Gliflozins for the Treatment of Congestive Heart Failure and Renal Failure in Type 2 Diabetes
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Background: Gliflozins are effective drugs for the treatment of type 2 diabetes. They inhibit sodium glucose cotransporter 2 in the proximal renal tubule, leading to increased glucose excretion. On the basis of findings from relevant studies, gliflozins are also increasingly used in clinical practice to treat congestive heart failure and renal failure.
Methods: This review is based on pertinent publications retrieved from a selective literature search in PubMed and GoogleScholar.
Results: Cardiovascular safety studies revealed early on that gliflozins can lower the hospitalization rate of patients suffering from congestive heart failure with a reduced left-ventricular ejection fraction (HFrEF). They also showed favorable effects on multiple renal endpoints. In recent years, studies such as DAPA-HF and CREDENCE have further documented the benefit of gliflozins in the treatment of congestive heart failure and renal failure in patients with type 2 diabetes, and gliflozins have accordingly been incorporated into the pertinent guidelines. In the recently published EMPEROR-Reduced trial, empagliflozin was found to significantly lower the frequency of a combined cardiovascular endpoint in patients with HFrEF (19.4 % versus 24.7%; hazard ratio [HR] 0.75; 95% confidence interval [0.65; 0.86]; number needed to treat [NNT] 19, p <0.001). In the DAPA-CKD trial, which was also recently published, dapagliflozin was found to significantly lower the frequency of a combined renal endpoint (9.2% versus 14.5%; HR 0.61 [0.51; 0.72]; NNT 19; p <0.001).
Conclusion: On the basis of findings from specific studies, gliflozins will henceforth be a major class of drug for the treatment of HFrEF and renal failure, independently of the presence of type 2 diabetes.
Type 2 diabetes (T2D) is a risk factor for developing congestive heart failure and/or renal failure, making it a disease of significant public health concern (1, 2). Consequently, one of the goals of T2D management is to reduce the rate of cardiovascular and renal complications. Gliflozins, also referred to as SGLT2 inhibitors, are an effective class of drug to tread T2D. They selectively inhibit sodium glucose cotransporter type 2 (SGLY2) in the proximal renal tubule, leading to increased glucose excretion. In addition, they exert favorable pleiotropic effects on body weight, arterial hypertension and vascular rigidity, as well as albuminuria (3) (eFigure). Besides its role in diabetology, gliflozins have emerged on the basis of findings from randomized trials as drugs to treat congestive heart failure and renal failure.
This review is based on pertinent publications retrieved from a selective literature search in PubMed and Google Scholar. The key search terms used, alone and in various combinations, were “SGLT2 inhibitors“, “diabetes“, “heart failure“, “chronic kidney disease“, “cardiovascular effects“, and “renal effects“. The primary English-language literature up to and including September 2020 as well as the current recommendations of the European Association for the Study of Diabetes [EASD] and the European Society of Cardiology [ESC]) were taken into account. No pertinent Cochrane reviews were identified.
Gliflozins and cardiovascular endpoint studies
The conduct of cardiovascular safety studies is a mandatory requirement for obtaining approval of new antidiabetic agents by the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA). The so-called 3-point major adverse cardiovascular event (3P-MACE) outcome is chosen as the primary endpoint in these trials. 3P-MACE is a composite of cardiovascular mortality, nonfatal myocardial infarction and nonfatal stroke. Currently, four gliflozins are approved for treatment: empagliflozin, canagliflozin, dapagliflozin and ertugliflozin. For empagliflozin, canagliflozin and dapagliflozin, data of the relevant safety studies were published in high-ranking journals. These are listed in Table 1.
