Diabetologia :新型降糖药物对心血管结局的有效性和安全性

2021-10-13 从医路漫漫 MedSci原创

最近发布了一些关于钠-葡萄糖共转运体2抑制剂(SGLT2i)的心血管结局试验,包括纳入充血性心力衰竭(CHF)和慢性肾脏疾病(CKD)患者的试验。

目的:最近发布了一些关于钠-葡萄糖共转运体2抑制剂(SGLT2i)的心血管结局试验,包括纳入充血性心力衰竭(CHF)和慢性肾脏疾病(CKD)患者的试验。因此,需要更新比较SGLT2i、胰高血糖素样肽-1受体激动剂(GLP-1RA)和二肽基肽酶-4抑制剂(DPP-4i)的疗效和安全性。目前还缺乏对患者亚组的评估,即按年龄或有无CHF、CKD或动脉粥样硬化性心血管疾病(ASCVD)分层的评估。

方法:检索PubMed、Embase和Cochrane数据库,查找截至2020年12月5日发表的相关研究。将SGLT2i、GLP-1RA和DPP-4i与安慰剂(或其他对照)或彼此与心血管(CV)或肾脏结果进行比较的rct符合纳入的条件。主要疗效终点为3点主要心血管不良事件(3PMACE),定义为CV死亡、非致死性心肌梗死和非致死性缺血性卒中。还分析了全因死亡率、因心力衰竭(HHF)住院和综合肾脏结局。预先指定的3PMACE亚组分析也进行了。

结果:共有21项试验,170930名参与者被纳入这项网络荟萃分析。与安慰剂相比,GLP-1RA和SGLT2i与较低的3P-MACE风险相关(RR 0.89, 95% CI 0.84, 0.94和RR 0.88, 95% CI 0.83, 0.94)。与DPP-4i相比,GLP-1RA和SGLT2i也与更低的3P-MACE风险相关(RR分别为0.89,95% CI 0.82, 0.98和0.89,95% CI 0.81, 0.97)。比较SGLT2i和GLP-1RA的3P-MACE风险无差异(RR 0.99, 95% CI 0.91, 1.08)。与安慰剂相比,只有GLP-1RA与较低的中风风险相关(RR 0.85, 95% CI 0.76, 0.94)。SGLT2i在降低HHF (RR 0.76, 95% CI 0.68, 0.84)和肾脏结局方面优于GLP-1RA (RR 0.78, 95% CI 0.65, 0.93)。亚组分析表明,SGLT2i和GLP-1RA的益处在老年患者、白人和亚洲患者、患有ASCVD的患者以及糖尿病持续时间较长和血糖控制较差的患者中更明显。

图1 3P-MACE (a)、致死性或非致死性MI (b)、致死性或非致死性缺血性卒中(c)和CV死亡(d)网络meta分析的森林图

图2 全因死亡(a)、HHF (b)和综合肾脏结局(c)网络元分析的森林图

图3 按年龄(a)、种族(b)、确定ASCVD (c)和糖尿病持续时间(d)进行3P-MACE亚组分析

结论:SGLT2i和GLP-1RA在CV和肾脏预后方面优于DPP-4i。GLP-1RA是唯一一种可以降低中风风险的药物。SGLT2i在降低HHF和肾脏预后方面具有优势。因此,在SGLT2i和GLP-1RA之间的选择应该根据患者的情况进行个体化。

原文出处:

 Lin DS,  Lee JK,  Hung CS,  Chen WJ,The efficacy and safety of novel classes of glucose-lowering drugs for cardiovascular outcomes: a network meta-analysis of randomised clinical trials.Diabetologia 2021 Sep 18

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