Effects of Empagliflozin on Left Ventricular Diastolic Function Compared to Usual Care in Type 2 Diabetics (EmDia)

A Phase IV, Single-center, Randomized, Double-blind, Placebo-controlled, Parallel Group Study on the Effects of Empagliflozin on Left Ventricular Diastolic Function Compared to Usual Care in Individuals With Type 2 Diabetes

The purpose of the EmDia trial is to compare the effects of empagliflozin with placebo in addition to standard diabetic treatment or dietetic treatment on cardiac diastolic function in patients with type 2 Diabetes mellitus.

Study Overview

• Status: Completed
• Conditions: Diabetes Mellitus, Type 2; Diastolic Dysfunction
• Intervention / Treatment: Drug: Empagliflozin; Drug: Placebo

Detailed Description

Diabetes is a serious and increasing global health burden. It has been shown, that diabetes is associated with a two-fold higher risk for coronary heart disease, stroke and for the aggregate of other vascular death independently of other conventional risk factors. It is the leading cause of cardiovascular disease.

Diabetes mellitus substantially increases the risk of macrovascular and microvascular complications, such as vascular dysfunction with developing coronary, cerebrovascular, and peripheral arterial disease, heart failure, nerve disorders (neuropathy), eye complications (e.g. cataracts, glaucoma diabetic retinopathy), kidney disease (nephropathy), foot ulcers, restriction of mental function, and psychosomatic diseases (e.g. stress, anxiety and depression).

The most common of the cardiovascular complications in diabetics are ischemic cardiomyopathy and left ventricular (LV) dysfunction. Of particular interest here is the diastolic dysfunction, as an early sign of diabetic heart muscle disease followed by systolic damage.

Although diabetes has a decisive role in the development of cardiovascular disease, traditional glucose lowering agents have failed to convincingly show that intensive glucose control significantly reduces CVD events.

A new approach for treatment of adult patients with type 2 diabetes was found with the selective inhibition of sodium glucose cotransporter 2 (SGLT2). Studies have shown that empagliflozin, a potent SGLT2 inhibitor, not only effectively reduces the rates of hyperglycemia but also blood pressure and weight. (16, 18) In addition, beneficial effects on arterial stiffness and vascular resistance, visceral adiposity, albuminuria and plasma urate have been reported.

The results of the EMPA-REG OUTCOME study suggest that empagliflozin added to the standard therapy has a positive influence on cardiovascular outcomes and heart failure hospitalization in individuals with diabetic mellitus.

The aim of the present study is to investigate the effects of empagliflozin, in comparison with placebo, on cardiac and vascular function as well as on cardiac biomarker in individuals with type 2 diabetes with standard therapy, increased E/E' ratio and poor glycemic control.

• Study Type: Interventional
• Enrollment (Actual): 144
• Phase: Phase 4

Contacts and Locations

Study Locations

• Germany
  • Mainz, Germany, 55131
    • Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Zentrum für Kardiologie, Präventive Kardiologie und Medizinische Prävention

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 84 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

Subjects meeting all of the following criteria at visit 0 (screening) will be considered for admission to the trial:

• Diagnosis of type 2-diabetes mellitus with stable glucose-lowering background therapy and/or dietetic treatment for at least 12 weeks
• In subjects without glucose-lowering background therapy: the application of Metformin was considered to be unsuitable due to drug intolerance
• HbA1c level of ≥6.5% and ≤10.0% at visit 0 (screening) for subjects on antidiabetic background therapy or HbA1c level of ≥6.5% and ≤9.0% for drug-naïve subjects with dietetic treatment
• Diastolic cardiac dysfunction E/E' ratio ≥8 (2D-echocardiography)
• Age 18 - 84 years
• BMI ≤ 45 kg/m² (Body Mass Index)

• For women: post-menopausal for more than 12 months without an alternative medical cause can participate in the trial. Women with childbearing potential can only participate, if they are surgically sterile or a negative pregnancy test (serum or urine) is available at visit 1 and they are willing to practice highly effective birth control method during trial. Reliable highly effective contraception comprises

  • combined (estrogen and progesteron containing) hormonal contraception associated with inhibition of ovulation (oral, intravaginal, transdermal)
  • progesteron-only hormonal contraception associated with inhibition of ovaluation (oral, injectable, implantable)
  • intrauterine device (IUD)
  • intrauterine hormone-releasing system (IUS)
  • bilateral tubal occlusion
  • vasectomised partner (provided that partner is the sole sexual partner and that the vasectomised partner has received medical assessment of the surgical success)
  • sexual abstinence (defined as refraining from heterosexual intercourse during the entire period of risk associated with the study treatment. The reliability of sexual abstinence needs to be evaluated in relation to the duration of the clinical trial and the preferred and usual lifestyle of the subject.
• Ability of subject to understand nature, importance and individual consequences of clinical trial
• Signed and dated informed consent of the subject must be available before start of any specific trial procedures which is consistent with ICH-GCP guidelines and local legislation

Exclusion Criteria:

Subjects presenting with any of the following criteria at visit 0 (screening) will not be included in the trial:

