AUCTORES
Globalize your Research
Chat with us
Research Article | DOI: https://doi.org/10.31579/2641-0419/406
Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, AR.
*Corresponding Author: Iad Alhallak, MD MPH, Department of Cardiology, University of Arkansas for Medical Sciences 4110 Outpatient Circle Outpatient Center, Suite 2H, Little Rock, AR 72205.
Citation: Iad Alhallak, Hakan Paydak, Jawahar L. Mehta, (2024), SGLT2 Inhibitors: Risks and Benefits, J Clinical Cardiology and Cardiovascular Interventions, 7(10); DOI: 10.31579/2641-0419/406
Copyright: © 2024, Iad Alhallak. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 26 August 2024 | Accepted: 03 September 2024 | Published: 17 September 2024
Keywords: sodium-glucose transporter 2 inhibitors; adverse drug events; canagliflozin
Background: Inconsistent meta-analysis results and the increased risk of co-morbid conditions in type two diabetes make it challenging to distinguish if adverse effects of Fournier’s Gangrene, acute kidney injury, ketoacidosis, genitourinary fungal infections, amputations, and bone fractures are attributed to SGLT2 inhibitors.
Methods: This is a retrospective cohort study that calculates the relative risk and hazard ratio using the Food and Drug Administration Adverse Event Reporting System to compare the users of metformin and the SGLT2 inhibitors for adverse events. The Medical Expenditure Panel Survey database was used to generate total users of dapagliflozin, empagliflozin, canagliflozin, and metformin from the years 2014-2021.
Results: We observed an average increased risk of Fournier’s Gangrene by 156-fold, ketoacidosis by 67-fold, genitourinary fungal infections by 185-fold, amputations by 277-fold, and bone fractures by 15-fold compared to individuals taking metformin. Canagliflozin had the highest increased risk in all categories except for Fournier’s Gangrene, and empagliflozin did not have an increased relative risk of acute kidney injury.
Conclusion: We measured an increase in complications of patients on SGLT2 inhibitors, especially canagliflozin, compared to patients on metformin. We as health providers should re-evaluate our patients with increased risks of these complications and reassess if the cardiovascular benefits outweigh the possible dangerous side effects
When the Food and Drug Administration (FDA) approved the sodium-glucose transport protein 2 (SGLT2) inhibitors for patients with type 2 diabetes, this gave health care providers another oral anti-diabetic medication class that effectively lowers hemoglobin A1C levels by more than 0.5 percent (1-2). In addition to the SGLT2 inhibitor’s glucose lowering effects, recent trials have demonstrated the medication’s protective effects on the cardiovascular system through the reduction of cardiovascular-related mortality and heart failure exacerbations (3-5). This prompted the American Heart Association, the American College of Cardiology, and the Heart Failure Society of America to add SGLT2 inhibitors to the guideline-directed medical therapy for heart failure with reduced ejection fraction in 2022 (6). SGLT2 inhibitors have also been shown to have a renal protective effect, as it reduces the decline of the glomerular filtration rate (3,7-8) and reduces the onset of microalbuminuria (3,5,7,9). With positive effects on glucose metabolism and the cardiorenal system, SGLT-2 inhibitors still have potentially dangerous side effects.
The FDA has placed boxed warnings for the side effects of amputation, bone fracture, acute kidney injury (AKI), ketoacidosis, genital fungal infection, urinary tract infections (UTI), and necrotizing fasciitis of the perineum, known as Fournier’s gangrene (FG) (10). Of all the adverse events, FG is the deadliest with a mortality rate of 20% and 72% in individuals with diabetes (11-12); several case reviews have implicated that FG is associated with the use of SGLT2 inhibitors (13-16). In contrast, meta-analyses have revealed that SGLT2 inhibitors decrease the incidence of AKIs (17-20). Further, most meta-analyses indicated that SGLT2 inhibitors cause a two-fold increased risk of ketoacidosis (17, 21-24), and similarly, a meta-analysis measured an increase in genital fungal infections with SGLT2 inhibitor usage (25). For the side effect of UTIs, many meta-analyses showed no difference in the incidence of individuals taking SGLT2 inhibitors (17,26-28), and likewise, meta-analyses showed no increased incidence for bone fractures (21,29-31). For the side effect of amputations, there are meta-analyses that found an increased incidence of amputations with SGLT2 inhibitors, and some studies found no difference (21-22,29-31). SGLT2 inhibitors act in the proximal tubules by increasing glucose excretion in the urine, which can create a favorable environment for infections and this mechanism is similar to how the body reduces blood sugar levels in diabetic ketoacidosis (34). For the adverse events of bone fractures and amputations, there are proposed mechanisms of how SGLT2 inhibitors increase tissue ischemia (36) and increase bone mineral loss by enhancing fibroblast growth factor-23 and parathyroid hormone levels and reducing 1,25-dihydroxyvitamin D levels (35).
