Russian Medical Review
* Impact factor according to the SCIENCE INDEX 2017
D.A. Lebedev, A.Yu. Babenko
V.A. Almazov National Medical Research Center, St. Petersburg, Russian Federation
Background: several randomized clinical trials have demonstrated that dapagliflozin, like other inhibitors of sodium-glucose cotransporter 2 (SGLT2), significantly improves cardiovascular and renal outcomes in type 2 diabetes (T2D). However, underlying mechanisms remain unclear.
Aim: to assess changes in the levels of serum markers associated with fibrosis and inflammation in patients with T2D receiving dapagliflozin.
Patients and Methods: this prospective single-center study included 27 patients aged 40–65 years with T2D that lasts more than 1 year and without verified atherosclerosis but multiple cardiovascular risk factors (i.e., dyslipidemia, obesity, hypertension). In addition to basic treatment for T2D, all patients received dapagliflozin 10 mg daily for 6 months. Before and 6 months after treatment, the levels of the markers of fibrosis (including procollagen type I carboxy-terminal propeptide/PICP) and inflammation were measured.
Results: the median age was 56 [49; 61] years and the median duration of T2D was 7 [4; 12] years. After 6-month treatment with dapagliflozin, significant reduction in the concentration of PICP from 136.8 [100,4; 200,6] ng/ml to 104.8 [79.7; 162.0] ng/ml (р = 0.019). The levels of galectin-3, matrix metalloproteinase (MMP) 9, tissue inhibitor of MMP-1, growth stimulating expressed gene 2, high-sensitivity C-reactive protein, and N-terminal pro-atrial natriuretic peptide were similar at baseline and after 6-month treatment.
Conclusions: 6-month treatment with dapagliflozin reduced the levels of PICP. Together with other mechanisms, this phenomenon illustrates the positive effects of dapagliflozin on cardiovascular and renal outcomes in T2D.
Keywords: type 2 diabetes, fibrosis, chronic inflammation, dapagliflozin, cardiovascular diseases.
For citation: Lebedev D.A., Babenko A.Yu. Effects of dapagliflozin of the markers of fibrosis and inflammation in type 2 diabetes and very high cardiovascular risk. Russian Medical Inquiry. 2021;5(4):185–188 (in Russ.). DOI: 10.32364/2587-6821-2021-5-4-185-188.
Inhibitors of sodium-glucose cotransporter 2 (SGLT2) demonstrate significant cardiovascular benefits in patients with type 2 diabetes (T2D) and verified cardiovascular diseases or multiple risk factors [1–3]. Several hypotheses explain the positive effect of SGLT2 inhibitors on cardiovascular outcomes. Thus, some studies report on the reduction in cardiac preload due to increased sodium uresis, improved metabolism of cardiomyocytes, and reduction in the severity of fibrosis and inflammation in the myocardium and vascular wall [4–6]. However, this issue is still a matter of extensive exploration.
T2D is associated with chronic inflammation mediated by various mechanisms. For example, it was demonstrated that SGLT2 inhibitors reduce the levels of some cytokines, e.g., tumor necrosis factor α, interleukin-6, and high-sensitive C-reactive protein (hs-CRP) . In addition, it is well-known that myocardial fibrosis develops in T2D irrespective of hypertension and the severity of coronary atherosclerosis . Considering this, studying fibrotic and inflammatory processes in T2D is essential.
To assess dynamic changes in the levels of serum markers associated with fibrosis and inflammation in patients with T2D receiving dapagliflozin.
Patients and Methods
The Ethics Committee approved the protocol of this single-center prospective study of the V.A. Almazov National Medical Research Center. All participants signed an informed consent form before entering the study. The study enrolled patients with T2D (HbA1c 7-10%) that lasts more than one year and without verified cardiovascular atherosclerosis but with multiple cardiovascular risk factors (i.e., dyslipidemia, obesity, hypertension). Additional inclusion criteria were age 40-65 years and taking stable glucose-lowering, lipid-lowering, and antihypertensive therapy for at least 12 weeks before the enrollment. Exclusion criteria were atrial fibrillation, congenital heart valve disease, rheumatic diseases, exacerbations of chronic diseases, type 1 diabetes, symptoms of hypotension and systolic blood pressure (BP) less than 95 mm Hg, N-terminal pro-b-type natriuretic peptide (NT-proBNP) > 125 ng/ml, glomerular filtration rate (GFR) < 60 ml/min/1.73 m2 and chronic kidney disease, liver diseases, insulin therapy, and treatment with corticosteroids or mineralocorticoid receptor antagonists. In addition to primary treatment for T2D, all patients received dapagliflozin 10 mg daily for six months.
