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SGLT2 Inhibitors as Add-On Therapy to Metformin for People with Type 2 Diabetes: A Review of Placebo-Controlled Trials in Asian versus Non-Asian Patients

Authors Scheen AJ

Received 17 April 2020

Accepted for publication 8 July 2020

Published 5 August 2020 Volume 2020:13 Pages 2765—2779


Checked for plagiarism Yes

Review by Single anonymous peer review

Peer reviewer comments 2

Editor who approved publication: Professor Ming-Hui Zou

André J Scheen1,2

1Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège University, Liège, Belgium; 2Clinical Pharmacology Unit, CHU Liège, Center for Interdisciplinary Research on Medicines (CIRM), Liège University, Liège, Belgium

Correspondence: André J Scheen Email

Abstract: Metformin remains the first pharmacological choice for treating hyperglycemia in type 2 diabetes (T2DM) in most international guidelines. Sodium-glucose cotransporter type 2 inhibitors (SGLT2is) are increasingly used as add-on therapy. T2DM pathophysiology is different in Asian and non-Asian (mainly Caucasian) patients. The aim of this systematic review is to compare the efficacy of SGLT2is vs placebo added to metformin in randomized controlled trials (RCTs: range 12– 52 weeks) in Asian versus non-Asian patients with T2DM. The primary endpoint is the reduction in glycated hemoglobin (HbA1c) from baseline and key secondary endpoints are reductions in fasting plasma glucose (FPG), body weight (BW) and systolic blood pressure (SBP). Systematic literature search collected 7 RCTs (3 with 2 doses) in Asian patients (10 analyses, n=1164, iSGLT2: canagliflozin, dapagliflozin, ertugliflozin, ipragliflozin, tofogliflozin)) and 10 RCTs (6 with two doses) in non-Asian patients (16 analyses, n=2482, iSGLT2: canagliflozin, dapagliflozin, empagliflozin, ertugliflozin, ipragliflozin). Baseline values of HbA1c (7.98± 0.19 vs 7.89± 0.27%), FPG (8.80 ± 0.46 vs 9.11± 0.49 mmol/l) and SBP (128.4± 1.6 vs 130.2± 3.1 mmHg) were not significantly different in Asian vs non-Asian patients, but BW was lower in Asian patients (71.6± 4.8 vs 88.0± 2.5 kg, p< 0.001). The placebo-adjusted weighed mean differences (WMD, 95% CI) were similar in Asian versus non-Asian patients regarding the reductions in HbA1c − 0.60 (− 0.68, − 0.53) % versus − 0.54 (− 0.59, − 0.49) % (p=0.568), FPG − 1.37 (− 1.53, − 1.22) mmol/l vs − 1.37 (− 1.47, − 1.27) mmol/l (p=0.627), BW when expressed in percentage of baseline BW − 2.23 (− 2.55, − 1.90) % vs − 2.16 (− 2.37, − 1.96) % (p=0.324), and SBP − 4.53 (− 5.53, − 3.53) mmHg vs − 4.06 (− 4.83, − 3.29) mmHg) (p=0.223). In conclusion, clinical efficacy of SGLT2i, as an add-on treatment to metformin monotherapy in patients with T2DM, is similar in Asian versus non-Asian patients, despite known ethnic differences in phenotype and pathophysiology of T2DM.

Keywords: blood pressure, body weight, combined therapy, glucose control, HbA1c, oral antidiabetic drug

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