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Pasqua MR, Jafar A, Kobayati A, Tsoukas MA, Haidar A. Low-Dose Empagliflozin as Adjunct to Hybrid Closed-Loop Insulin Therapy in Adults With Suboptimally Controlled Type 1 Diabetes: A Randomized Crossover Controlled Trial. Diabetes Care 2023; 46:165-172. [PMID: 36331522 PMCID: PMC9797647 DOI: 10.2337/dc22-0490] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 10/09/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To assess whether low doses of empagliflozin as adjunct to hybrid closed-loop therapy improve glycemia compared with placebo in adults with type 1 diabetes (T1D) who are not able to achieve targets with the system alone. RESEARCH DESIGN AND METHODS A double-blind crossover randomized controlled trial was performed in adults with suboptimally controlled T1D (HbA1c 7.0-10.5%) who were not able to achieve a target time in range (3.9-10.0 mmol/L) ≥70% after 14 days of hybrid closed-loop therapy. Three 14-day interventions were performed with placebo, 2.5 mg empagliflozin, or 5 mg empagliflozin as adjunct to the McGill artificial pancreas. Participants were assigned at a 1:1:1:1:1:1 ratio with blocked randomization. The primary outcome was time in range (3.9-10.0 mmol/L). Analysis was by intention to treat, and a P value <0.05 was regarded as significant. RESULTS A total of 24 participants completed the study (50% male; age 33 ± 14 years; HbA1c 8.1 ± 0.5%). The time in range was 59.0 ± 9.0% for placebo, 71.6 ± 9.7% for 2.5 mg empagliflozin, and 70.2 ± 8.0% for 5 mg empagliflozin (P < 0.0001 between 2.5 mg empagliflozin and placebo and between 5 mg empagliflozin and placebo). Mean daily capillary ketone levels were not different between arms. There were no serious adverse events or cases of diabetic ketoacidosis or severe hypoglycemia in any intervention. CONCLUSIONS Empagliflozin at 2.5 and 5 mg increased time in range during hybrid closed-loop therapy by 11-13 percentage points compared with placebo in those who otherwise were unable to attain glycemic targets. Future studies are required to assess long-term efficacy and safety.
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Affiliation(s)
- Melissa-Rosina Pasqua
- Division of Endocrinology, Department of Medicine, McGill University, Montréal, Québec, Canada
- The Research Institute of McGill University Health Centre, Montréal, Québec, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University, Montréal, Québec, Canada
| | - Adnan Jafar
- The Research Institute of McGill University Health Centre, Montréal, Québec, Canada
- Department of Biomedical Engineering, McGill University, Montréal, Québec, Canada
| | - Alessandra Kobayati
- The Research Institute of McGill University Health Centre, Montréal, Québec, Canada
- Department of Biomedical Engineering, McGill University, Montréal, Québec, Canada
| | - Michael A. Tsoukas
- Division of Endocrinology, Department of Medicine, McGill University, Montréal, Québec, Canada
- The Research Institute of McGill University Health Centre, Montréal, Québec, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University, Montréal, Québec, Canada
| | - Ahmad Haidar
- Division of Endocrinology, Department of Medicine, McGill University, Montréal, Québec, Canada
- The Research Institute of McGill University Health Centre, Montréal, Québec, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University, Montréal, Québec, Canada
- Department of Biomedical Engineering, McGill University, Montréal, Québec, Canada
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ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, Collins BS, Hilliard ME, Isaacs D, Johnson EL, Kahan S, Khunti K, Leon J, Lyons SK, Perry ML, Prahalad P, Pratley RE, Seley JJ, Stanton RC, Gabbay RA, on behalf of the American Diabetes Association. 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes-2023. Diabetes Care 2023; 46:S140-S157. [PMID: 36507650 PMCID: PMC9810476 DOI: 10.2337/dc23-s009] [Citation(s) in RCA: 377] [Impact Index Per Article: 377.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Silva VB, Fonseca L, Duarte DB, Puga FM, Assuncao G, Garrido S, Teixeira S, Vilaverde J, Cardoso MH. Efficacy and safety of SGLT2 inhibitors in individuals with type 1 diabetes under continuous subcutaneous insulin infusion: a real-world study. Endocr Regul 2023; 57:144-151. [PMID: 37561831 DOI: 10.2478/enr-2023-0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2023] Open
