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Original ArticleDiabetes and the Kidney
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Fracture Risk of Sodium-Glucose Cotransporter-2 Inhibitors in Chronic Kidney Disease

Andrea Cowan, Nivethika Jeyakumar, Yuguang Kang, Stephanie N. Dixon, Amit X. Garg, Kyla Naylor, Matthew A. Weir and Kristin K. Clemens
CJASN June 2022, 17 (6) 835-842; DOI: https://doi.org/10.2215/CJN.16171221
Andrea Cowan
1Institute for Clinical and Evaluative Sciences (ICES), London, Ontario, Canada
2Department of Medicine, Western University, London, Ontario, Canada
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Nivethika Jeyakumar
1Institute for Clinical and Evaluative Sciences (ICES), London, Ontario, Canada
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Yuguang Kang
1Institute for Clinical and Evaluative Sciences (ICES), London, Ontario, Canada
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Stephanie N. Dixon
1Institute for Clinical and Evaluative Sciences (ICES), London, Ontario, Canada
3Department of Epidemiology & Biostatistics, Western University, London, Ontario, Canada
4Lawson Health Research Institute, London, Ontario, Canada
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Amit X. Garg
1Institute for Clinical and Evaluative Sciences (ICES), London, Ontario, Canada
2Department of Medicine, Western University, London, Ontario, Canada
3Department of Epidemiology & Biostatistics, Western University, London, Ontario, Canada
4Lawson Health Research Institute, London, Ontario, Canada
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Kyla Naylor
1Institute for Clinical and Evaluative Sciences (ICES), London, Ontario, Canada
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Matthew A. Weir
1Institute for Clinical and Evaluative Sciences (ICES), London, Ontario, Canada
2Department of Medicine, Western University, London, Ontario, Canada
4Lawson Health Research Institute, London, Ontario, Canada
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Kristin K. Clemens
1Institute for Clinical and Evaluative Sciences (ICES), London, Ontario, Canada
2Department of Medicine, Western University, London, Ontario, Canada
3Department of Epidemiology & Biostatistics, Western University, London, Ontario, Canada
4Lawson Health Research Institute, London, Ontario, Canada
5St. Joseph’s Health Care London, London, Ontario, Canada
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    Table 1.

    Selected characteristics of older adults in Ontario, Canada, upon initiation of a sodium-glucose cotransporter-2 inhibitor or dipeptidyl peptidase-4 inhibitor

