Abstract
BackgroundSulfonylureas are an effective and inexpensive treatment for type 2 diabetes. There is conflicting data about the safety of these drugs regarding mortality and cardiovascular outcomes. The objective of the present study was to evaluate the safety of the sulfonylureas most frequently used and to use trial sequential analysis (TSA) to analyze whether the available sample was powered enough to support the results.Methods and FindingsElectronic databases were reviewed from 1946 (Embase) or 1966 (MEDLINE) up to 31 December 2014. Randomized clinical trials (RCTs) of at least 52 wk in duration evaluating second- or third-generation sulfonylureas in the treatment of adults with type 2 diabetes and reporting outcomes of interest were included. Primary outcomes were all-cause and cardiovascular mortality. Additionally, myocardial infarction and stroke events were evaluated. Data were summarized with Peto odds ratios (ORs), and the reliability of the results was evaluated with TSA. Forty-seven RCTs with 37,650 patients and 890 deaths in total were included. Sulfonylureas were not associated with all-cause (OR 1.12 [95% CI 0.96 to 1.30]) or cardiovascular mortality (OR 1.12 [95% CI 0.87 to 1.42]). Sulfonylureas were also not associated with increased risk of myocardial infarction (OR 0.92 [95% CI 0.76 to 1.12]) or stroke (OR 1.16 [95% CI 0.81 to 1.66]). TSA could discard an absolute difference of 0.5% between the treatments, which was considered the minimal clinically significant difference. The major limitation of this review was the inclusion of studies not designed to evaluate safety outcomes.ConclusionsSulfonylureas are not associated with increased risk for all-cause mortality, cardiovascular mortality, myocardial infarction, or stroke. Current evidence supports the safety of sulfonylureas; an absolute risk of 0.5% could be firmly discarded.Review registrationPROSPERO CRD42014004330
Highlights
Sulfonylureas are still used frequently in the treatment of patients with type 2 diabetes because they are effective in both improving glycemic control [1] and reducing the microvascular complications of diabetes [2]; in addition, they have the advantage of being inexpensive [3].There are concerns regarding the safety of sulfonylureas that have persisted from the first randomized clinical trial (RCT) that evaluated sulfonylureas for diabetes treatment (University Group Diabetes Program) [4] until the present time [5,6,7]
Sulfonylureas are not associated with increased risk for all-cause mortality, cardiovascular mortality, myocardial infarction, or stroke
Current evidence supports the safety of sulfonylureas; an absolute risk of 0.5% could be firmly discarded
Summary
Sulfonylureas are still used frequently in the treatment of patients with type 2 diabetes because they are effective in both improving glycemic control [1] and reducing the microvascular complications of diabetes [2]; in addition, they have the advantage of being inexpensive [3].There are concerns regarding the safety of sulfonylureas that have persisted from the first randomized clinical trial (RCT) that evaluated sulfonylureas for diabetes treatment (University Group Diabetes Program) [4] until the present time [5,6,7]. Sulfonylureas are still used frequently in the treatment of patients with type 2 diabetes because they are effective in both improving glycemic control [1] and reducing the microvascular complications of diabetes [2]; in addition, they have the advantage of being inexpensive [3]. Observational studies have reported conflicting results regarding sulfonylurea safety [8,14,15,16], some of them disclosing an association of sulfonylurea use with increased risk of cardiovascular events [8,15]. The objective of the present study was to evaluate the safety of the sulfonylureas most frequently used and to use trial sequential analysis (TSA) to analyze whether the available sample was powered enough to support the results. Long-term complications of diabetes, which include an increased risk of cardiovascular problems such as heart attacks (myocardial infarctions) and stroke, reduce the life expectancy of people with diabetes by about ten years compared to people without diabetes
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