medwireNews: The results of a network meta-analysis offer strong support for use of sodium-glucose cotransporter (SGLT)2 inhibitors to prevent heart failure (HF) in patients with type 2 diabetes.
By contrast, the degree to which the various antidiabetic medications reduced patients’ glycated hemoglobin was not significantly associated with their risk for developing HF.
“These findings suggest that specific drug classes, rather than glycemic targets, should be the focus of HF prevention efforts,” write Adam DeVore and Jennifer Green, both from Duke University School of Medicine in Durham, North Carolina, USA, in an editorial accompanying the study in JACC: Heart Failure.
The research by Ravi Retnakaran (Mount Sinai Hospital, Toronto, Ontario, Canada) and colleagues included 87,162 patients with type 2 diabetes who participated in nine manufacturer-sponsored cardiovascular outcome studies published between 2013 and 2017.
DeVore and Green note that some previous studies, such as the UKPDS, found that intensive glycemic control did reduce HF risk. But they observe that the UKPDS recruited patients in relatively early stages of diabetes at a time when background therapy was very different, with, for example, little recognition of the importance of blood pressure control.
“It is possible that achievement of a reasonable degree of glycemic control early in the course of diabetes provides some protection against the development of HF over the long term,” they speculate.
“However, this advantage may be lost in patients with more established and complicated disease. In such patients, the selection of particular antihyperglycemic drug classes may be more important to reducing HF risk.”
In a standard meta-analysis of each medication class versus placebo, SGLT2 inhibitors reduced HF hospitalization risk by a significant 44%, whereas glucagon-like peptide (GLP)-1 receptor agonists and dipeptidyl peptidase (DPP)-4 inhibitors were respectively associated with a nonsignificant 6% reduction and 11% increase in risk.
In the network meta-analysis, which allows comparison of interventions that have not been directly compared, SGLT2 inhibitors were associated with a significantly reduced HF hospitalization risk of 41% versus GLP-1 receptor agonists and 50% versus DPP-4 inhibitors.
The researchers calculated a 99.6% probability that SGLT2 inhibitors were the best of the three medication classes for preventing HF hospitalization, followed by GLP-1 receptor agonists at 0.27% and DPP-4 inhibitors at 0.1%.
“Resolving whether specific drug classes or glycemic control for diabetic patients with stage A HF is important, and the public health implications are profound,” say DeVore and Green. “To our knowledge, there are no current trials designed to answer this issue though these questions are ideal for a pragmatic clinical trial on strategies to prevent HF.”
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