    Baseline CharacteristicsUnweighted, n=144,694Weighted, n=76,443
    Dipeptidyl Peptidase-4 Users, n=105,700Sodium-Glucose Cotransporter-2 Inhibitor Users, n=38,994Standardized DifferenceDipeptidyl Peptidase-4 Users, n=37,449Sodium-Glucose Cotransporter-2 Inhibitor Users, n=38,994Standardized Difference
    Demographics
     Age, mean, yr (SD)74 (7)72 (5)0.3872 (3)72 (5)0.00
     Women, no. (%)49,289 (47)15,457 (40)0.1415,258 (41)15,457 (40)0.02
     Long-term care, no. (%)3560 (3)283 (1)0.19302 (1)283 (1)0.01
     Prescriber specialty, no. (%)
      Cardiology440 (0)1580 (4)0.25636 (2)1580 (4)0.14
      Endocrinology8743 (8)5480 (14)0.185068 (14)5480 (14)0.02
      General practitioner85,858 (81)26,190 (67)0.3226,398 (71)26,190 (67)0.07
      Internal medicine3579 (3)2652 (7)0.162421 (7)2652 (7)0.01
      Nephrology803 (1)758 (2)0.10612 (2)758 (2)0.02
      Other6277 (6)2334 (6)0.002313 (6)2334 (6)0.01
    Comorbidities, no.(%)
     Mean duration of diabetes, yr (SD)11.5 (7.4)12.4 (7.6)0.1112.2 (4.4)12.4 (7.6)0.03
     Fragility fracture4,012 (4)1204 (3)0.041197 (3)1204 (3)0.01
     Previous fall17,225 (16)5572 (14)0.065439 (15)5572 (14)0.01
     Dementia7636 (7)1094 (3)0.201111 (3)1094 (3)0.01
     Rheumatoid arthritis2398 (2)848 (2)0.01815 (2)848 (2)0.00
     Osteoporosis7839 (7)1969 (5)0.101926 (5)1969 (5)0.00
     Coronary artery disease24,571 (23)12,258 (31)0.1810,961 (29)12,258 (31)0.05
     Diabetic retinopathy750 (1)338 (1)0.02314 (1)338 (1)0.01
     Diabetic neuropathy1431 (1)604 (2)0.01577 (2)604 (2)0.00
    Medication use, no. (%)
     Bisphosphonates9199 (9)1952 (5)0.151939 (5)1952 (5)0.01
     Denosumab2053 (2)486 (1)0.06479 (1)486 (1)0.01
     Oral steroid8038 (8)2732 (7)0.022641 (7)2732 (7)0.00
    Diabetes and kidney function, no. (%)
     No. of diabetes medications
      037,006 (35)10,916 (28)0.1510,454 (28)10,916 (28)0.00
      151,484 (49)20,902 (54)0.1019,976 (53)20,902 (54)0.01
      2+17,210 (16)7176 (18)0.067019 (19)7176 (18)0.01
     Metformin61,485 (58)25,896 (66)0.1724,803 (66)25,896 (66)0.00
     Mean hemoglobin A1C, % (SD)8.1 (1.6)8.0 (1.5)0.038.1 (0.9)8.0 (1.5)0.02
     Diabetes management54,022 (51)22,108 (57)0.1121,383 (57)22,108 (57)0.01
     Mean no. of general practitioner visits (SD)14.2 (19.2)12.37 (15.0)0.1112.4 (8.2)12.37 (14.96)0.01
     Mean no. of endocrinology visits (SD)0.5 (2.0)0.8 (2.2)0.130.7 (1.2)0.8 (2.2)0.06
     Mean eGFR, ml/min per 1.73 m2 (SD)69 (19)73 (17)0.2373 (10)73 (17)0.01
     eGFR category, ml/min per 1.73 m2
      ≥9014,853 (14)6485 (17)0.076319 (17)6485 (17)0.01
      60 to <9055,500 (53)23,520 (60)0.1622,547 (60)23,520 (60)0.00
      45 to <6020,617 (20)6577 (17)0.076250 (17)6577 (17)0.01
      30 to <4514,730 (14)2412 (6)0.262332 (6)2412 (6)0.00
    • eGFR is measured in milliliters per minute per 1.73 m2. The most recent eGFR measurement in the 365-day period was before the cohort entry date (including the cohort entry date). eGFR was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation: 141×min([serum creatinine concentration in micromoles per liter per 88.4]/ĸ, 1)α×max([serum creatinine concentration in micromoles per liter per 88.4]/ĸ, 1)−1.209×0.993Age×1.018 [if a woman]. ĸ=0.7 if a woman and 0.9 if a man; α=−0.329 if a woman and −0.411 if a man. Min is the minimum of serum creatinine concentration/ĸ or one; max is the maximum of serum creatinine concentration/ĸ or one. On the basis of recent Ontario Renal Network guidelines, race was not factored into the calculation of eGFR.

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    Table 2.

    Prescription characteristics of sodium-glucose cotransporter-2 inhibitors and dipeptidyl peptidase-4 inhibitors

    MedicationMean Continuous Use, d (SD)Median Continuous Use, d (Interquartile Range)
    SGLT2i
     All, n=38,994428 (414)287 (89–645)
     Empagliflozin, n=22,095379 (342)283 (85–566)
     Canagliflozin, n=11,939464 (477)272 (78–711)
     Dapagliflozin, n=4960414 (368)291 (91–664)
    DPP-4i
     All, n=105,700501 (454)348 (135–778)
     Sitagliptin, n=78,633480 (443)329 (125–733)
     Linagliptin, n=22,415504 (452)358 (125–794)
     Saxagliptin, n=4652470 (462)283 (104–723)
    • SGLT2i, sodium-glucose cotransporter-2 inhibitor; DPP-4i, dipeptidyl peptidase-4 inhibitor.

