Female reproductive factors closely associated with COPD risk: BMJ study

A recent study published in the BMJ Thorax unveiled the intricate relationship between female reproductive factors and the development of Chronic Obstructive Pulmonary Disease (COPD). This research looks into how aspects like the age at menarche, childbirth, miscarriage, stillbirth and menopause could influence the susceptibility of woman to COPD. 

This study analyzed data across three cohorts from over 280,000 women that makes it one of the most extensive investigations into this subject. Over a median follow-up period of 11 years, 3.8% of the participants were diagnosed with COPD. The findings revealed a U-shaped relationship was observed between age at menarche and COPD risk which indicates that both early and late onset of menstruation could increase susceptibility. Also, women with three or more children were found to have an increased risk of COPD when compared to those with fewer offspring, with a similar pattern observed in the individuals who experienced multiple miscarriages or stillbirths.

Among postmenopausal women, an earlier onset of natural menopause was associated to an elevated risk of COPD. The individuals who experienced menopause before the age of 40 were almost twice as likely to develop COPD when compared to those who reached menopause between the ages of 50 and 51. These findings underline the complex relationship between reproductive health and respiratory outcomes in women. While previous studies have primarily focused on the impact of smoking and environmental factors on COPD risk, this study in particular, highlights the significance of considering female-specific variables.

This study emphasized the importance of the outcomes in informing healthcare strategies and personalized interventions for COPD prevention in women. The findings highlight the need for a comprehensive approach to COPD prevention which takes into account the traditional risk factors and reproductive history in addition.

Reference:

Liang, C., Chung, H.-F., Dobson, A. J., Sandin, S., Weiderpass, E., & Mishra, G. D. (2024). Female reproductive histories and the risk of chronic obstructive pulmonary disease. Thorax. https://doi.org/10.1136/thorax-2023-220388

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Social media platforms can play crucial role in promoting oral health, research suggests

Iran: A recent systematic review published in PLOS One has revealed the positive impact of implementing social media interventions on multiple aspects of oral health among laypeople.

Online platforms such as Instagram, WhatsApp, YouTube, and Telegram can be effectively utilized to promote oral health among patients, the researchers suggested.

They note that although social media offers efficiency and convenience for interventions aimed at preventing and promoting oral health, its utilization is not yet widespread.

While social media can improve content accessibility and enhance knowledge transfer, the success of interventions depends on individual participation and evidence-based approaches, the study stated.

However, it is important to note that there is no single method or platform that can be deemed universally suitable for all regions. Nevertheless, audio-visual platforms may be more effective than text-based social media in promoting oral health.

Social media, described as “a group of internet-based applications that are built on Web 2.0,” has gained significant popularity in recent decades, allowing users to create, share, and participate in social networks. The most commonly used social networking platforms include YouTube, Facebook, WhatsApp, Instagram, and WeChat. These platforms have become a common means of sharing personal experiences, information, and lifestyles. They can also be used as cost-effective methods for individuals to acquire health information and promote oral health.

Against the above background, Zahra Ghorbani, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran, and colleagues aimed to systematically review the current literature on the interventions taken through social media for promoting lay people’s oral health. The systematic review followed the PRISMA (preferred reporting items for systematic reviews and meta-analyses) 2020 guidelines.

For this purpose, the researchers conducted a comprehensive search in four electronic databases for relevant articles published between 2012 and 2023. Data such as sample size, study design, utilized social media platforms, follow-up duration and main findings were extracted from the eligible studies.

The quality of the included studies was evaluated by the quality assessment tools for intervention studies recommended by the National Collaborating Centre for Methods and Tools.

Key findings were as follows:

  • Out of the 1934 records identified in the initial search, the qualitative synthesis included ten studies which met the inclusion criteria. These studies consisted of seven randomized control trials, one field trial and two quasi-experimental.
  • Various social media platforms, including Instagram, Telegram, YouTube, WhatsApp and Snapchat, were used for communication with patients.
  • Some studies solely utilized social media interventions, while others combined online and traditional interventions.
  • The quality assessment categorized 30% of the studies as “strong”, 50% as “moderate”, and the remaining as “weak”.
  • The implementation of social media interventions positively influenced multiple aspects of oral health among laypeople.

“Collaborations between oral health professionals, organizations, and influencers on social media will amplify credibility and reach,” the researchers wrote.