The EMPA-REG OUTCOME study evaluated empagliflozin in patients with T2D and cardiovascular disease (4). In addition to usual care for T2D, patients received empagliflozin (10 mg or 25 mg/day) or placebo. Treatment with empagliflozin resulted in a statistically significant reduction of 3P-MACE (10.5% versus 12.1%, p<0.001 for non-inferiority, p = 0.04 for superiority). This corresponds to an absolute risk reduction (ARR) of 1.6% points, a relative risk reduction (RRR) of 13.5% and a number needed to treat (NNT) of 62. The difference is explained by a statistically significant reduction in cardiovascular mortality (3.7% versus 5.9% in the placebo group, ARR = 2.2 % points, RRR = 37.5 %, NNT = 46, p<0.001). In contrast, the analysis of individual components found no statistically significant differences with regard to nonfatal myocardial infarction or stroke. All-cause mortality, however, was found lower in the empagliflozin group (5.7% versus 8.3%, ARR = 2.6% points, RRR = 31.0%, NNT = 39, p<0.001).
In CANVAS, canagliflozin was evaluated in patients with T2D and cardiovascular disease (65.6%) or high cardiovascular risk (34.4%) (5). Subjects received either canagliflozin (100–300 mg/day) or placebo. 3P-MACE occurred significantly less frequently in the canagliflozin group compared to the placebo group (26.9 versus 31.5 events per 1000 patient-years, ARR = 4.6 events per 1000 patient-years, RRR = 14.6%, NNT = not specified, p<0.001 for non-inferiority, p = 0.02 for superiority). No statistically significant differences were found for individual components and all-cause mortality.
In DECLARE-TIMI 58, patients with T2D and cardiovascular disease (40.6%) or high cardiovascular risk (59.4%) were randomized to receive either dapagliflozin (10 mg/day) or placebo (6). For 3P-MACE, no statistically significant difference between dapagliflozin group and placebo group was found (8.8% versus 9.4%, p = 0.17 for superiority).
Gliflozins and congestive heart failure
In the safety studies, specific endpoints were analyzed for congestive heart failure.
EMPA-REG OUTCOME showed for empagliflozin a reduction in the rate of hospitalization for heart failure (2.7% versus 4.1%, ARR = 1.4% points, RRR = 34.0%, NNT = 73, p = 0.002) (4). The result of this explorative endpoint was as a trend also found for canagliflozin, but could not be satisfactorily supported statistically (5). In DECLARE-TIMI 58, by contrast, a composite of cardiovascular mortality or hospitalization for heart failure was used as a further primary endpoint, besides 3P-MAC. Treatment with dapagliflozin led to a statistically significant reduction of this endpoint (4.9% versus 5.8%, ARR = 0.9% points, RRR = 16.0%, NNT = 109, p = 0.005), resulting from a reduction in the rate of hospitalization for heart failure (6).
Subsequently, studies were specifically designed to evaluate the role of gliflozins in the management of congestive heart failure with a reduced left-ventricular ejection fraction (HFrEF) (Table 2). The DAPA-HF study (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure) included patients with overt HFrEF (EF ≤ 40%, NYHA stages II–IV, elevated N-terminal pro-brain natriuretic peptide [NT-proBNP] levels) (7). Both patients with (42.0%) and without T2D (58.0%) were enrolled in the trial. In addition to guideline-recommended heart failure therapy, patients received either dapagliflozin (10 mg/day) or placebo. For the primary endpoint (worsening heart failure or cardiovascular mortality), a statistically significant superiority of the dapagliflozin group (16.3% versus 21.2%, ARR = 4.9% points, RRR = 23.2%, NNT = 21, p < 0.001) was found. The recently published EMPEROR-Reduced trial included HFrEF patients who received either empagliflozin (10 mg/day) or placebo in addition to guideline-adherent heart failure therapy (8). With regard to the primary composite outcome of cardiovascular mortality or hospitalization for heart failure, a significant advantage was demonstrated for the Empagliflozin group (19.4% versus 24.7%, ARR: 5.3% points, RRR: 21.7%, NNT 19, p<0.001). This was largely attributable to a statistically significant reduction in the rate of hospitalization for heart failure, whereas the individual analysis failed to demonstrate a statistically significant reduction of cardiovascular mortality (10.0% versus 10.8%, p = not specified). However, a meta-analysis of the data of the EMPEROR-Reduced and DAPA-HF studies suggests that gliflozin treatment is also associated with a reduction in cardiovascular mortality (pooled hazard ratio 0.86 [0.76; 0.98], p = 0.027) and all-cause mortality (pooled hazard ratio 0.87 [0.77; 0.98], p = 0.018) (9). The subgroup analysis, however, revealed relevant differences in respect to NYHA class and ethnicity (potentially weaker treatment effect in patients with NYHA class III/IV as well as in white patients) (8, 9).
