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Patient-centered Management of Type 2 Diabetes Mellitus Based on Specific Clinical Scenarios: Systematic Review,
Lana C Pinto1, Dimitris V Rados1, Luciana R Remonti1
1Internal Medicine Department, Post-graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Endocrine Division, Hospital de Clínicas de Porto Alegre, Endocrine Division, Ramiro Barcelos, Porto Alegre, Brazil.
Introduction:
New antihyperglycemic medications have been proven to have cardiovascular (CV) and renal benefits in type 2 diabetes mellitus (T2DM); however, an evidence-based decision tree in specific clinical scenarios is lacking.
Materials And Methods:
Systematic review and meta-analysis of randomized controlled trials (RCTs), with trial sequential analysis (TSA). Randomized controlled trial inclusion criteria were patients with T2DM from 1 of these subgroups: elderly, obese, previous atherosclerotic CV disease (ASCVD), previous coronary heart disease (CHD), previous heart failure (HF), or previous chronic kidney disease (CKD). Randomized controlled trials describing those subgroups with at least 48 weeks of follow-up were included. Outcomes: 3-point major adverse cardiovascular events (MACE), CV death, hospitalization due to HF, and renal outcomes. We performed direct meta-analysis with the number of events in the intervention and control groups in each subset, and the relative risk of the events was calculated.
Results:
Sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1 RA) were the only antihyperglycemic agents related to a reduction in CV events in different populations. For obese and elderly populations, GLP-1 RA were associated with benefits in 3-point MACE; for patients with ASCVD, both SGLT2i and GLP-1 RA had benefits in 3-point MACE, while for patients with CHD, only SGLT2i were beneficial.
Conclusions:
SGLT2i and GLP-1 RA reduced CV events in selected populations: SGLT2i led to a reduction in events in patients with previous CHD, ASCVD, and HF. GLP-1 RA led to a reduction in CV events in patients with ASCVD, elderly patients, and patients with obesity. Trial sequential analysis shows that these findings are conclusive. This review opens a pathway towards evidence-based, personalized treatment of T2DM.
Registration:
PROSPERO CRD42019132807.
Insights
New antihyperglycemic drugs, sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1 RA), offer cardiovascular benefits for type 2 diabetes mellitus (T2DM) patients. Specific drug classes show benefits in distinct patient subgroups, guiding personalized treatment.
Area of Science:
- Cardiology
- Endocrinology
- Nephrology
Background:
- New antihyperglycemic medications demonstrate cardiovascular (CV) and renal benefits in type 2 diabetes mellitus (T2DM).
- A lack of evidence-based decision trees exists for specific clinical scenarios involving these medications.
- This highlights a need for clear guidance in managing T2DM with advanced therapies.
Purpose of the Study:
- To systematically review and meta-analyze the cardiovascular and renal benefits of new antihyperglycemic medications in specific T2DM patient subgroups.
- To provide an evidence-based approach for selecting appropriate therapies based on patient characteristics.
- To establish conclusive findings using trial sequential analysis.
Main Methods:
- Systematic review and meta-analysis of randomized controlled trials (RCTs) including patients with T2DM and specific comorbidities (elderly, obese, ASCVD, CHD, HF, CKD).
- Included RCTs had a minimum follow-up of 48 weeks.
- Outcomes assessed included major adverse cardiovascular events (MACE), CV death, HF hospitalization, and renal outcomes. Trial sequential analysis (TSA) was performed.
Main Results:
- Sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1 RA) were associated with reduced CV events.
- GLP-1 RA showed benefits in 3-point MACE for obese and elderly patients.
- SGLT2i demonstrated benefits in 3-point MACE for patients with previous coronary heart disease (CHD) and atherosclerotic cardiovascular disease (ASCVD). Both agents were beneficial for ASCVD patients.
Conclusions:
- SGLT2i and GLP-1 RA offer significant cardiovascular event reduction in specific T2DM populations.
- SGLT2i are beneficial for patients with prior CHD, ASCVD, and heart failure (HF).
- GLP-1 RA are beneficial for patients with ASCVD, elderly patients, and those with obesity. TSA confirmed these findings, supporting personalized T2DM treatment.
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