Fasting blood samples were collected before starting treatment and after six months of treatment. The levels of HbA1c, ALAT, ASAT, creatinine, total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides, NT-proBNP, hs-CRP, galectin-3, matrix metalloproteinase (MMP) 9, tissue inhibitor of MMP-1 (TIMP-1), growth stimulation expressed gene 2 (ST2), and procollagen I carboxy-terminal propeptide (PICP) were measured. The hs-CRP level was measured by immunoturbidimetry (Cobas Integra 400+). NT-proBNP concentration was measured by electrochemiluminescence immunoassay (Elecsys, Roche Diagnostics). Serum levels of galectin-3, MMP-9 and TIMP-1 (R&D Systems), ST2 (Clinical Diagnostics, Presage ST2 kit), and PICP (USCN Life Science) were measured by enzyme immunoassay. In addition, weight, height, waist circumference, and BP were measured at the beginning and end of the study. Fifteen age-matched individuals without T2D or other chronic diseases, including cardiovascular and kidney diseases (control group), were also enrolled to evaluate normal levels of fibrosis biomarkers.
Statistical analysis was performed using the SPSS Statistics software. Quantitative data were represented as the median, and the upper and lower quartiles Me [Q25; Q75] and qualitative data were represented as absolute and relative indices. The differences between quantitative parameters were assessed using the Wilcoxon signed-rank test. Spearman's rank correlation coefficient was applied to perform correlation analysis. The null hypothesis was rejected if the p-value was less than 0.05.
The study included 27 patients (the mean age was 56 [49; 61] years). Most of these patients were diagnosed with T2D, which lasted four years or more (7 [4; 12] years) and had stage 1 obesity. Primary glucose-lowering therapy included a combination of metformin and sulphonylurea preparations or dipeptidyl peptidase 4 (DPP-4) inhibitors.
Major patient characteristics and dynamic changes in the levels of the markers of fibrosis and inflammation are listed in Table 1. A 6-month treatment with dapagliflozin resulted in the significant reduction in HbA1c level from 8.2% [7.6; 8.8] to 7.8 [7.2; 8.1] % (р = 0.001), body mass index (BMI), and waist circumference. No significant changes in the levels of triglycerides, GFR, and BP were reported.
The levels of hs-CRP and NT-proBNP were within normal ranges and did not significantly change after 6-month treatment with dapagliflozin. At baseline, the concentrations of galectin-3, PICP, and MMP-9 were significantly higher compared to the control group (p = 0.017, p = 0.006, and p = 0.008, respectively). No significant changes in the levels of galectin-3, MMP-9, TIMP-1, and ST2 compared to baseline were reported (see Table 1). Meanwhile, PICP concentration significantly reduced from 136.8 [100.4; 200.6] ng/ml to 104.8 [79.7; 162.0] ng/ml (р = 0.019) and TIMP-1 concentration significantly increased from 188 [138; 270] ng/ml to 234 [205; 315] ng/ml (р = 0.011) after 6-month treatment with dapagliflozin.
The predominance of type I collagen synthesis over its degradation results in the over-accumulation of collagen fibers in the myocardium and illustrates fibrosis in the interstitial and perivascular space (including diabetic cardiomyopathy) . In addition, the levels of PICP considered the marker of type I collagen synthesis and degradation strongly correlate with the amount of producing collagen in patients with or without congestive heart failure (CHF) .
Some studies demonstrate that PICP concentrations are higher in patients with T2D than those without T2D . Our study produced similar findings. 6-month treatment with dapagliflozin resulted in a significant reduction in PICP levels compared to baseline. A trial of another SGLT2 inhibitor in patients with T2D and very high cardiovascular risk demonstrated a similar pattern of changes .
Our study did not reveal significant changes in NT-proBNP concentration after 6-month treatment with dapagliflozin. The enrollment of patients without CHF or high concentrations of NT-proBNP accounts for this phenomenon. Since NT-proBNPis a marker of CHF and its level correlates with CHF severity, even studies in T2D patients with CHF and preserved ejection fraction did not identify a significant reduction in NT-proBNP concentration . Meanwhile, the DAPA-HF study has demonstrated that the risk of CHF worsening or death from cardiovascular diseases is lower in the dapagliflozin group vs. placebo . Therefore, SGLT2 inhibitors improve clinical outcomes in patients with CHF despite their limited effects on NT-proBNP levels, thereby illustrating the discrepancy between short-term changes in NT-proBNP levels and clinical outcomes.
The concentrations of ST2, hs-CRP, MMP-9, and TIMP-1 did not significantly change after 6-month treatment with dapagliflozin. These findings are in line with other data [11, 14, 15]. The lack of significant changes in the levels of several markers is potentially accounted for by the fact that patients without CHF or cardiovascular events are at the stage of the cardiovascular continuum when concentrations of markers do not fully illustrate disease severity and prognosis, and their changes cannot be recorded during 6-month follow-up. In addition, the lack of negative changes in the levels of these markers indicates slowing inflammation and fibrosis in T2D being realized through the improvement of cardiovascular outcomes. Finally, obesity and other unaccounted factors that potentially alter the levels of these markers should also be considered.
6-month treatment with dapagliflozin reduced PICP levels. Together with other mechanisms, this phenomenon illustrates the positive effects of dapagliflozin on cardiovascular and renal outcomes in T2D. Further prospective studies with longer follow-up in larger groups are needed to study in detail the course of fibrosis and changes in the levels of its markers. In addition, evaluation of fibrosis in two subgroups of T2D patients (with anamnestic cardiovascular events or cardiovascular risk factors) is helpful.
