The Association between Sulfonylurea Use and All-Cause and Cardiovascular Mortality: A Meta-Analysis with Trial Sequential Analysis of Randomized Clinical Trials

• Published in: PLoS medicine 2016-04, Vol.13 (4), p.e1001992
• Main Authors: Varvaki Rados, Dimitris, Catani Pinto, Lana, Reck Remonti, Luciana, Bauermann Leitão, Cristiane, Gross, Jorge Luiz
• Format: Article
• Language: English
• Subjects: Brazil; Cardiovascular Diseases - chemically induced; Cardiovascular Diseases - diagnosis; Cardiovascular Diseases - mortality; Cause of Death; Chi-Square Distribution; Diabetes Mellitus, Type 2 - diagnosis; Diabetes Mellitus, Type 2 - drug therapy; Diabetes Mellitus, Type 2 - mortality; Drug therapy; Engineering and Technology; Female; Health aspects; Health risk assessment; Heart attack; Heart attacks; Humans; Hyperglycemia; Male; Medicine and Health Sciences; Middle Aged; Mortality; Odds Ratio; Patient Safety; Physical Sciences; Randomized Controlled Trials as Topic; Research and Analysis Methods; Risk Assessment; Risk Factors; Studies; Sulfonylurea Compounds - adverse effects; Sulfonylureas; Time Factors; Treatment Outcome; Type 2 diabetes
• ISSN: 1549-1676; 1549-1277; 1549-1676
• DOI: 10.1371/journal.pmed.1001992

Sulfonylureas 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. Electronic 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. 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. PROSPERO CRD42014004330.