Abstract
Objective. Adjuvant therapy with sodium-glucose cotransport 2 inhibitors (SGLT2i) in type 1 diabetes (T1D) is associated with an improvement in glycemic control, but increases the risk of diabetic ketoacidosis (DKA). However, real-life studies in individuals with T1D under continuous subcutaneous insulin infusion (CSII) are still scarce. We present the first real-life study performed in patients with T1D exclusively treated with CSII. The aim of the present study was to assess the metabolic impact and safety of SGLT2i in T1D individuals under CSII. Methods. Retrospective study includes 34 T1D adult individuals under CSII, who started SGLT2i until 30th June 2021. Data regarding the glycemic control and acute diabetes complications at the moment of introduction of SGLT2i and after 3, 6, and 12 months of use were collected. Results. Twenty-three individuals were included. Comparing with the moment of SGLT2i introduction after 3, 6, and 12 months of use, there was a statistically significant increase of time in range (TIR) (∆T3M=12.8%; ∆T6M=11.5%; ∆T12M=11.1%), and a decrease in time above range (∆T3M=13.6%; ∆T6M=11.9%; ∆T12M=10.5%). There were no significant differences in time below the range. Mean glucose and mean glucose management indicator significantly reduced in the 3 evaluated moments. A significant reduction in median weight was also observed (∆T6M=2 kg; ∆T12M=4.5 kg). Two patients (8.7%) developed mild euglycemic DKA during SGLT2i treatment, both were women and had body mass index (BMI) <27 kg/m2. One of them had a total daily insulin dose (TDDI) reduction of 26.9% after 3 months of use. Conclusions. The use of SGLT2i, as an adjuvant treatment in T1D individuals under CSII, was associated with a significant increase of TIR without increasing time in hypoglycemia. It also had a weight benefit. Careful use in selected participants is necessary to reduce the occurrence of DKA.
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Affiliation(s)
- Vania Benido Silva
- 1Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitario do Porto, Porto, Portugal
| | - Liliana Fonseca
- 1Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitario do Porto, Porto, Portugal
| | - Diana Borges Duarte
- 1Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitario do Porto, Porto, Portugal
| | - Francisca Marques Puga
- 1Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitario do Porto, Porto, Portugal
| | - Guilherme Assuncao
- 1Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitario do Porto, Porto, Portugal
| | - Susana Garrido
- 1Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitario do Porto, Porto, Portugal
| | - Sofia Teixeira
- 1Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitario do Porto, Porto, Portugal
| | - Joana Vilaverde
- 1Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitario do Porto, Porto, Portugal
| | - Maria Helena Cardoso
- 1Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitario do Porto, Porto, Portugal
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Kugathasan L, Dubrofsky L, Advani A, Cherney DZI. The anti-hypertensive effects of sodium-glucose cotransporter-2 inhibitors. Expert Rev Cardiovasc Ther 2023; 21:15-34. [PMID: 36524239 DOI: 10.1080/14779072.2023.2159810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Hypertension is a well-established risk factor for cardiovascular (CV) events in patients with chronic kidney disease (CKD), heart failure, obesity, and diabetes. Despite the usual prescribed antihypertensive therapies, many patients fail to achieve the recommended blood pressure (BP) targets. AREAS COVERED This review summarizes the clinical BP-lowering data presented in major CV and kidney outcome trials for sodium-glucose cotransporter-2 (SGLT2) inhibitors, as well as smaller dedicated BP trials in high-risk individuals with and without diabetes. We have also highlighted potential mechanisms that may contribute to the antihypertensive effects of SGLT2 inhibitors, including natriuresis and hemodynamic changes, a loop diuretic-like effect, and alterations in vascular physiology. EXPERT OPINION The antihypertensive properties of SGLT2 inhibitors are generally modest but may be larger in certain patient populations. SGLT2 inhibitors may have an additional role as an adjunctive BP-lowering therapy in patients with hypertension at high risk of CV disease or kidney disease.