Gliflozins and renal failure
Since chronic kidney disease (CKD) is a common complication of T2D, in the EMPA-REG OUTCOME trial a composite microvascular outcome of laser treatment for retinopathy, vitreous hemorrhage, diabetes-related blindness, or incident/worsening nephropathy was used in a secondary analysis (10). The outcome occurred less frequently in the empagliflozin group compared to the placebo group (14.0% versus 20.5%, ARR = 6.5% points, RRR = 31.9%, NNT = 16, p<0.001) and was almost completely due to renal effects. Another secondary outcomes included incident or worsening nephropathy (defined as macroalbuminuria, doubling of the serum creatinine level along with an estimated glomerular filtration rate [eGFR] of ≤ 45 mL/min/1.73 m², initiation of renal-replacement therapy, or death from renal disease). In patients treated with empagliflozin, a reduction in this endpoint was found (12.7% versus 18.8%, ARR = 6.1% points, RRR = 32.4%, NNT = 17, p<0.001). Despite a statistically significant reduction in the progression to macroalbuminuria (hazard ratio 0.62 [0.54; 0.72], p<0.001), empagliflozin had no effect on the rate of incident albuminuria. However, as this was a post-hoc analysis, its results are of hypothesis-generating nature.
For canagliflozin, CREDENCE, a study with a renal endpoint, was initiated (Table 3) (11). Patients with T2D and an eGFR of 30–90 mL/min/1.73 m² and albuminuria (ratio of urine albumin to creatinine of 300 to 5000 mg/g) were randomized. A composite outcome of end-stage kidney disease, a doubling of the serum creatinine level, or death from cardiovascular or renal causes was defined. A statistically significant advantage was found for the canagliflozin group (11.1% versus 15.5%, ARR = 4.3% points, RRR = 28.0%, NNT = 24, p < 0.001). The recently published DAPA-CKD trial also included specific patients with chronic kidney disease (Table 3) (12). At baseline, participating patients had an eGFR of 25 to 75 mL/min/1.73 m² and a urinary albumin-to-creatinine ratio of 200 to 5000 mg/g. For the primary composite outcome (decline in eGFR by ≥ 50%, end-stage renal disease and death from renal or cardiovascular causes) a significant advantage in favor of the dapagliflozin group was found (9.2% versus 14.5%, ARR = 5.3% points, RRR = 36.9%, NNT = 19, p<0.001).
The safety of gliflozins
The main adverse drug reactions (ADRs) of gliflozins are summarized in the eTable. Recent information from pharmacovigilance activities is included in this list (4th Quarter 2003 to 4th Quarter 2019, OpenVigil 2.1-MedDRA).
As the result of the induced glucosuria, gliflozins lead to an increased rate of urinary tract and genital infections, especially in women (4, 5, 6). The incidence of genital infections varied from 0.9% (dapagliflozin) to about 6.4% (empagliflozin) in safety studies. However, the treatment was rarely discontinued because of these infections. In addition, an increased incidence of euglycemic ketoacidosis was found in patients treated with gliflozins, especially if taken in combination with insulin therapy (13). The DECLARE-TIMI 58 trial found a statistically significant increase in the occurrence of euglycemic ketoacidosis in patient taking dapagliflozin (incidence: 0.3 versus 0.1%; hazard ratio 2.18 [1.10; 4.30], p = 0.02) (6). In contrast, the relevant safety studies for empagliflozin and canagliflozin did not show such an increase (4, 5). Canagliflozin, in turn, was associated with an increased risk of amputation of the lower extremity in the CANVAS PROGRAM (5). Furthermore, an increased risk of fracture was noticed with canagliflozin. These observation were not confirmed for empagliflozin and dapagliflozin.