“However, these advancements come with ethical considerations, demanding vigilance in combatting misinformation and adhering to privacy regulations.”

“Considering these changes, researchers and practitioners must recognize and address research gaps,” the research team concluded. “Future studies should explore unexplored areas to better understand the intersection between social media and oral health promotion.”

Reference:

Farrokhi, F., Ghorbani, Z., Farrokhi, F., Namdari, M., & Salavatian, S. (2023). Social media as a tool for oral health promotion: A systematic review. PLOS ONE, 18(12), e0296102. https://doi.org/10.1371/journal.pone.0296102

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Study reveals additive effects of SGLT2i and GLP-1RA in enhancing vascular repair among patients with diabetes and obesity

Canada: A recent study published in Cardiovascular Research has shed light on restoring blood vessel regeneration in the era of the combination of SGLT2 inhibitors and GLP-1 receptor agonist therapy for diabetes and obesity.

In the study, David A Hess, University of Western Ontario, London, Canada, and colleagues focused on the clinical potential of SGLT2i and GLP-1RA therapy to improve oxidative stress levels in the human bone marrow to reverse regenerative cell exhaustion and restore vessel repair capacity. Finally, they explored the use of combination SGLT2i/GLP-1RA therapy to synergize cardiovascular benefits compared to SGLT2i and GLP-1RA monotherapy and commented on the future of this therapeutic strategy in improving RCE and vascular repair.

As sodium-glucose cotransporter-2 (SGLT2) inhibitor and glucagon-like peptide-1 receptor agonists (GLP-1RAs) therapies are emerging as a novel therapeutic opportunity for patients with poorly controlled hyperglycemia, potential additive effects in reducing oxidative stress may also enhance vascular repair and further reduce the ischaemic cardiovascular (CV) comorbidities associated with type 2 diabetes (T2D) and obesity, the study stated.

Ischemic cardiovascular diseases, including coronary and peripheral artery disease, stroke, and myocardial infarction remain major comorbidities for individuals with T2D and obesity. During cardiometabolic chronic disease (CMCD), excess adiposity and hyperglycemia elevate oxidative stress and promote endothelial damage, alongside an imbalance in circulating pro-vascular progenitor cells that mediate vascular repair.

Individuals with CMCD demonstrate pro-vascular ‘regenerative cell exhaustion’ (RCE) characterized by excess pro-inflammatory granulocyte precursor mobilization into the circulation, monocyte polarization towards pro-inflammatory versus anti-inflammatory phenotype, and decreased pro-vascular progenitor cell content, impairing the capacity for vessel repair.

Remarkably, targeted treatment with the SGLT2 inhibitor empagliflozin in subjects with type 2 diabetes and coronary artery disease, and gastric bypass surgery in subjects with severe obesity, has been shown to partially reverse these RCE phenotypes.

SGL2 inhibitors and GLP-1 receptor agonists have reshaped the management of patients with T2D and comorbid obesity. In addition to glucose-lowering action, both drug classes have been shown to induce weight loss and reduce mortality and adverse CV outcomes in landmark clinical trials. Furthermore, both drug families also act to reduce systemic oxidative stress through altered activity of overlapping oxidase and antioxidant pathways, providing a putative mechanism to augment circulating pro-vascular progenitor cell content.

“The pleiotropic cardiorenal protective and weight loss benefits of SGLT2 inhibitor and GLP-1 receptor agonist treatments, respectively, present a novel opportunity for combination therapy to abrogate this chronic cardiometabolic cycle and potentially restore progenitor cell-mediated blood vessel repair,” the researchers wrote.

“Further examination of combination therapies in humans is now warranted in the context of the recovery of endogenous vascular regeneration to uncover if the synergistic benefit can be observed in individuals within the CMCD spectrum,” they concluded.

Reference:

Terenzi, D. C., Bakbak, E., Teoh, H., Krishnaraj, A., Puar, P., Rotstein, O. D., Cosentino, F., Goldenberg, R. M., Verma, S., & Hess, D. A. (2024). Restoration of blood vessel regeneration in the era of combination SGLT2i and GLP-1RA therapy for diabetes and obesity. Cardiovascular Research, 119(18), 2858-2874. https://doi.org/10.1093/cvr/cvae016

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Weight Change Not Associated with Hand Osteoarthritis Progression and Pain

A recent study found the association between weight change and the development of hand osteoarthritis (OA) was investigated. The study published in the Arthritis Care & Research assessed if weight loss or gain have any bearing on the incidence and progression of hand OA along with the development and resolution of hand pain.