• Pretreatment with empagliflozin or other SGLT2 inhibitor within the last 3 months
• Pretreatment with known inducers of UGT enzymes
• Uncontrolled hyperglycemia with a glucose level > 240 mg/dl (>13.3 mmol/L) after an overnight fast
• Impaired renal function, defined as eGFR <45 ml/min/1.73 m² of body-surface-area
• End-stage renal failure or dialysis
• Severe hepatic dysfunction, defined by serum levels of either SGPT, SGOT, or alkaline phosphatase above 3 x upper limit of normal (ULN)
• Acute urinary tract infection (UTI)
• Known acute genital infection (GI)
• Symptomatic hypotension
• Hematocrit above the upper limit of the reference range
• Hypoglycemic tendencies
• Severe PAD (Fontaine classification Stage IIb - IV)
• Medical history of cancer and/or treatment for cancer within the last 5 years, subjects basalioma can be included in the study
• Medical history of pancreatitis or surgery on pancreas
• Known ketoacidosis (in the past)
• Acute febrile disease
• NYHA classification III - IV
• Pregnant and/or nursing women at visit 1 (baseline)
• Acute coronary syndrome, stroke or TIA within the last 2 months
• Planned cardiac surgery or angioplasty within 3 months
• Gastrointestinal surgeries that induce chronic malabsorption
• Blood dyscrasia or any disorders causing hemolysis or unstable Red Blood Cells (e.g. malaria, babesiosis, hemolytic anemia)
• History of hypersensitivity to the investigational medicinal product or to any drug with similar chemical structure or to any excipient present in the pharmaceutical form of the investigational medicinal product
• Alcohol or drug abuse within the last 3 months that would interfere with trial participation
• Medical or psychological conditions that would jeopardize an adequate and orderly completion of the trial (at visit 0 (screening) or at visit 1 (baseline))
• Medical condition that does not allow enrollment in the trial at visit 1 (baseline)
• Current treatment with systemic steroids or change in dosage of thyroid hormones within the last 6 weeks or any other uncontrolled endocrine disorder except type 2 diabetes mellitus
• Hereditary glucose intolerance, galactose intolerance, Lapp-lactase deficiency or glucose-galactose-malabsorption
• Intake of an investigational drug in another trial within 30 days prior to intake of study medication in this trial or participating in another trial (involving an investigational drug and/or follow-up)

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Quadruple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Empagliflozin; 10 mg Empagliflozin daily per os for 12 weeks	Drug: Empagliflozin; 10 mg per os daily for 12 weeks; Other Names: Jardiance
Experimental: Placebo; amount of Placebo corresponding to empagliflozin 10 mg daily per os for 12 weeks	Drug: Placebo; amount of Placebo corresponding to empagliflozin 10 mg per os daily for 12 weeks

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
difference in E/E' ratio between 12 weeks after baseline and at baseline	difference in E/E' ratio (noninvasive surrogate marker for left ventricular diastolic function (LVEDP) measured by 2D-echocardiography) between 12 weeks after baseline and at baseline	12 weeks

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
difference in E/E' ratio (change from baseline (V1) to 1 week follow-up)	difference in E/E' ratio (change from baseline (V1) to 1 week follow-up (2D-echocardiography)	1 week
difference in Left ventricular systolic function (LVEF)	difference in Left ventricular systolic function (LVEF) from baseline to week 1	1 week
difference in Left ventricular systolic function (LVEF)	difference in Left ventricular systolic function (LVEF) from baseline to week 12	12 weeks
difference in Left end-diastolic volume (LEDV)	difference in Left end-diastolic volume (LEDV) from baseline to week 1	1 week
difference in Left end-diastolic volume (LEDV)	difference in Left end-diastolic volume (LEDV) from baseline to week 12	12 weeks
difference in Carotid-femoral pulse wave velocity	difference in Carotid-femoral pulse wave velocity (cf-PWV, vascular explorer - calculated) from baseline to week 1	1 week
difference in Carotid-femoral pulse wave velocity	difference in Carotid-femoral pulse wave velocity (cf-PWV, vascular explorer - calculated) from baseline to week 12	12 weeks
difference in Augmentation index (AIx)	difference in Augmentation index (AIx, vascular explorer) from baseline to week 1	1 week
difference in Augmentation index (AIx)	difference in Augmentation index (AIx, vascular explorer) from baseline to week 12	12 week
difference in Arterial stiffness index (SI)	difference in Arterial stiffness index (SI, photo plethysmography) from baseline to week 1	1 week
difference in Arterial stiffness index (SI)	difference in Arterial stiffness index (SI, photo plethysmography) from baseline to week 12	12 weeks
difference in Reflection index	difference in Reflection index (photo plethysmography) from baseline to week 1	1 week
difference in Reflection index	difference in Reflection index (photo plethysmography) from baseline to week 12	12 weeks
difference in Brain natriuretic peptide (BNP)	difference in Brain natriuretic peptide (BNP) from baseline to week 1	1 week
difference in Brain natriuretic peptide (BNP)	difference in Brain natriuretic peptide (BNP) from baseline to week 12	12 weeks
difference in High sensitive troponin I (hs TnI)	difference in High sensitive troponin I (hs TnI) from baseline to week 1	1 week
difference in High sensitive troponin I (hs TnI)	difference in High sensitive troponin I (hs TnI) from baseline to week 12	12 weeks
difference in High sensitive C-reactive protein (hs CRP)	difference in High sensitive C-reactive protein (hs CRP) from baseline to week 1	1 week
difference in High sensitive C-reactive protein (hs CRP)	difference in High sensitive C-reactive protein (hs CRP) from baseline to week 12	12 weeks
difference in E/E' ratio (change from baseline (V1) to 12 weeks follow-up) in the subgroup of patients with eGFR 45-59 ml/min/1.73 m²	difference in E/E' ratio (noninvasive surrogate marker for left ventricular diastolic function (LVEDP) measured by 2D-echocardiography) between 12 weeks after baseline and at baseline in the subgroup of patients with eGFR 45-59 ml/min/1.73 m²	12 weeks
difference in E/E' ratio (change from baseline (V1) to 12 weeks follow-up) in the subgroup of patients with HbA1c 6.5%-6.9%	difference in E/E' ratio (noninvasive surrogate marker for left ventricular diastolic function (LVEDP) measured by 2D-echocardiography) between 12 weeks after baseline and at baseline in the subgroup of patients with with HbA1c 6.5%-6.9%	12 weeks