EMPA-REG OUTCOME was the first study to draw attention to gliflozins as promising substances for the treatment of congestive heart failure and renal failure (4). The EMPA-REG OUTCOME patient population was clearly different from those of the two other large safety studies: In the CANVAS PROGRAM and DECLARE-TIMI 58, only 65.6% and 40.6% of patients, respectively, suffered from overt cardiovascular disease (5, 6). This implies that the patients were in better overall health and could explain why no superiority of dapagliflozin over placebo was found for 3P-MACE.
DAPA-HF was the first study to look specifically at the use of a gliflozin in the management of HFrEF (7). At the end of the recruitment period, only 42% of patients had a known T2D diagnosis. An additional 3% of subjects were newly diagnosed with T2D during the study. In subgroup analyses, the positive results for dapagliflozin were found for patients with and without diabetes. However, for an accurate interpretation of the DAPA-HF data it is critical that 67% of patients without diabetes were prediabetic (HbA1c ≥ 5.7%) (14). Thus, ultimately only about 18% of the DAPA-HF patients had a normal glucose metabolism. From the follow-up of the Diabetes Prevention Program Outcomes Study (DPPOS) we know that vascular complications, such as retinopathy, neuropathy and nephropathy, can already be triggered in the prediabetic stage. Patients with prediabetes had a cardiovascular 10-year risk of 16.2%, based on the Framingham risk score. This corresponded to an absolute risk increase of 1.8% points compared to the 10-year risk of 14.4% in the group with overt T2D (15).
In DAPA-HF, the positive effects on congestive heart failure already occurred early after randomization (7). Furthermore, a subgroup analysis showed that the effects of dapagliflozin can be more pronounced in patients with NYHA II compared to patients with NYHA III and IV. This would support the use of gliflozins early in the management of HFrEF patients with (pre-) diabetes. In contrast, an advantage for patients with advanced disease (e.g. worse pump function and lower eGFR) was found in other subgroups. Thus, there are some inconsistencies in the findings of the DAPA-HF trial. Furthermore, only 10.5% and 10.9% of patients (dapagliflozin group and placebo group, respectively) were treated with an angiotensin-receptor neprilysin inhibitor (sacubitril/valsartan). Given the prominent role of sacubitril/valsartan in the treatment of HFrEF, the comparatively small proportion of patients receiving this drug is an important limitation of DAPA-HF (16, 17). It has also been the subject of considerable discussion whether in DAPA-HF an increase in the dose of loop diuretics could have reduced the effectiveness of gliflozins. A relevant subgroup analysis indicated consistent positive effects of dapagliflozin, independently of the preexisting dose of diuretics (18). Following these findings for dapagliflozin, the EMPEROR-Reduced trial, the results of which were published in August 2020, demonstrated a therapeutic benefit in patients with HFrEF for empagliflozin too. According to the authors, the positive effects of empagliflozin were independently of the presence of T2D (8). In comparison to DAPA-HF, EMPEROR-Reduced enrolled patients with a slightly lower EF (mean EF about 27% versus about 31% in DAPA-HF).
On the basis of the existing data, gliflozins were included in the joint 2019 guideline of the European Association for the Study of Diabetes and the European Society of Cardiology (EASD and ESC). The guideline explicitly recommends the use of gliflozins to reduce the hospitalization rate in HFrEF patients with T2D (class 1A recommendation) (19). It can be expected that the new data from EMPEROR-Reduced and also from DAPA-HF will further boost the role of gliflozins in the treatment of HFrEF in future guidelines (9). In addition, ongoing studies are evaluating the potential benefits of empagliflozin (EMPEROR-Preserved) and dapagliflozin (DELIVER) in the treatment of congestive heart failure with preserved ejection fraction (HFpEF).