Since these side effects are possible complications of type 2 diabetes (37-38), it is challenging to establish relationships among these adverse events and SGLT2 inhibitors. Further, most patients with type 2 diabetes take metformin, and this is why we used the FDA Adverse Event Reporting System (FAERS) database to study the association among SGLT2 inhibitors and the adverse events of FG, AKIs, ketoacidosis, genital fungal infections, UTIs, amputations, and fractures to compare the SGLT2 inhibitor users to patients using metformin to see which of these effects are attributable to SGLT2 inhibitor use.
| Adverse events | Dapagliflozin (2015-2021) | Empagliflozin (2016-2021) | Canagliflozin (2014-2020) | Metformin (2014-2021) |
| FG | 171 | 450 | 207 | 48 |
| AKI | 360 | 439 | 1,806 | 7,923 |
| Ketoacidosis | 2,885 | 4,262 | 3,917 | 1,778 |
| Fungal Urogenital Infections | 110 | 187 | 336 | 41 |
| Amputations | 96 | 170 | 3,620 | 164 |
| Bone Fractures | 103 | 116 | 148 | 299 |
| Total Number of Drug Users | 2,900,893 | 5,993,571 | 3,537,359 | 137,547,148 |
Table 1: Total number of reported adverse events throughout the indicated years, obtained through the FAERS database, and total number of users in the United States throughout the indicated years, obtained through the MEPS database. Abbreviations: Fournier’s gangrene (FG), acute kidney injury (AKI), and Food and Drug Administration Adverse Event Reporting System (FAERS).
| Adverse Reaction | Dapagliflozin (2015-2021) | Empagliflozin (2016-2021) | Canagliflozin (2014-2020) | Average RR | |||
| RR (CI) | NNH | RR(CI) | NNH | RR(CI) | NNH | ||
| FG | 150 (109-206) | 17,078 | 166 (123-224) | 13,400 | 153 (111-211) | 17,201 | 156 |
| AKI | 2 (1.8-2.3) | 15,895 | 1.1(1-1.2) | 144,630 | 8.7(8.2-9.1) | 2,214 | 4 |
| Ketoacidosis | 70 (66-74) | 1,020 | 45 (43-48) | 1,436 | 85 (81-91) | 913 | 67 |
| Fungal Urogenital Infections | 119(82-171) | 26,596 | 150(97-234) | 32,266 | 287(206-399) | 10,565 | 185 |
| Amputations | 25(20-32) | 31,473 | 19(15-24) | 37,197 | 787(669-925) | 978 | 277 |
| Bone Fractures | 16(13-20) | 30,051 | 9(7-11) | 58,346 | 19(16-24) | 25,207 | 15 |
Table 2: Relative risk with a 95% confidence interval of the side effects of Fournier’s gangrene, acute kidney injury, ketoacidosis, genitourinary fungal infection, amputations, and bone fractures, for the medications dapagliflozin, empagliflozin, and canagliflozin using metformin as the control. Abbreviations: Relative Risk (RR), Confidence Interval (CI), Number needed to harm (NNH), Fournier’s gangrene (FG), and acute kidney injury (AKI).
For this retrospective cohort study, we calculated relative risk (RR) and hazard ratio (HR) with 95% confidence interval (CI) using reported adverse events to FAERS. The information that was used for the calculations comes from patients and providers mostly from the United States who submit adverse events of FG, AKI, ketoacidosis, genitourinary fungal infections, amputations, and bone fractures to FAERS. For our total population group, we have 2,900,893 users of dapagliflozin from 2015-2021, 5,993,571 users of empagliflozin from 2016-2021, 3,537,359 users of canagliflozin from 2014-2020, and 137,547,148 users of metformin from 2014-2021 obtained from the Medical Expenditure Panel Survey (MEPS) database. MEPS is a national survey that asks participants about their prescription medications and then is confirmed with their pharmacies. This survey publishes the 200 most reported medications. MEPS publishes the number of users of specific medications, and this was used to estimate the number of individuals taking SGLT2 inhibitors. Based on the years that SGLT2 inhibitors were one of the top 200 most prescribed medications, FAERS was used to gather the frequency of adverse events, including sex and age of the affected individuals.