The study from the Osteoarthritis Initiative involved a total of 4,598 participants but excluded the individuals with cancer, rheumatoid arthritis or a body mass index under 18.5 kg/m2. The study analyzed weight change from baseline to the 4-year follow-up, as well as its impact on radiographic hand OA and hand pain over an 8-year period utilizing the multivariable logistic regression.

The results found no statistically significant relationship between weight change and the investigated outcomes. For instance, for every 5% weight loss, the odds ratios for the incidence and progression of radiographic hand OA were 0.90 and 0.92, respectively, with confidence intervals that ranged from 0.67 to 1.23 and 0.84 to 1.00. Also, for each 5% weight loss, the odds ratios for the development and resolution of hand pain at the 8-year follow-up were 1.00 and 1.07, respectively, with confidence intervals from 0.92 to 1.09 and 0.91 to 1.25.

The outcomes of this study found no compelling evidence to suggest a strong link between weight change and the risk of developing or progressing radiographic hand OA over a 4-year period. Also, the research did not find any significant association of the development or resolution of hand pain with weight change over a timeframe of 8 years. The weight management remains critical for overall health and well-being, while its direct impact on hand OA progression may be more precise than previously established. Further research may improve the understanding of the complex link between weight change and osteoarthritis development in different joints of the body.

Source:

Salis, Z., Driban, J. B., McAlindon, T. E., Eaton, C. B., & Sainsbury, A. (2024). Association of Weight Loss and Weight Gain With Structural Defects and Pain in Hand Osteoarthritis: Data From the Osteoarthritis Initiative. In Arthritis Care & Research. Wiley. https://doi.org/10.1002/acr.25284

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Dapagliflozin leads to modest reduction in systolic BP in patients with CKD and albuminuria: Study

USA: Treatment with dapagliflozin in patients with chronic kidney disease (CKD) and albuminuria is associated with modest but clinically meaningful reductions in systolic blood pressure (SBP), according to a pre-specified analysis of data from the DAPA-CKD trial.

In the study published in the American Heart Journal, the placebo-adjusted reduction in systolic BP was evident soon after the initiation of therapy and maintained throughout the trial.

Sodium–glucose cotransporter 2 (SGLT2) inhibitors have emerged as a potent therapy to lower the risk of progressive kidney disease and cardiovascular events in patients with chronic kidney disease. These agents reduce the absorption of sodium and glucose in the proximal tubule, thereby increasing glycosuria and diuresis, typically reducing intravascular volume, which leads to a reduction in blood pressure. However, the consistency and magnitude of BP lowering with dapagliflozin in CKD patients is unknown.

To fill this knowledge gap, Glenn M Chertow, Stanford University School of Medicine, Stanford, California, USA, and colleagues conducted a pre-specified analysis of the DAPA-CKD trial to determine the effect of systolic blood pressure in patients with CKD, with and without type 2 diabetes.

The study included 4304 adults with baseline estimated glomerular filtration rate (eGFR) 25–75 mL/min/1.73m2 and urinary albumin-to-creatinine ratio (UACR) 200–5000 mg/g. They were randomized to either dapagliflozin 10 mg or placebo once daily and followed for a median of 2.4 years.

The study’s primary endpoint was a composite of sustained ≥50% eGFR decline, end-stage kidney disease, or death from a cardiovascular or kidney cause. Change in SBP was a pre-specified outcome.

The main findings of the study are as follows:

  • The baseline mean SBP was 137.1 mmHg. By Week 2, dapagliflozin compared to placebo reduced SBP by 3.6 mmHg, an effect maintained throughout the trial (2.9 mmHg, 2.3−3.6 mmHg).
  • Time-averaged reductions in SBP were 3.2 mmHg in patients with diabetes and 2.3 mmHg in patients without diabetes.
  • The time-averaged effect of dapagliflozin on diastolic blood pressure (DBP) was 1.0 mmHg; 0.8 mmHg in patients with diabetes and 1.4 mmHg in patients without diabetes.
  • The benefits of dapagliflozin on the primary composite and secondary endpoints were evident across the spectrum of baseline SBP and DBP.