Early on in cardiovascular safety studies, signs of nephroprotective effects of gliflozins were noticed (4, 5, 6). In the CREDENCE study, a primary renal endpoint was explicitly chosen (11). In patients with T2D and existing pharmacological inhibition of the renin-angiotensin-aldosterone system, canagliflozin led to a statistically significant reduction in the composite renal endpoint. The effects on renal function were measurable despite the fact that for blood sugar control, blood pressure and body weight only minor differences were found between the placebo group and the canagliflozin group. This suggests that gliflozins may have directs molecular effects on the kidney. By increasing natriuresis, gliflozins stimulate the tubuloglomerular feedback mechanism. This results in vasoconstriction of the afferent arterioles and consequently in a decrease in filtration pressure (20). Since AT1 receptor antagonist and ACE inhibitors reduce filtration pressure by means of vasodilation of the efferent vessel, additive nephroprotective effects of these substance classes are conceivable.
For dapagliflozin (DAPA-CKD) and empagliflozin (EMPA-KIDNEY), studies were subsequently designed to evaluate the potential benefits of gliflozins in patients with chronic kidney disease. DAPA-CKD was terminated early because a statistically significant advantage of the dapagliflozin group had already been noticeable in an interim analysis. The recently published final results of DAPA-CKD underscore the potential role of gliflozins as a treatment option in patients with chronic renal disease independently of the presence of T2D (12). It is also remarkable that patients receiving dapagliflozin showed a reduction in the secondary endpoint of all-cause mortality (4.7% versus 6.8%, ARR = 2.1% points, RRR = 30.8%, NNT = 48. p = 0.004).
Overall, gliflozins have a favorable side-effect profile (13). Hypoglycemic episodes usually only occur in combination therapy with other antidiabetic agents, most notably insulin and sulfonylurea drugs. Diabetic ketoacidosis is a rare complication and is often associated with euglycemia. The risk of ketoacidosis can be reduced by pausing treatment with gliflozins when the patient has an acute illness (so-called “sick day break“). Hypotension and hypovolemia result from increased natriuresis and should be balanced by modifying concomitant treatment with diuretics. The increased rate of fractures and amputations with canagliflozin, but not with empagliflozin and dapagliflozin, can currently not be explained conclusively (5). With an incidence of up to 6.4%, genital infections are a comparatively common side effect of gliflozins (4, 5, 6). By applying appropriate hygienic measures and, if necessary, initiating antifungal or anti-infective therapy, it can usually be treated successfully.
Gliflozins are effective substances for the treatment of T2D. In addition, they have been gaining increasing importance in the treatment of HFrEF and chronic renal disease. Based on the currently available evidence, their effects on congestive heart failure and renal failure are independent of a purely antidiabetic activity and can already be observed in early stages of the disease. Future studies will further define the therapeutic significance of gliflozins in specific subgroups.
Conflict of interest
Prof. Schulte received reimbursement of travel expenses and lecture fees from AstraZeneca and Lilly.
Prof. Laudes received consulting fees and lecture fees as well as reimbursement of travel expenses from AstraZeneca and Lilly. He received consulting fees from Böhringer.
The remaining authors declare no conflict of interest.
Manuscript received on 25 May 2020, revised version accepted on 21 October 2020
Translated from the original German by Ralf Thoene, MD.
Prof. Dr. med. Matthias Laudes
Lehrstuhl für Innere Medizin – Endokrinologie, Diabetologie und klinische Ernährungsmedizin, Klinik für Innere Medizin 1
Universitätsklinikum Schleswig-Holstein, Campus Kiel
Düsternbrooker Weg 17, 24105 Kiel, Germany
Cite this as:
Seoudy AK, Schulte DM, Hollstein T, Böhm R, Cascorbi I, Laudes M:
Gliflozins for the treatment of congestive heart failure and renal failure
in type 2 diabetes. Dtsch Arztebl Int 2021; 118: 122–9.
This article has been certified by the North Rhine Academy for Continuing Medical Education. Participation in the CME certification program is possible only over the internet: cme.aerzteblatt.de. The deadline for submissions is 25 February 2022.
Participation is possible at cme.aerztebatt.de
Institute of Experimental and Clinical Pharmacology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany: Dr. med. Ruwen Böhm, Prof. Dr. med. Dr. rer. nat. Ingolf Cascorbi
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