• TavaresCaio A MCAMHospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil.Geriatric Cardiology Unit, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil., AzevedoLuciano C PLCPHospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil., Álvaro Rea-Neto, Niklas S Campos, Cristina P Amendola, Amanda C Kozesinski-Nakatani, Paula G David-João, Suzana M Lobo, Thiago C Filiponi, Guacyra M B Almeida, Ricardo R Bergo, Mário R R Guimarães-Júnior, Rodrigo C Figueiredo, Joan R Castro, Clewer J Schuler, Glauco A Westphal, Ana C R Carioca, Frederico Monfradini, Josue Nieri, Flavia M O Neves, Jaqueline A Paulo, Camila S N Albuquerque, Mariana C R Silva, Mikhail N Kosiborod, Adriano J Pereira, Lucas P Damiani, Thiago D Corrêa, Ary Serpa-Neto, Otavio Berwanger, Fernando G Zampieri, and DEFENDER Investigators.
• Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil.
• JAMA. 2024 Aug 6; 332 (5): 401411401-411.

ImportanceSodium-glucose cotransporter 2 (SGLT-2) inhibitors improve outcomes in patients with type 2 diabetes, heart failure, and chronic kidney disease, but their effect on outcomes of critically ill patients with organ failure is unknown.ObjectiveTo determine whether the addition of dapagliflozin, an SGLT-2 inhibitor, to standard intensive care unit (ICU) care improves outcomes in a critically ill population with acute organ dysfunction.Design, Setting, And ParticipantsMulticenter, randomized, open-label, clinical trial conducted at 22 ICUs in Brazil. Participants with unplanned ICU admission and presenting with at least 1 organ dysfunction (respiratory, cardiovascular, or kidney) were enrolled between November 22, 2022, and August 30, 2023, with follow-up through September 27, 2023.InterventionParticipants were randomized to 10 mg of dapagliflozin (intervention, n = 248) plus standard care or to standard care alone (control, n = 259) for up to 14 days or until ICU discharge, whichever occurred first.Main Outcomes And MeasuresThe primary outcome was a hierarchical composite of hospital mortality, initiation of kidney replacement therapy, and ICU length of stay through 28 days, analyzed using the win ratio method. Secondary outcomes included the individual components of the hierarchical outcome, duration of organ support-free days, ICU, and hospital stay, assessed using bayesian regression models.ResultsAmong 507 randomized participants (mean age, 63.9 [SD, 15] years; 46.9%, women), 39.6% had an ICU admission due to suspected infection. The median time from ICU admission to randomization was 1 day (IQR, 0-1). The win ratio for dapagliflozin for the primary outcome was 1.01 (95% CI, 0.90 to 1.13; P = .89). Among all secondary outcomes, the highest probability of benefit found was 0.90 for dapagliflozin regarding use of kidney replacement therapy among 27 patients (10.9%) in the dapagliflozin group vs 39 (15.1%) in the control group.Conclusion And RelevanceThe addition of dapagliflozin to standard care for critically ill patients and acute organ dysfunction did not improve clinical outcomes; however, confidence intervals were wide and could not exclude relevant benefits or harms for dapagliflozin.Trial RegistrationClinicalTrials.gov Identifier: NCT05558098.

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