The FAERS database medication search included dapagliflozin, dapagliflozin propanediol, empagliflozin, canagliflozin, canagliflozin anhydrous, metformin, metformin extended release 500mg, metformin hydrochloride, metformin hydrochloride extended release 500mg, metformin pamoate.
For FG, we combined the FAERS adverse reactions FG and scrotal gangrene. For AKI, we included the FAERS adverse reaction of acute kidney injury. For ketoacidosis, we included the FAERS adverse reactions diabetic ketoacidosis, ketoacidosis, and euglycaemic diabetic ketoacidosis. For fungal urogenital infections, we included the FAERS adverse reactions vulvovaginal mycotic infection, genital infection fungal, balanitis candida, vulvovaginal candidiasis, genital candidiasis, urinary tract candidiasis, urinary tract infection fungal, fungal cystitis, fungal balanitis, urogenital infection fungal, bladder candidiasis, and fungal urethritis. For bone fractures, we included the FAERS adverse reactions hip fracture, femur fracture, lower limb fracture, fracture, ankle fracture, foot fracture, upper limb fracture, humerus fracture, rib fracture, hand fracture, shoulder fracture, spinal compression fracture, radius fracture, fibula fracture, tibia fracture, lumbar vertebral fracture, clavicle fracture, spinal fracture, femoral neck fracture, fractured coccyx, forearm fracture, cervical vertebral fracture, facial bones fracture, scapula fracture, pelvic fracture, ulna fracture, sternal fracture, and skull fractured base. For amputations, we included the FAERS adverse reactions toe amputation, leg amputation, foot amputation, amputation, limb amputation, finger amputation, hand amputation, and arm amputation.
The statistical program R was used to adjust the weight of the reported users of SGLT2 inhibitors to accurately reflect the total number of users in the United States. The statistical program R was also used to calculate RR and HR from the FAERS and MEPS databases. For the RR and HR calculations, metformin was used as the unexposed/control group. The CI was calculated, and a CI above the number one is considered statistically significant. During the RR and HR analyses, identical years of both SGLT2 inhibitors and metformin was used depending on the MEPS data that were available, for example dapagliflozin adverse events from 2015-2021 was compared to the adverse events of metformin from 2015-2021. Data were extracted and checked at three different time periods, and the data were compared between the three periods for any input errors. Data for age and sex of the individuals have been extracted from the FAERS website and graphed as a percentage. The analyses were performed using RStudio (Boston, MA, USA), and the figures were made using BioRender (Toronto, CA) and Prism 9 (Irvine, CA).
As shown in Figure 1, we observed an average 156-fold increase in FG with SGLT2 inhibitors compared to individuals on metformin, and we measured an inconsistent relative risk of AKI among the medications, with canagliflozin having the highest relative risk of 9 for AKI. Further, we observed an average 67-fold increase in ketoacidosis with the use of SGLT2 inhibitors compared to the individuals on metformin; canagliflozin had the highest relative risk of 85. We observed an average 185-fold increased risk of genitourinary fungal infections, again, with highest relative risk of 287-fold from canagliflozin. We also observed a 787-fold higher risk of amputations for individuals taking canagliflozin compared to individuals taking metformin. Further, we observed an average 15-fold increased risk of bone fractures among the users of these medications.
As shown in Figure 2, there were no consistent trends in side effects affecting a particular age group, except for FG and ketoacidosis, as the majority for these adverse events occurred in subjects under the age of 65. We also observed a consistent pattern for sex, except for individuals that developed AKI and ketoacidosis. We observed a male majority being affected by FG and amputations, and a female majority being affected by bone fractures and genitourinary fungal infections.
Figure 1: Relative risk with 95% confidence interval of adverse events of Fournier’s gangrene, acute kidney injury, ketoacidosis, genitourinary fungal infection, amputations, and bone fractures, for the medications dapagliflozin, empagliflozin, and canagliflozin using metformin as the control.
Figure 2: Sex and age of affected individuals for the side effects of Fournier’s gangrene, acute kidney injury, ketoacidosis, genitourinary fungal infection, amputations, and bone fractures.
Figure 3: Illustration of the mechanism of action of the potential side effects of the SGLT2-inhibitors. Abbreviations glucose (glc), sodium glucose transport protein 2 (SGLT2), fibroblast growth factor 23 (FGF), parathyroid hormones (PTH).