About the authors:
Denis A. Lebedev — junior researcher of the Research Laboratory of Diabetology, V.A. Almazov National Medical Research Center; 2, Akkuratov str., St. Petersburg, 197341, Russian Federation; ORCID iD 0000-0003-1808-1331.
Alina Yu. Babenko — Dr. Sc. (Med.), Head of the Research Laboratory of Diabetology, V.A. Almazov National Medical Research Center; 2, Akkuratov str., St. Petersburg, 197341, Russian Federation; ORCID iD 0000-0002-0559-697X.
Contact information: Alina Yu. Babenko, e-mail: firstname.lastname@example.org.
Financial Disclosure: no authors have a financial or property interest in any material or method mentioned.
There is no conflict of interests.
2. Neal B., Perkovic V., Mahaffey K.W. et al. Canagliflozin and cardiovascular and renal events in type 2 diabetes. N Engl J Med. 2017;377(7):644–657. DOI: 10.1056/NEJMoa1611925.
3. Wiviott S.D., Raz I., Bonaca M.P. et al. Dapagliflozin and Cardiovascular Outcomes in Type 2 Diabetes. N Engl J Med. 2019;380(4):347–357. DOI: 10.1056/NEJMoa1812389.
4. Nikolic M., Zivkovic V., Jovic J.J. et al. SGLT2 inhibitors: a focus on cardiac benefits and potential mechanisms. Heart Fail Rev. 2021 Feb 3. DOI: 10.1007/s10741-021-10079-9. Online ahead of print.
5. Uthman L., Baartscheer A., Bleijlevens B. et al. Class effects of SGLT2 inhibitors in mouse cardiomyocytes and hearts: inhibition of Na+/H+ exchanger, lowering of cytosolic Na+ and vasodilation. Diabetologia. 2018;61:722–726. DOI: 10.1007/s00125-017-4509-7.
6. Lee T.M., Chang N.C., Lin S.Z. Dapagliflozin, a selective SGLT2 inhibitor, attenuated cardiac fibrosis by regulating the macrophage polarization via STAT3 signaling in infarcted rat hearts. Free Radic Biol Med. 2017;104:298–310. DOI: 10.1016/j.freeradbiomed.2017.01.035.
7. Bonnet F., Scheen A.J. Effects of SGLT2 inhibitors on systemic and tissue low-grade inflammation: The potential contribution to diabetes complications and cardiovascular disease. Diabetes Metab. 2018;44(6):457–464. DOI: 10.1016/j.diabet.2018.09.005.
8. Russo I., Frangogiannis N.G. Diabetes-associated cardiac fibrosis: cellular effectors, molecular mechanisms and therapeutic opportunities. J Mol Cell Cardiol. 2016;90:84–93. DOI: 10.1016/j.yjmcc.2015.12.011.
9. López B., González A., Ravassa S. et al. Circulating Biomarkers of Myocardial Fibrosis: The Need for a Reappraisal. J Am Coll Cardiol. 2015;65(22):2449–2456. DOI: 10.1016/j.jacc.2015.04.026.
10. Ihm S.H., Youn H.J., Shin D.I. et al. Serum carboxy-terminal propeptide of type I procollagen (PIP) is a marker of diastolic dysfunction in patients with early type 2 diabetes mellitus. Int J Cardiol. 2007;122(3):e36–e38. DOI: 10.1016/j.ijcard.2007.07.057.
11. Лебедев Д.А., Бабенко А.Ю. Маркеры фиброза у пациентов с сахарным диабетом 2 типа и очень высоким риском сердечно-сосудистых заболеваний: результаты проспективного исследования. РМЖ. 2020;1:3–6. [Lebedev D.A., Babenko A.Yu. Markers of fibrosis in patients with type 2 diabetes mellitus and cardiovascular high-risk patients: prospective study results. RMJ. 2020;1:3–6 (in Russ.)].
12. Nassif M., Windsor S., Tang F. et al. Dapagliflozin effects on biomarkers, symptoms, and functional status in patients with heart failure with reduced ejection fraction: the DEFINE‐HF trial. Circulation. 2019;140:1463–1476. DOI: 10.1161/CIRCULATIONAHA.119.042929.
13. McMurray J., Solomon S., Inzucchi S. et al. Dapagliflozin in patients with heart failure and reduced ejection fraction. N Engl J Med. 2019;381:1995–2008. DOI: 10.1056/NEJMoa1911303.
14. Garvey W., van Gaal L., Leiter L. et al. Effects of canagliflozin versus glimepiride on adipokines and inflammatory biomarkers in type 2 diabetes. Metabolism. 2018;85:32–37. DOI: 10.1016/j.metabol.2018.02.002.
15. Januzzi J.L. Jr., Butler J., Jarolim P. et al. Effects of Canagliflozin on Cardiovascular Biomarkers in Older Adults With Type 2 Diabetes. J Am Coll Cardiol. 2017;70(6):704–712. DOI: 10.1016/j.jacc.2017.06.016.
This work is licensed under a Creative Commons «Attribution» 4.0 License.