, aspartate aminotransferase and gamma-glutamyl transferase reductions were fully explained by HbA1c and body weight reductions. CONCLUSIONS Canagliflozin provided improvements in liver function tests versus either placebo or sitagliptin treatments that were fully explained by the combined effects of HbA1c and body weight reductions with canagliflozin.
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Iijima H, Kifuji T, Maruyama N, Inagaki N. Pharmacokinetics, Pharmacodynamics, and Safety of Canagliflozin in Japanese Patients with Type 2 Diabetes Mellitus. Adv Ther 2015; 32:768-82. [PMID: 26280756 PMCID: PMC4569680 DOI: 10.1007/s12325-015-0234-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [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] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Indexed: 01/29/2023]
Abstract
Introduction Canagliflozin is a sodium glucose co-transporter 2 inhibitor approved worldwide for the treatment of patients with type 2 diabetes mellitus (T2DM). The present study evaluated pharmacokinetics, pharmacodynamics, and safety of canagliflozin in Japanese patients with T2DM. Methods Canagliflozin, at doses of 25, 100, 200, or 400 mg, was administered as a single dose and, after a washout of 1 day, in repeated doses for 14 consecutive days to 61 subjects in a randomized, double-blind, placebo-controlled study. Plasma concentrations of canagliflozin and urinary glucose excretion (UGE) were measured, and renal threshold for glucose excretion (RTG) was calculated. Safety was evaluated on the basis of adverse event (AE) reports, blood and urine laboratory parameters, and vital signs. Results Plasma canagliflozin maximum concentration and area under the concentration–time curve (AUC) values increased in a dose-dependent manner with the time to maximum concentration (tmax) of 1.0 h and elimination half-life (t1/2) of 10.22–13.26 h on Day 1. No significant changes in tmax and t1/2 were observed after multiple-dose administration. The linearity factors, as calculated from the ratios of AUC0–24h on Day 16 to AUC0–∞ on Day 1, were close to 1 in all canagliflozin groups. Canagliflozin increased UGE0–24h (80–110 g/day with canagliflozin ≥100 mg) and decreased RTG from the first day of treatment; these effects were sustained during the entire period of multiple administration. No significant AEs were noted. Urine volume was slightly increased on Day 1, but subsequent changes after repeated doses for 14 days were small. Urinary sodium tended to be higher in the early treatment period, whereas no particular change was observed in serum osmolality and hematocrit. Conclusion Canagliflozin increased UGE, decreased RTG, and was well tolerated throughout the entire period of multiple administrations in Japanese patients with T2DM. Funding Mitsubishi Tanabe Pharma Corporation. Trial registration ClinicalTrials.gov#NCT00707954. Electronic supplementary material The online version of this article (doi:10.1007/s12325-015-0234-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hiroaki Iijima
- Medical Affairs Department, Mitsubishi Tanabe Pharma Corporation, Tokyo, Japan.
| | - Takayuki Kifuji
- Development Division, Clinical Pharmacology Department, Mitsubishi Tanabe Pharma Corporation, Tokyo, Japan
| | - Nobuko Maruyama
- Development Division, Clinical Research Department II, Mitsubishi Tanabe Pharma Corporation, Tokyo, Japan
| | - Nobuya Inagaki
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto, Japan
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17
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Abstract
BACKGROUND Treatment of type 2 diabetes mellitus invariably requires the use of multiple daily medications which can impact negatively on patient adherence. As a result, there is growing interest in the use of single-pill combinations that can reduce the pill burden. Many such formulations incorporate metformin, although this agent is not suitable for all patients. The single-pill combination of the dipeptidyl peptidase-4 inhibitor linagliptin with the sodium glucose co-transporter 2 inhibitor empagliflozin offers a new and attractive option, given their complementary mechanisms of action. SCOPE Publications with titles containing the keywords 'linagliptin' or 'empagliflozin' were identified from a non-systematic search of PubMed without date restrictions, together with abstracts presented at the annual meetings of the American Diabetes Association and the European Association for the Study of Diabetes 2012-2014. ClinicalTrials.gov was searched for entries containing these two keywords. Additional references known to the author were included. FINDINGS The efficacy and safety of linagliptin and empagliflozin as monotherapy or in combination with other oral antidiabetic drugs has been established through extensive clinical trial programs. Studies specifically evaluating the efficacy/safety of a dipeptidyl peptidase-4 inhibitor/sodium glucose co-transporter 2 inhibitor in combination are limited, but do include two studies of linagliptin/empagliflozin of up to 52 weeks in duration. These studies show that the single-pill combination of linagliptin and empagliflozin produced clinical improvements in glycemic control that were generally superior to the improvements seen with linagliptin and empagliflozin alone, but with a safety profile comparable to that of the individual constituents. CONCLUSIONS The single-pill combination of linagliptin and empagliflozin, with their complementary mechanisms of action, is a promising treatment option for patients with type 2 diabetes mellitus. It would reduce the daily pill burden in this population, potentially improving adherence to, and optimizing the benefits of, treatment of diabetes mellitus.
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Affiliation(s)
- Ronnie Aronson
- LMC Diabetes & Endocrinology , Toronto, Ontario , Canada
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18
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Wilding JPH, Blonde L, Leiter LA, Cerdas S, Tong C, Yee J, Meininger G. Efficacy and safety of canagliflozin by baseline HbA1c and known duration of type 2 diabetes mellitus. J Diabetes Complications 2015; 29:438-44. [PMID: 25660137 DOI: 10.1016/j.jdiacomp.2014.12.016] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [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: 10/09/2014] [Revised: 12/23/2014] [Accepted: 12/24/2014] [Indexed: 02/01/2023]
Abstract
AIMS Canagliflozin, a sodium glucose co-transporter 2 inhibitor, has demonstrated glycemic improvements across studies of patients with type 2 diabetes mellitus (T2DM). The impact of canagliflozin on HbA1c lowering was assessed by baseline HbA1c and known duration of T2DM. METHODS This post hoc analysis pooled data from patients with T2DM enrolled in four 26-week, placebo-controlled, Phase 3 studies of canagliflozin (N=2313). Change in HbA1c from baseline to Week 26 was assessed in the overall population and in subgroups by baseline HbA1c (<8.0%, 8.0%-<9.0%, and ≥9.0%) and known duration of T2DM (<5 years, 5-<10 years, and ≥10 years). RESULTS Relative to placebo, canagliflozin 100 and 300 mg provided greater HbA1c reductions in the overall population. Progressively larger placebo-subtracted reductions in HbA1c with canagliflozin 100 and 300 mg were seen with increasing baseline HbA1c. HbA1c reductions were similar across subgroups based on known duration of T2DM. Both canagliflozin doses were generally well tolerated across subgroups, with a safety and tolerability profile consistent with that seen in Phase 3 studies. CONCLUSIONS Canagliflozin provided glycemic improvements in patients with T2DM across a range of baseline HbA1c and known duration of T2DM.
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Affiliation(s)
- John P H Wilding
- Department of Obesity and Endocrinology, University of Liverpool, Liverpool, United Kingdom.
| | - Lawrence Blonde
- Department of Endocrinology, Diabetes, and Metabolic Diseases, Ochsner Medical Center, New Orleans, LA, USA
| | - Lawrence A Leiter
- Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital; Division of Endocrinology and Metabolism, University of Toronto, Toronto, ON, Canada
| | - Sonia Cerdas
- Hospital Cima, Centro de Investigacíon Clínica San Agustín, San José, Costa Rica
| | - Cindy Tong
- Janssen Research & Development, LLC, Raritan, NJ, USA
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