Dapagliflozin Effect on Cardiovascular Events–Thrombolysis in Myocardial Infarction 58 - DECLARE–TIMI 58

Contribution To Literature:

The DECLARE–TIMI 58 trial showed that dapagliflozin is superior to placebo in improving glycemic control and noninferior but not superior for reducing MACE in patients with DM2 and high CV risk.

Description:

The goal of the trial was to assess the cardiovascular (CV) safety of dapagliflozin in patients with type 2 diabetes mellitus (DM2) and either established CV disease (CVD) or multiple risk factors.


Study Design

Patients were randomized in a 1:1 fashion to either dapagliflozin 10 mg (n = 8,582) or matching placebo (n = 8,578).

  • Total number of enrollees: 17,160
  • Duration of follow-up: 4.2 years
  • Mean patient age: 64.0 years
  • Percentage female: 37%

Inclusion criteria:

  • Age ≥40 years
  • DM2
  • Glycosylated hemoglobin (HbA1c) of ≥6.5% and ≤12%
  • Glomerular filtration rate (GFR) of >60
  • Established CVD or multiple risk factors including men ≥55 years or women ≥60 years with hypertension, dyslipidemia, or tobacco use

Exclusion criteria:

  • Diagnosis of type 1 DM
  • History of bladder cancer or history of radiation therapy to the lower abdomen or pelvis at any time
  • Chronic cystitis and/or recurrent urinary tract infections
  • Pregnant or breast-feeding patients

Other salient features/characteristics:

  • White: 79%, Asian 13.5%
  • Body mass index: 32 kg/m2
  • Median duration of DM: 10.5 years
  • HbA1c: 8.3%
  • Established atherosclerotic CVD: 40.7%
  • Insulin: 41%, metformin: 82%
  • Statins: 75%

Principal Findings:

The primary outcome of major adverse cardiac events (MACE) for dapagliflozin vs. placebo: 8.8% vs. 9.4%, hazard ratio (HR) 0.93, 95% confidence interval (CI) 0.84-1.03, p < 0.001 for noninferiority; p = 0.17 for superiority

Secondary outcomes for dapagliflozin vs. placebo:

  • Reduction in HbA1c with dapagliflozin: 0.42%
  • CV death or heart failure (HF) hospitalization: 4.9% vs. 5.8%, p = 0.005
  • HF hospitalization: 2.5% vs. 3.3%, p < 0.005
  • All-cause mortality: 6.2% vs. 6.6%, p > 0.05
  • >40% decrease in GFR, end-stage renal disease, or death due to renal or CV causes: 4.3% vs. 5.6%, p < 0.05
  • Diabetic ketoacidosis: 0.3% vs. 0.1%, p = 0.02
  • Genital infections: 0.9% vs. 0.1%, p < 0.001
  • Amputation: 1.4% vs. 1.3%, p = 0.53

Based on presence of peripheral artery disease (PAD): PAD was present in 1,025 of randomized patients, with nearly 75% being asymptomatic or with mild claudication symptoms. MACE and renal events were higher among PAD patients compared with those without PAD. Limb events were also higher (20.3% vs. 2.1%). No effect modification was noted by PAD status for the effect of dapagliflozin vs. placebo. Limb events were also similar, including major adverse limb events (1.4% vs. 1.2%), urgent revascularization (0.5% vs. 0.6%), and elective revascularization (1.6% vs. 1.5%). Amputation rates were overall similar (1.4% vs. 1.3%). Among patients with PAD, event rates were higher, but no effect modification by PAD status was noted. There was a numerically higher rate of amputations among PAD patients with dapagliflozin (8.4% vs. 5.6%; HR 1.51, 95% CI 0.94-2.42).

Patients with prior myocardial infarction (MI): (n = 3,584). Dapagliflozin reduced the relative risk of MACE by 16% and the absolute risk by 2.6% among patients with prior MI (15.2% vs. 17.8%; HR 0.84, 95% CI 0.72-0.99, p = 0.039), whereas there was no effect in patients without prior MI (7.1% vs. 7.1%; HR 1.00, 95% CI 0.88-1.13, p = 0.97; p-interaction for relative difference 0.11).