The findings show that randomization to dapagliflozin in patients with chronic kidney disease and albuminuria is associated with modest reductions in systolic and diastolic BP. 

The magnitude reduction in systolic blood pressure was observed to be similar to that provided by several commonly prescribed antihypertensive agents or following renal denervation.

“These findings should inform clinical decisions undertaken when aiming to optimize control of hypertension in CKD patients,” the researchers concluded. 

Reference:

Heerspink, H. J., Provenzano, M., Vart, P., Jongs, N., Correa-Rotter, R., Rossing, P., Mark, P. B., Pecoits-Filho, R., McMurray, J. J., Langkilde, A. M., Wheeler, D. C., Toto, R. B., & Chertow, G. M. (2024). Dapagliflozin and Blood Pressure in Patients with Chronic Kidney Disease and Albuminuria. American Heart Journal. https://doi.org/10.1016/j.ahj.2024.02.006

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Is new care strategy required for survivors of critical illnesses with multimorbidity?

Recently published study reviewed the impact of multimorbidity on the recovery trajectories and outcomes of critical illness survivors, aiming to identify factors that predispose such survivors to worse outcomes and explore potential strategies to enhance their long-term recovery.

Influence of Multimorbidity on Critical Illness Outcomes

The study notes that previous research efforts have largely focused on rehabilitation interventions to address physical, psychological, and cognitive functional sequelae after critical illness. However, recent evidence suggests that a person’s existing health status, particularly multimorbidity and frailty, strongly influences long-term outcomes. The review examines the complex relationship between multimorbidity and patient outcomes after critical illness, highlighting the multitude of factors, including the number, severity, and modifiability of medical conditions, treatment burden, functional status, healthcare delivery, and social support, that mediate these relationships.

Factors Mediating the Relationship

Critical illness survivors with multimorbidity, defined as the coexistence of at least two chronic conditions, experience significantly worse recovery trajectories and outcomes compared to previously healthy patients. The review proposes that the impact of the acute illness on survivors with multimorbidity may be overwhelmed by pre-illness factors, leading to worse outcomes. Several factors play a role in mediating the relationship between multimorbidity and outcomes, including biological and pathophysiological mechanisms, specific conditions and multimorbidity clusters, functional impairment and frailty, social context, treatment burden, and healthcare context. The review also explores the potential mechanisms by which critical illness may drive biological aging and exacerbate existing conditions.

To improve outcomes for critical illness survivors with multimorbidity, the review suggests several potential strategies, such as personalized care, shared decision making, identification and optimization of multimorbidity and related factors, and management of treatment burden and self-management support. The proposed care pathways for these patients would need to consider individual patient priorities and preferences, address fragility and social circumstances, and include a multifaceted approach to optimize care. The review recommends enhanced identification and optimization of multimorbidity and related factors, provision of personalized care based on patient priorities and preferences, and orientation towards family and informal carer support.

Recommendations for Enhanced Care

The study proposes the need to enhance care for critical illness survivors with multimorbidity by considering their pre-existing health status and personal factors. It highlights the importance of addressing treatment burden, self-management support, family and informal carer orientation, health and social care context, and the potential benefits of digital health solutions in supporting self-management for these patients. The review concludes by noting that despite the numerous unanswered questions, the identification of multimorbidity and related factors is crucial in developing an optimal model of care for these individuals.

Reference-

Stewart, J., Bradley, J., Smith, S. et al. Do critical illness survivors with multimorbidity need a different model of care?. Crit Care 27, 485 (2023). https://doi.org/10.1186/s13054-023-04770-6.

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Conbercept efficacious in short-term treatment of Diabetic Macular Edema with or without Diabetic Nephropathy

Diabetic macular edema (DME) is a common complication of diabetes, and when coupled with diabetic nephropathy (DN), it poses additional challenges to management. In a recent retrospective study, researchers aimed to evaluate the therapeutic effects of conbercept on DME patients with and without DN.

This study was published in the International Journal Of Ophthalmology by Zhu YZ and colleagues.

The study included 54 patients diagnosed with DME, categorized into two groups: those with DN (25 eyes) and those without DN (29 eyes). Various parameters, including fasting blood glucose, HbA1c, microalbumin/creatinine, serum creatinine, central macular thickness (CMT), best corrected visual acuity (BCVA), and retinal hyperreflective foci (HF), were assessed before and during treatment. Optical coherence tomography (OCT) was utilized to evaluate ellipsoidal zone (EZ) and external limiting membrane (ELM) integrity.