Compared to users of metformin, we observed increased relative risks for FG, ketoacidosis, genitourinary fungal infections, and amputations among users of dapagliflozin, empagliflozin, and canagliflozin, with canagliflozin having the highest relative risk. We saw variable effects of SGLT2 inhibitors on AKI, with empagliflozin having no increase in relative risk and canagliflozin having the largest relative risk for AKI. Our data with empagliflozin does support the meta-analyses that did not find a difference in AKI (17,19) but does not show any decreased risk of AKI with SGLT2 inhibitors.
Interestingly enough, canagliflozin had the highest relative risks among the adverse events, except for FG. Pharmacokinetic-wise, canagliflozin has the longest half-life in the plasma among the SGLT2 inhibitors (39), which may explain its unfavorable profile. Similarly, canagliflozin has increased urinary glucose excretion and decreased post prandial glucose excretion compared to dapagliflozin (40), which may explain the increased risks of ketoacidosis and fungal urogenital infections. Further, the relative risk for amputations with canagliflozin was significantly higher than metformin and much higher than dapagliflozin and empagliflozin. Canagliflozin has been shown to inhibit the paracrine function of bone marrow derived mesenchymal stem cells, impairing reperfusion of ischemic vessels (41), which is exacerbated by the SGLT2 inhibitor side effect of hypotension and blood hyperviscosity, due to increase in hematocrit, leading to reduced limb perfusion and thus amputation (35).
The sex differences in the affected individuals can be explained by increased prevalence of smoking and peripheral neuropathy in men, which increases risks of amputations (42) and epidemiological prevalence of FG in men (43). The female majority for fractures and urogenital fungal infection can be explained by the overall lower bone mineral density (44), the higher incidence of urogenital fungal infection, and the shorter urethra in women (45). Male patients on SGLT2 inhibitors should be warned of
the side effects of FG and amputations, and female patients should be warned of the adverse event of fungal urogenital infections and bone fractures.
Importantly, the reporting of adverse events to FAERS is vastly underreported with a study indicating that the FAERS only captures 0.01% to 44% of all adverse events (46). Similarly, another study estimates that the FDA only receives about 1-10% of all adverse events (47). This can be attributed to the 5% of providers who do not report these adverse events because of ignorance, procrastination, and the belief that only safe drugs are currently available on the market (48-49). This suggests that the relative risks may be higher and NNH may be lower than what was calculated in this study.
A limitation to this study is that FAERS does not include existing medical conditions, A1C levels, and other medications taken by the patients, which simplifies possible complicated setting of adverse events. This paper did not include all the possible SGLT2 inhibitors. However, this is due to the MEPS database and according to this database and most Americans are using these SGLT2 inhibitors.
With high relative risks of potentially life-threatening conditions like FG and ketoacidosis and serious conditions of amputations, fractures, and fungal urogenital infections from empagliflozin, dapagliflozin, and canagliflozin, should we attempt to restrict certain patients from taking all or certain SGLT2 inhibitors? Based on this data and the positive cardiorenal effects shown by SGLT2 inhibitors (3-9), we believe a personalized risk and benefit analysis should be done with every patient and providers should reconsider SGLT2 inhibitors for patients with increased risks of complications. For instance, immobility drastically increases the risk for the potentially fatal side effect of FG (50).
Due to the limited data on empagliflozin and metformin combination, future research can help distinguish if the adverse events are either solely due to SGLT2 inhibitors, in part due to metformin, or due to the etiology of type 2 diabetes. Future research should also focus on the possible mechanisms for these side-effects to help us understand and prevent these dangerous adverse effects, so we can utilize SGLT2 inhibitors’ cardiorenal protective effects.
Patients on a SGLT2 inhibitor with history of ketoacidosis, immobility, history of frequent genitourinary fungal infections, osteoporosis, and patients with pre-existing conditions like peripheral arterial disease that increases risk of amputation should be re-evaluated for a SGLT2 inhibitor, especially if it is not needed for heart failure with reduced ejection fraction management. However, if the benefits outweigh the risks, empagliflozin has the lowest relative risk of ketoacidosis, amputations, and bone fractures. Since canagliflozin had the highest risk of adverse events, except for FG, among dapagliflozin and empagliflozin, we encourage providers to transition patients to a safer SGLT2 inhibitor.
None
None
None Declared
The data underlying this article are available in [FDA Databases, FDA Adverse Event Reporting System (FAERS)], at https://www.fda.gov/. The datasets were derived from sources in the public domain: [https://www.fda.gov/drugs/questions-and-answers-fdas-adverse-event-reporting-system-faers/fda-adverse-event-reporting-system-faers-public-dashboard].
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