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Affiliation(s)
- Luxcia Kugathasan
- Department of Medicine, Division of Nephrology, University Health Network, Toronto, Ontario, Canada.,Department of Physiology, University of Toronto, Toronto, Ontario, Canada.,Cardiovascular Sciences Collaborative Specialization, University of Toronto, Toronto, Ontario, Canada
| | - Lisa Dubrofsky
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Nephrology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Division of Nephrology, Women's College Hospital, Toronto, Ontario, Canada
| | - Andrew Advani
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, University Health Network, Toronto, Ontario, Canada.,Department of Physiology, University of Toronto, Toronto, Ontario, Canada.,Cardiovascular Sciences Collaborative Specialization, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
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Abstract
Objective Young people with type 1 diabetes are likely to gain body weight and not achieve optimal glycemic control with only high doses of insulin. This study examined the efficacy of the sodium-glucose cotransporter 2 (SGLT2) inhibitor dapagliflozin as an adjunct-to-insulin therapy in young Japanese subjects with type 1 diabetes who had been diagnosed before 15 years old, were overweight, and had inadequate control despitereceiving intensive insulin therapy. Methods Twenty-two patients with type 1 diabetes (12 boys and 10 girls 16.0-33.9 years old) were involved in the study. All patients had a body mass index (BMI) >25 kg/m2, glycated hemoglobin (HbA1c) level >7.0%, and daily insulin dose >0.5 units/kg. They were treated with a low dose of dapagliflozin (5.0 mg/day) as an adjunctive therapy to insulin. Fourteen patients were treated with multiple daily injections of insulin, while eight used an insulin pump. Results The body weights and BMIs were significantly reduced during the 12-month study period (change of -4.4 kg and -1.7 kg/m2, p<0.001, respectively). Their insulin dose was significantly decreased (-0.17 units/kg, P <0.001), and glycemic control was significantly improved (fasting plasma glucose: -18.7 mg/dL, HbA1c: -0.62%, p<0.001) during the study period. There was one episode of diabetic ketoacidosis, with no other problematic adverse events, including severe hypoglycemia, observed. Conclusion The use of low-dose dapagliflozin as an adjunct therapy may be beneficial in overweight young people with poorly controlled type 1 diabetes.
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Affiliation(s)
- Tatsuhiko Urakami
- Department of Pediatrics, Nihon University School of Medicine, Japan
| | - Kei Yoshida
- Department of Pediatrics, Nihon University School of Medicine, Japan
| | - Junichi Suzuki
- Department of Pediatrics, Nihon University School of Medicine, Japan
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Kowalska K, Wilczopolski P, Buławska D, Młynarska E, Rysz J, Franczyk B. The Importance of SGLT-2 Inhibitors as Both the Prevention and the Treatment of Diabetic Cardiomyopathy. Antioxidants (Basel) 2022; 11:antiox11122500. [PMID: 36552708 PMCID: PMC9774735 DOI: 10.3390/antiox11122500] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 11/30/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
According to the 2021 report of the International Diabetes Federation (IDF), there have been approximately 573 million cases of type 2 diabetes mellitus (T2DM) among adults, which sets the disease as a major concern in healthcare worldwide. The development of T2DM is strongly promoted by unhealthy lifestyle factors associated with urbanization and western civilization. The disease is associated with a broad list of systemic complications that can result in premature death, disability and significantly reduced quality of life. The most dramatic in their consequences are cardiovascular complications of T2DM. Our work focuses on one such complication that is specific for diabetes, named diabetic cardiomyopathy (DC). In this condition cardiac dysfunction occurs despite the absence of underlying hypertension, coronary artery disease and valvular disease, which suggest a leading role for metabolic disturbances as a cause. We aimed to establish the role of relatively new hypoglycaemic drugs that have taken the medical world by storm with their broad pleiotropic effects-SGLT-2 inhibitors-in the prevention and treatment of DC at any stage.
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Affiliation(s)
- Klaudia Kowalska
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Piotr Wilczopolski
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Dominika Buławska
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Ewelina Młynarska
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
- Correspondence: ; Tel.: +48-(042)-639-3750
| | - Jacek Rysz
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Beata Franczyk
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
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Timmons JG, Littlejohn L, Boyle JG, Petrie JR. Recent developments in adjunct therapies for type 1 diabetes. Expert Opin Investig Drugs 2022; 31:1311-1320. [PMID: 36655950 DOI: 10.1080/13543784.2022.2159806] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION There have been many recent advances in the treatment of type 1 diabetes (T1D) including in insulin formulations, continuous glucose monitoring (CGM) technology and automated insulin delivery. However, long-term optimal glycemic control is still only achieved in a minority. AREAS COVERED Adjunct therapy - the use of therapeutic agents other than insulin - is one strategy aimed at improving outcomes. An ideal adjunct agent would improve glycemic control, reduce weight (or weight gain), reduce insulin requirement and prevent complications (e.g. cardiorenal) without increasing hypoglycemia. The amylin analogue pramlintide has been licensed in the USA, while the sodium glucose co-transporter-2 inhibitor (SGLT2i) dapagliflozin, was briefly (2019 - 2021) licensed for type 1 diabetes in Europe and the UK. However, other agents from the type 2 diabetes (T2D) arena including metformin, other SGLT2is, glucagon-like peptide-1 receptor agonists (GLP-1RA) and dipeptidyl peptidase-IV (DPP-4) inhibitors have been investigated. EXPERT OPINION As evidence emerges for cardiorenal protection by SGLT2is and GLP-1RAs in T2D, it has become increasingly important to know whether people with T1D can also benefit. Here, we review recent trials of adjunct agents in T1D and discuss the efficacy and safety of these agents (alone and in combination) in an era in which continuous glucose monitoring is becoming standard of care.