The key findings of the study were:

  • Significant differences were observed between the two groups in fasting blood glucose, HbA1c, serum creatinine, urinary microalbumin/creatinine, and estimated glomerular filtration rate (eGFR).

  • EZ and ELM continuity were worse in the DME+DN group.

  • BCVA was significantly better in the DME group compared to the DME+DN group throughout treatment. CMT and HF values were higher in the DME+DN group and decreased with treatment in both groups over time.

  • The mean number of injections at 6 months was higher in the DME+DN group compared to the DME group.

Conbercept demonstrated significant efficacy in the short-term treatment of DME, with or without DN. It improved BCVA, CMT, and reduced HF counts. However, treatment efficacy was better in DME patients without DN. These findings highlight the potential of conbercept in managing DME, particularly in patients without DN. Further research is warranted to validate these results and explore long-term outcomes.

Reference:

Zhu YZ, Dou ZZ, Wang WY, Ma QY, Yi WD, Yao NN, Liu YC, Gao XD, Zhang Q, Luo WJ. Intravitreal injection of conbercept for diabetic macular edema complicated with diabetic nephropathy

DOI:10.18240/ijo.2024.02.12

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Surgical remission of Cushing’s disease tied to higher risk of developing autoimmune disease

Researchers have found in a new study that Surgical emission of Cushing’s disease tied to higher risk of developing autoimmune disease. 

ln a study of more than 250 persons undergoing surgical therapy for Cushing’s disease (CD) or nonfunctioning pituitary adenomas (NFPAs), the researchers found that patients who achieved remission of CD were more likely than those with surgically treated NFPAs to develop new-onset autoimmune disease within 3 years after remission.

The study is published in Annals of Internal Medicine.

CD results from excessive production of corticotropin (ACTH) by a pituitary adenoma, which causes hypercortisolemia. Transsphenoidal surgery (TSS) is the first-line treatment for most hypersecreting pituitary adenomas. After TSS for CD, adrenal insufficiency occurs once the ACTH-secreting tumor is removed, the signs and symptoms of hypercortisolemia typically improve over time but steroid withdrawal symptoms may develop after remission of CD. In addition, the development of new autoimmune disease in patients after CD remission has been observed, but research is limited.

Researchers from Harvard Medical School identified 194 persons with CD and 92 persons with NFPA, frequency-matched for age and sex, who underwent pituitary surgery. The authors found that persons with CD who achieved remission were more likely than those with surgically treated NFPAs to develop new-onset autoimmune disease within 3 years after remission.

The cumulative incidence was 10.4 percent. According to the authors, higher prevalence of adrenal insufficiency and the lower nadir serum cortisol levels in the CD group suggest that the postoperative adrenal insufficiency might have contributed to the development of autoimmune diseases. They also note that patients with CD who have a family history of autoimmune disease should be carefully monitored after achieving remission. In addition, the authors add that higher doses of early postoperative glucocorticoid replacement might be associated with decreased risk for development of autoimmune disease. These findings have implications for the understanding of the natural history of autoimmune disease and its relationship to cortisol fluctuations.

Reference:

Dennis Delasi Nyanyo, , Masaaki Mikamoto, Francesca Galbiati, Autoimmune Disorders Associated With Surgical Remission of Cushing’s Disease, Annals of Internal Medicine, https://doi.org/10.7326/M23-2024.

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Are body temperature and depression linked? Science says, yes

People with depression have higher body temperatures, suggesting there could be a mental health benefit to lowering the temperatures of those with the disorder, a new UC San Francisco-led study found.

The study, publishing today in Scientific Reports, doesn’t indicate whether depression raises body temperature or a higher temperature causes depression. It’s also unknown whether the higher body temperature observed in people with depression reflects decreased ability to self-cool, increased generation of heat from metabolic processes or a combination of both.

Researchers analyzed data from more than 20,000 international participants who wore a device that measures body temperature, and also self-reported their body temperatures and depression symptoms daily. The seven-month study began in early 2020 and included data from 106 countries.

The results showed that with each increasing level of depression symptom severity, participants had higher body temperatures. The body temperature data also showed a trend toward higher depression scores in people whose temperatures had less fluctuation throughout a 24-hour period, but this finding didn’t reach significance.