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    Table 3.

    Primary and secondary outcomes in the sodium-glucose cotransporter-2 inhibitor or dipeptidyl peptidase-4 inhibitor cohorts

    Outcome at 180 dDipeptidyl Peptidase-4, n=37,449, n (%)Sodium-Glucose Cotransporter-2 Inhibitor, n=38,994, n (%)Weighted Hazard Ratio (95% Confidence Interval)
    All fracture172 (0.5)170 (0.4)0.95 (0.79 to 1.13)
    Falls880 (2.4)897 (2.3)0.98 (0.91 to 1.05)
    Hypotension40 (0.1)41 (0.1)0.98 (0.65 to 1.47)
    Hypoglycemia81 (0.2)77 (0.2)0.91 (0.68 to 1.22)
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    Table 4.

    Fractures at 180 and 365 days assessed by eGFR group

    eGFR Group, ml/min per 1.73 m2 and MedicationFracture at 180 d, N (%)Weighted Hazard Ratio (95% Confidence Interval)P Value for Subgroup InteractionFracture at 365 d, N (%)Weighted Hazard Ratio (95% Confidence Interval)P Value for Subgroup Interaction
    All
     DPP-4i, n=37,449172 (0.46)0.95 (0.79 to 1.13)N/A360 (0.96)0.88 (0.77 to 1.00)N/A
     SGLT2i, n=38,994170 (0.44)329 (0.84)
    eGFR ≥90
     DPP-4i, n=633028 (0.45)0.79 (0.46 to 1.38)0.3761 (0.96)0.90 (0.63 to 1.28)0.53
     SGLT2I, n=648523 (0.35)56 (0.86)
    eGFR 60 to <90
     DPP-4i, n=22,62595 (0.42)1.10 (0.81 to 1.36)194 (0.86)0.94 (0.78 to 1.13)
     SGLT2i, n=23,520104 (0.44)189 (0.80)
    eGFR 45 to <60
     DPP-4i, n=619828 (0.46)1.00 (0.70 to 1.50)68 (1.10)0.82 (0.61 to 1.10)
     SGLT2i, n=657731 (0.47)59 (0.90)
    eGFR 30 to <45
     DPP-4i, n=220619 (0.88)0.56 (0.30 to 1.06)36 (1.64)0.64 (0.43 to 0.95)
     SGLT2i, n=241212 (0.50)25 (1.04)
    • DPP-4i, dipeptidyl peptidase-4 inhibitor; SGLT2i, sodium-glucose cotransporter-2 inhibitor, eGFR, estimated glomerular filtration rate.

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Clinical Journal of the American Society of Nephrology: 17 (6)
Clinical Journal of the American Society of Nephrology
Vol. 17, Issue 6
June 2022
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Fracture Risk of Sodium-Glucose Cotransporter-2 Inhibitors in Chronic Kidney Disease
Andrea Cowan, Nivethika Jeyakumar, Yuguang Kang, Stephanie N. Dixon, Amit X. Garg, Kyla Naylor, Matthew A. Weir, Kristin K. Clemens
CJASN Jun 2022, 17 (6) 835-842; DOI: 10.2215/CJN.16171221

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Fracture Risk of Sodium-Glucose Cotransporter-2 Inhibitors in Chronic Kidney Disease
Andrea Cowan, Nivethika Jeyakumar, Yuguang Kang, Stephanie N. Dixon, Amit X. Garg, Kyla Naylor, Matthew A. Weir, Kristin K. Clemens
CJASN Jun 2022, 17 (6) 835-842; DOI: 10.2215/CJN.16171221
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