Effect of SGLT2 Inhibitors on Discontinuation of Renin–angiotensin System Blockade: A Joint Analysis of the CREDENCE and DAPA-CKD Trials
Year: 2023
Type: article
Abstract: SIGNIFICANCE STATEMENT: Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) are foundational therapy for CKD but are underused, in part because they are frequently withheld and not restarted due to hyperkalemia, AKI, or hospitalization. Consequently, ensuring persistent use of ACE inhibitors and ARBs in CKD has long been a major clinical priority. In this joint analysis of the CREDENCE and DAPA-CKD trials, the relative risk of discontinuation of ACE inhibitors and ARBs was reduced by 15% in patients randomized to sodium-glucose cotransporter 2 (SGLT2) inhibitors. This effect was more pronounced in patients with urine albumin:creatinine ratio ≥1000 mg/g, for whom the absolute benefits of these medications are the greatest. These findings indicate that SGLT2 inhibitors may enable better use of ACE inhibitors and ARBs in patients with CKD. BACKGROUND: Strategies to enable persistent use of renin-angiotensin system (RAS) blockade to improve outcomes in CKD have long been sought. The effect of SGLT2 inhibitors on discontinuation of RAS blockade has yet to be evaluated. METHODS: We conducted a joint analysis of canagliflozin and renal events in diabetes with established nephropathy clinical evaluation (CREDENCE) and dapagliflozin and prevention of adverse outcomes in CKD (DAPA-CKD), two randomized, double-blind, placebo-controlled, event-driven trials of SGLT2 inhibitors in patients with albuminuric CKD. The main outcome was time to incident temporary or permanent discontinuation of RAS blockade, defined as interruption of an ACE inhibitor or ARB for at least 4 weeks or complete cessation during the double-blind on-treatment period. Cox regression analyses were used to estimate the treatment effects from each trial. Hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) were pooled with fixed effects meta-analysis to obtain summary treatment effects, overall and across key subgroups. RESULTS: During median follow-up of 2.2 years across both trials, 740 of 8483 (8.7%) patients discontinued RAS blockade. The relative risk for discontinuation of RAS blockade was 15% lower in patients randomized to receiving SGLT2 inhibitors (HR, 0.85; 95% CI, 0.74 to 0.99), with consistent effects across trials ( P -heterogeneity = 0.92). The relative effect on RAS blockade discontinuation was more pronounced among patients with baseline urinary albumin:creatinine ratio ≥1000 mg/g (pooled HR, 0.77; 95% CI, 0.63 to 0.94; P -heterogeneity = 0.009). CONCLUSIONS: In patients with albuminuric CKD with and without type 2 diabetes, SGLT2 inhibitors facilitate the use of RAS blockade. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER: ClinicalTrials.gov, NCT02065791 and NCT03036150 . PODCAST: This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/JASN/2023_11_21_JASN0000000000000248.mp3.
Authors: Robert A. Fletcher, Niels Jongs, Glenn M. Chertow, John J.V. McMurray, Clare Arnott, Meg J. Jardine, Kenneth W. Mahaffey, Vlado Perkovic, Patrick Rockenschaub, Peter Rossing, Ricardo Correa-Rotter, Robert D. Toto, Muthiah Vaduganathan, David C. Wheeler, Hiddo J.L. Heerspink, Brendon L. Neuen
Institutions: UNSW Sydney, The George Institute for Global Health, University Medical Center Groningen, University of Groningen, Stanford Medicine, Stanford University, University of Glasgow, The University of Sydney, Royal Prince Alfred Hospital, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charité – Universitätsmedizin Berlin, University of Copenhagen, Steno Diabetes Center Copenhagen, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, The University of Texas Southwestern Medical Center, Brigham and Women's Hospital, University College London, Royal North Shore Hospital
Language: English
Subfield: Nephrology
Field: Medicine
Domain: Health Sciences
Open Access status: green
Funders: American Society of Nephrology, Amgen, Bristol-Myers Squibb, Eli Lilly and Company, Pfizer, AstraZeneca, GlaxoSmithKline, Sanofi, Alexander von Humboldt-Stiftung, Gilead Sciences, Alnylam Pharmaceuticals, CSL Behring, Regeneron Pharmaceuticals, Wellcome Trust, Ablynx, Alan Turing Institute, Cytokinetics, MyoKardia, Verily Life Sciences, University of Glasgow, Novo Nordisk, Astellas Pharma, Vifor Pharma, Servier, Akebia Therapeutics, National Institutes of Health, University of California, San Francisco, Defense Acquisition Program Administration, Relypsa, Medical Research Future Fund, Health Data Research UK
OpenAlex ID: W4387930826