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Response: Increased Risk of Hospitalization for Heart Failure with Newly Prescribed Dipeptidyl Peptidase-4 Inhibitors and Pioglitazone Using the Korean Health Insurance Claims Database (Diabetes Metab J 2015;39:247-52)
Sunghwan Suh1, Gi Hyeon Seo2, Chang Hee Jung3, Mee-Kyoung Kim4, Sang-Man Jin5, You-Cheol Hwang6, Byung-Wan Lee7, Jae Hyeon Kim5
Diabetes & Metabolism Journal 2015;39(4):350-351.
DOI: https://doi.org/10.4093/dmj.2015.39.4.350
Published online: August 17, 2015
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1Division of Endocrinology and Metabolism, Department of Internal Medicine, Dong-A Medical Center, Dong-A University College of Medicine, Busan, Korea.

2Health Insurance Review and Assessment Service, Seoul, Korea.

3Division of Endocrinology and Metabolism, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

4Division of Endocrinology and Metabolism, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.

5Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

6Division of Endocrinology and Metabolism, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea.

7Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.

Corresponding author: Jae Hyeon Kim. Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea. jaehyeon@skku.edu

Copyright © 2015 Korean Diabetes Association

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

We appreciate your interest and comments on our article entitled "Dipeptidyl peptidase-4 inhibitors and hospitalization for heart failure using the Korean Health Insurance Claims Database" which was published in Diabetes and Metabolism Journal [1].
The objective of this study was to assess the association of the most widely used dipeptidyl peptidase-4 inhibitors (DPP4i) and thiazolidinediones (TZDs) with heart failure (HF) hospitalization using the National Health Insurance System (NHIS) database. We observed a 1.8- to 2.0-fold increase in hospitalization for HF in the initial 30 days of medication (pioglitazone, sitagliptin, and vildagliptin) compared with the subsequent follow-up period.
The strengths of this study include the large population of patients with type 2 diabetes mellitus (T2DM) with a mean follow-up of 337 days. These data were taken from the database of representative Korean diabetic patients in real-world clinical settings because the NHIS is a compulsory and universal health care system in Korea [2]. We acknowledge that we could not adjust for confounding variables because of limited information on known HF risk factors. As we already mentioned in the paper, further study with full data regarding medications and co-existing illness is needed.
Recent re-analysis of saxagliptin assessment of vascular outcomes recorded in patients with diabetes mellitus-thrombolysis in myocardial infarction (SAVOR-TIMI) 53 found that the increased risk of HF hospitalization was heightened among patients with elevated levels of natriuretic peptides, previous HF, or chronic kidney disease [3]. Sitagliptin also showed significantly increased risk of HF-related hospitalizations among patients with T2DM and HF [4]. Thus, one may suspect that undiagnosed HF might have given rise to the increase in HF hospitalization during the initial 30 days. However, we reduced these possibilities by eliminating those with a prior diagnosis of HF.
We agree with Lee DH that the comparison with metformin is important because it is the drug of first choice and is used the most in combination with other antidiabetic agents. However, characteristics of diabetic patients on metformin alone group and those on metformin along with DPP4i or TZD group are different. On the other hand, characteristics of groups treated with metformin and DPP4i or TZD are similar because NHIS allows reimbursement of these drug combinations in the same clinical settings. Therefore, we have chosen pioglitazone as a comparator for the analysis which is known to increase the risk of edema and HF [56]. In addition, we used a poisson regression to model the relationship and generate hazard ratios and 95% confidence intervals comparing days 0 to 30 with days 31 to 360 after prescription because these groups share the same baseline characteristics. However, we did not find a significant difference of HF hospitalization between the DPP4i and TZD. Collectively, our results indicate a class effect and a relatively acute drug effect on HF during the earlier period of medication.
In conclusion, our study suggested that vigilance in the early period of DPP4i prescription may be helpful for the management of patients with T2DM. We are awaiting the results of the ongoing trials with cardiovascular disease as a main endpoint. We sincerely appreciate Lee DH for his interest in our study and knowledgeable comments.

CONFLICTS OF INTEREST: No potential conflict of interest relevant to this article was reported.

  • 1. Suh S, Seo GH, Jung CH, Kim MK, Jin SM, Hwang YC, Lee BW, Kim JH. Increased risk of hospitalization for heart failure with newly prescribed dipeptidyl peptidase-4 inhibitors and pioglitazone using the Korean Health Insurance Claims Database. Diabetes Metab J 2015;39:247-252. ArticlePubMedPMC
  • 2. Song SO, Jung CH, Song YD, Park CY, Kwon HS, Cha BS, Park JY, Lee KU, Ko KS, Lee BW. Background and data configuration process of a nationwide population-based study using the korean national health insurance system. Diabetes Metab J 2014;38:395-403. ArticlePubMedPMC
  • 3. Scirica BM, Braunwald E, Raz I, Cavender MA, Morrow DA, Jarolim P, Udell JA, Mosenzon O, Im K, Umez-Eronini AA, Pollack PS, Hirshberg B, Frederich R, Lewis BS, McGuire DK, Davidson J, Steg PG, Bhatt DL. SAVOR-TIMI 53 Steering Committee and Investigators. Heart failure, saxagliptin, and diabetes mellitus: observations from the SAVOR-TIMI 53 randomized trial. Circulation 2014;130:1579-1588. ArticlePubMed
  • 4. Weir DL, McAlister FA, Senthilselvan A, Minhas-Sandhu JK, Eurich DT. Sitagliptin use in patients with diabetes and heart failure: a population-based retrospective cohort study. JACC Heart Fail 2014;2:573-582. PubMed
  • 5. Hernandez AV, Usmani A, Rajamanickam A, Moheet A. Thiazolidinediones and risk of heart failure in patients with or at high risk of type 2 diabetes mellitus: a meta-analysis and meta-regression analysis of placebo-controlled randomized clinical trials. Am J Cardiovasc Drugs 2011;11:115-128. PubMed
  • 6. Varas-Lorenzo C, Margulis AV, Pladevall M, Riera-Guardia N, Calingaert B, Hazell L, Romio S, Perez-Gutthann S. The risk of heart failure associated with the use of noninsulin blood glucose-lowering drugs: systematic review and meta-analysis of published observational studies. BMC Cardiovasc Disord 2014;14:129ArticlePubMedPMCPDF

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        Response: Increased Risk of Hospitalization for Heart Failure with Newly Prescribed Dipeptidyl Peptidase-4 Inhibitors and Pioglitazone Using the Korean Health Insurance Claims Database (Diabetes Metab J 2015;39:247-52)
        Diabetes Metab J. 2015;39(4):350-351.   Published online August 17, 2015
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