Effect of ejection fraction (EF): 3.9% had HF with reduced EF (HFrEF). Dapagliflozin reduced CV death/hospitalization for HF more in patients with HFrEF (HR 0.62, 95% CI 0.45-0.86) than in those without HFrEF (HR 0.88, 95% CI 0.76-1.02; p-interaction 0.046). Dapagliflozin reduced hospitalization for HF both in those with (HR 0.64, 95% CI 0.43-0.95) and without HFrEF (HR 0.76, 95% CI 0.62-0.92); it reduced CV death only in patients with HFrEF (HR 0.55, 95% CI 0.34-0.90) but not in those without HFrEF (HR 1.08, 95% CI 0.89-1.31; p-interaction 0.012). Similar results were noted for all-cause mortality.

Interpretation:

The results of this trial indicate that dapagliflozin is superior to placebo in improving glycemic control and noninferior but not superior for reducing MACE in patients with DM2 and high CV risk. There was a reduction in HF hospitalizations, and also a salutary effect on renal outcomes. Among patients with HFrEF, dapagliflozin reduced HF hospitalizations, and CV and all-cause mortality; however, this cohort comprised only about 4% of the total population. Unlike canagliflozin, there was no clear safety signal regarding increased amputations. These are important findings, and more or less consistent with findings noted with other selective inhibitor of sodium–glucose cotransporter 2 (SGLT-2) inhibitors. These drugs reduce hyperglycemia in patients with DM2 by reducing renal glucose reabsorption and thus increasing urinary glucose excretion.

Following the much-publicized CV safety concerns with rosiglitazone, the FDA mandated that all new diabetes drugs conduct studies demonstrating CV safety. The upper limit of the 95% CI for the HR had to be <1.8 for premarketing studies and <1.3 for postmarketing studies. This trial thus establishes the CV safety profile of dapagliflozin for use in patients with DM2. The reduction in HF hospitalization was noted even among patients with prior HF, and has been noted for the other SGLT-2 inhibitors. Dipeptidyl peptidase-4 (DPP-4) inhibitors on the other hand, particularly saxagliptin, may increase the risk of HF.

References:

DECLARE–TIMI 58 PAD: Presented by Dr. Marc P. Bonaca at the American College of Cardiology Annual Scientific Session (ACC 2019), New Orleans, LA, March 18, 2019.

DECLARE–TIMI 58 HFrEF: Presented by Dr. Eri T. Kato at the American College of Cardiology Annual Scientific Session (ACC 2019), New Orleans, LA, March 18, 2019.

Furtado RH, Bonaca MP, Raz I, et al. Dapagliflozin and Cardiovascular Outcomes in Patients With Type 2 Diabetes and Prior Myocardial Infarction: A Sub-analysis From DECLARE TIMI-58 Trial. Circulation 2019;Mar 18:[Epub ahead of print].

Kato ET, Silverman MG, Mosenzon O, et al. Effect of Dapagliflozin on Heart Failure and Mortality in Type 2 Diabetes Mellitus. Circulation 2019;Mar 18:[Epub ahead of print].

Editorial: Verma S, McMurray JJ. The Serendipitous Story of SGLT2 Inhibitors in Heart Failure: New Insights From DECLARE-TIMI 58. Circulation 2019;Mar 18:[Epub ahead of print].

Wiviott SD, Raz I, Bonaca MP, et al., on behalf of the DECLARE–TIMI 58 Investigators. Dapagliflozin and Cardiovascular Outcomes in Type 2 Diabetes. N Engl J Med 2019;380:347-57.

Presented by Dr. Stephen D. Wiviott at the American Heart Association Annual Scientific Sessions (AHA 2018), Chicago, IL, November 10, 2018.

Clinical Topics: Diabetes and Cardiometabolic Disease, Dyslipidemia, Heart Failure and Cardiomyopathies, Prevention, Acute Heart Failure, Hypertension, Smoking

Keywords: ACC Annual Scientific Session, ACC19, AHA Annual Scientific Sessions, AHA18, Amputation, Atherosclerosis, Brain Ischemia, Diabetic Ketoacidosis, Diabetes Mellitus, Type 2, Dyslipidemias, Heart Failure, Hemoglobin A, Glycosylated, Hyperglycemia, Hypertension, Metabolic Syndrome X, Myocardial Infarction, Myocardial Ischemia, Primary Prevention, Renal Insufficiency, Chronic, Smoking, Stroke, Vascular Diseases


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