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
difference in biomarkers of cardiac diseases	changes between baseline and follow-up after 1 week in biomarkers of cardiac diseases	1 week
difference in biomarkers of cardiac diseases	changes between baseline and follow-up after 12 weeks in biomarkers of cardiac diseases	12 weeks
difference in biomarkers of vascular diseases	changes between baseline and follow-up after 1 week in biomarkers of vascular diseases	1 week
difference in biomarkers of vascular diseases	changes between baseline and follow-up after 12 weeks in biomarkers of vascular diseases	12 weeks
difference in biomarkers of metabolic/diabetic status	changes between baseline and follow-up after 1 week in biomarkers of metabolic/diabetic status	1 week
difference in biomarkers of metabolic/diabetic status	changes between baseline and follow-up after 12 weeks in biomarkers of metabolic/diabetic status	12 weeks
changes in vascular/endothelial function	changes between baseline and follow-up after 1 week in vascular/endothelial function	1 week
changes in vascular/endothelial function	changes between baseline and follow-up after 12 weeks in vascular/endothelial function	12 weeks
changes in carotid atherosclerosis	changes between baseline and follow-up after 1 week in carotid atherosclerosis	1 week
changes in carotid atherosclerosis	changes between baseline and follow-up after 12 weeks in carotid atherosclerosis	12 weeks
changes in pulmonary function	changes between baseline and follow-up after 1 week in pulmonary function	1 week
changes in pulmonary function	changes between baseline and follow-up after 12 weeks in pulmonary function	12 weeks
changes in ophthalmological diseases	changes between baseline and follow-up after 1 week in ophthalmological diseases	1 week
changes in ophthalmological diseases	changes between baseline and follow-up after 12 weeks in ophthalmological diseases	12 weeks
changes in psychosomatic diseases	changes between baseline and follow-up after 1 week in psychosomatic diseases	1 week
changes in psychosomatic diseases	changes between baseline and follow-up after 12 weeks in psychosomatic diseases	12 weeks
association analysis for selected SNPs	association analysis for selected SNPs (measured at baseline)	baseline

Collaborators and Investigators

• Sponsor: Johannes Gutenberg University Mainz
• Collaborators: Boehringer Ingelheim
• Investigators: Principal Investigator: Philipp Wild, MD, MSc, Johannes Gutenberg University Mainz

Publications and helpful links

General Publications

• Junger C, Prochaska JH, Gori T, Schulz A, Binder H, Daiber A, Koeck T, Rapp S, Lackner KJ, Munzel T, Wild PS. Rationale and design of the effects of EMpagliflozin on left ventricular DIAstolic function in diabetes (EmDia) study. J Cardiovasc Med (Hagerstown). 2022 Mar 1;23(3):191-197. doi: 10.2459/JCM.0000000000001267.

Study record dates

Study Major Dates

• Study Start (Actual): October 10, 2016
• Primary Completion (Actual): June 15, 2020
• Study Completion (Actual): August 31, 2020

Study Registration Dates

• First Submitted: October 12, 2016
• First Submitted That Met QC Criteria: October 12, 2016
• First Posted (Estimate): October 13, 2016

Study Record Updates

• Last Update Posted (Actual): April 19, 2021
• Last Update Submitted That Met QC Criteria: April 16, 2021
• Last Verified: April 1, 2021

More Information

Terms related to this study

• Keywords: diastolic function; empagliflozin; poorly controlled type 2 diabetes mellitus
• Additional Relevant MeSH Terms: Glucose Metabolism Disorders; Metabolic Diseases; Endocrine System Diseases; Diabetes Mellitus; Diabetes Mellitus, Type 2; Hypoglycemic Agents; Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Sodium-Glucose Transporter 2 Inhibitors; Empagliflozin
• Other Study ID Numbers: UMCM-2016EPI05; 2016-001264-11 (EudraCT Number)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED