Effects of Canagliflozin on Fracture Risk in Patients With Type 2 Diabetes Mellitus

Abstract

Context: Canagliflozin is a sodium glucose cotransporter 2 inhibitor developed to treat type 2 diabetes mellitus (T2DM).

Objective: The purpose of this study was to describe the effects of canagliflozin on bone fracture risk.

Design and setting: This was a randomized phase 3 study in patients with T2DM.

Patients and interventions: Canagliflozin doses of 100 and 300 mg were evaluated in the overall population of patients from 9 placebo- and active-controlled studies (N = 10 194), as well as in separate analyses of a single trial enriched with patients with a prior history/risk of cardiovascular disease (ie, the CANagliflozin cardioVascular Assessment Study [CANVAS]; N = 4327) and a pooled population of 8 non-CANVAS studies (N = 5867).

Outcome measures: The incidence of adjudicated fracture adverse events (AEs), fall-related AEs, and volume depletion-related AEs was assessed.

Results: The incidence of fractures was similar with canagliflozin (1.7%) and noncanagliflozin (1.5%) in the pooled non-CANVAS studies. In CANVAS, a significant increase in fractures was seen with canagliflozin (4.0%) vs placebo (2.6%) that was balanced between the upper and lower limbs. The incidence of fractures was higher with canagliflozin (2.7%) vs noncanagliflozin (1.9%) in the overall population, which was driven by the increase of fractures in CANVAS. The incidence of reported fall-related AEs was low, but significantly higher with canagliflozin in CANVAS, potentially related to volume depletion-related AEs, but not significantly different in the pooled non-CANVAS studies and the overall population.

Conclusions: Fracture risk was increased with canagliflozin treatment, driven by CANVAS patients, who were older, with a prior history/risk of cardiovascular disease, and with lower baseline estimated glomerular filtration rate and higher baseline diuretic use. The increase in fractures may be mediated by falls; however, the cause of increased fracture risk with canagliflozin is unknown.

Trial registration: ClinicalTrials.gov NCT00968812 NCT01032629 NCT01064414 NCT01081834 NCT01106625 NCT01106651 NCT01106677 NCT01106690 NCT01137812.

Figure 1.

HRs (95% CIs) for pooled canagliflozin 100 and 300 mg vs noncanagliflozin in the incidence of fracture AEs in the 9 individual studies, the pooled non-CANVAS studies, CANVAS, and the overall population. CANA, canagliflozin; MET, metformin; PBO, placebo; SITA, sitagliptin; GLIM, glimepiride; SU, sulfonylurea; PIO, pioglitazone; NA, not assessed.

Figure 2.

Kaplan-Meier plot of time to first adjudicated fracture AE in CANVAS. HR (95% CI) for all CANA vs PBO = 1.51 (1.04–2.19). PBO, placebo; CANA, canagliflozin.

Figure 3.

HRs (95% CIs) for canagliflozin 100 and 300 mg vs placebo in the incidence of fracture AEs by subgroup (CANVAS). CANA, canagliflozin; PBO, placebo.