The findings shed light on how a novel depression treatment method might work, said Ashley Mason, PhD, the study’s lead author and associate professor of psychiatry at UCSF Weill Institute for Neurosciences. A small body of existing, causal studies has found that using hot tubs or saunas can reduce depression, possibly by triggering the body to self-cool, for example, through sweating.

“Ironically, heating people up actually can lead to rebound body temperature lowering that lasts longer than simply cooling people down directly, as through an ice bath,” said Mason, who is also a clinical psychologist at the UCSF Osher Center for Integrative Health. “What if we can track the body temperature of people with depression to time heat-based treatments well?”

“To our knowledge, this is the largest study to date to examine the association between body temperature – assessed using both self-report methods and wearable sensors – and depressive symptoms in a geographically broad sample,” added Mason. “Given the climbing rates of depression in the United States, we’re excited by the possibilities of a new avenue for treatment.”

Reference:

Ashley E. Mason et al, Elevated body temperature is associated with depressive symptoms: results from the TemPredict Study, Scientific Reports (2024). DOI: 10.1038/s41598-024-51567-w.

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Use of SGLT-2 inhibitors for HF management safe and well tolerated in adult congenital heart disease patients: Study

USA: A recent study showed that sodium-glucose transporter 2 inhibitors (SGLT-2i) use appears safe and well tolerated in a small cohort of the adult congenital heart disease (ACHD) population, including patients with complex congenital heart disease.

The findings, published in the International Journal of Cardiology Congenital Heart Disease, add to the literature on the SGLT-2i use in patients with ACHD. According to the authors, the study is the first to evaluate SGLT-2i in a complex ACHD cohort that included patients with single ventricle circulation.

“We found that SGLT2i initiation was well tolerated during short-term follow-up,” the researchers wrote. “Specifically, there was no significant worsening of renal function or reduction in blood pressure after initiation of SGLT-2 inhibitors in a heterogenous group of ACHD patients.”

SGLT2 inhibitors have shown efficacy and safety in heart failure (HF) patients. However, evidence is limited on the use of SGLT-2i in adult congenital heart disease patients with heart failure. To fill this knowledge gap, Ahmed Kheiwa, Loma Linda University, Loma Linda, CA, USA, and colleagues sought to evaluate the safety of this therapy in a small cohort of ACHD patients.

For this purpose, they performed a retrospective, single-centre analysis of 18 patients (>18 years of age) with ACHD and an HF diagnosis who were initiated on an SGLT2 inhibitor. Patient characteristics, including vital signs, concomitant medications, laboratory values, echocardiograms, and clinical outcomes, were obtained as a part of standardized clinical care at an ACHD program before and 2–6 months after initiation of SGLT-2i.

The primary outcome was to demonstrate the safety of SGLT-2i initiation via potential changes in systolic blood pressure, serum creatinine, and serum sodium.

The study revealed the following findings:

  • Of the 18 patients, 11 had moderate complexity congenital heart disease, while 7 had great complexity congenital heart disease.
  • Post initiation, there were no significant differences in systolic blood pressure (121.8 ± 20.8 mmHg to 114.4 ± 14.9 mmHg), creatinine level (0.85 ± 0.18 mg/dL to 0.89 ± 0.18 mg/dL), and sodium level (138.7 ± 2.9 mMol/L to 138.0 ± 2.2 mMol/L).
  • There was a statistically significant weight decline (78.9 ± 22.9 kg to 76.0 ± 23.0 kg) but without a statistically significant change in NT-pro NBP (1358.2 ± 2735.0 pg/mL to 601.6 ± 786.1 pg/mL).

The researchers report that the use of SGLT-2i in their small cohort of patients with heterogenous ACHD appears safe and well tolerated.

“The safety and potential efficacy of SGLT-2i in patients with adult congenital heart disease will require further evaluation in large-scale prospective multicenter studies,” they concluded.

Reference:

Kheiwa, A., Ssembajjwe, B., Chatta, P., Nageotte, S., & Abramov, D. (2024). Safety of SGLT-2 inhibitors in the management of heart failure in the adult congenital heart disease patient population. International Journal of Cardiology Congenital Heart Disease, 100495. https://doi.org/10.1016/j.ijcchd.2024.100495

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