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Affiliation(s)
- Joseph G Timmons
- School of Cardiovascular & Metabolic Health, BHF Glasgow Cardiovascular Research Centre (GCRC), 126 University Avenue, University of Glasgow, G12 8TA Glasgow, UK
| | - Lucy Littlejohn
- School of Cardiovascular & Metabolic Health, BHF Glasgow Cardiovascular Research Centre (GCRC), 126 University Avenue, University of Glasgow, G12 8TA Glasgow, UK
| | - James G Boyle
- School of Cardiovascular & Metabolic Health, BHF Glasgow Cardiovascular Research Centre (GCRC), 126 University Avenue, University of Glasgow, G12 8TA Glasgow, UK
| | - John R Petrie
- School of Cardiovascular & Metabolic Health, BHF Glasgow Cardiovascular Research Centre (GCRC), 126 University Avenue, University of Glasgow, G12 8TA Glasgow, UK
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Baigent C, Emberson J, Haynes R, Herrington WG, Judge P, Landray MJ, Mayne KJ, Ng SY, Preiss D, Roddick AJ, Staplin N, Zhu D, Anker SD, Bhatt DL, Brueckmann M, Butler J, Cherney DZ, Green JB, Hauske SJ, Haynes R, Heerspink HJ, Herrington WG, Inzucchi SE, Jardine MJ, Liu CC, Mahaffey KW, McCausland FR, McGuire DK, McMurray JJ, Neal B, Neuen BL, Packer M, Perkovic V, Sabatine MS, Solomon SD, Vaduganathan M, Wanner C, Wheeler DC, Wiviott SD, Zannad F. Impact of diabetes on the effects of sodium glucose co-transporter-2 inhibitors on kidney outcomes: collaborative meta-analysis of large placebo-controlled trials. Lancet 2022; 400:1788-1801. [PMID: 36351458 PMCID: PMC7613836 DOI: 10.1016/s0140-6736(22)02074-8] [Citation(s) in RCA: 289] [Impact Index Per Article: 144.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Large trials have shown that sodium glucose co-transporter-2 (SGLT2) inhibitors reduce the risk of adverse kidney and cardiovascular outcomes in patients with heart failure or chronic kidney disease, or with type 2 diabetes and high risk of atherosclerotic cardiovascular disease. None of the trials recruiting patients with and without diabetes were designed to assess outcomes separately in patients without diabetes. METHODS We did a systematic review and meta-analysis of SGLT2 inhibitor trials. We searched the MEDLINE and Embase databases for trials published from database inception to Sept 5, 2022. SGLT2 inhibitor trials that were double-blind, placebo-controlled, performed in adults (age ≥18 years), large (≥500 participants per group), and at least 6 months in duration were included. Summary-level data used for analysis were extracted from published reports or provided by trial investigators, and inverse-variance-weighted meta-analyses were conducted to estimate treatment effects. The main efficacy outcomes were kidney disease progression (standardised to a definition of a sustained ≥50% decrease in estimated glomerular filtration rate [eGFR] from randomisation, a sustained low eGFR, end-stage kidney disease, or death from kidney failure), acute kidney injury, and a composite of cardiovascular death or hospitalisation for heart failure. Other outcomes were death from cardiovascular and non-cardiovascular disease considered separately, and the main safety outcomes were ketoacidosis and lower limb amputation. This study is registered with PROSPERO, CRD42022351618. FINDINGS We identified 13 trials involving 90 413 participants. After exclusion of four participants with uncertain diabetes status, we analysed 90 409 participants (74 804 [82·7%] participants with diabetes [>99% with type 2 diabetes] and 15 605 [17·3%] without diabetes; trial-level mean baseline eGFR range 37-85 mL/min per 1·73 m2). Compared with placebo, allocation to an SGLT2 inhibitor reduced the risk of kidney disease progression by 37% (relative risk [RR] 0·63, 95% CI 0·58-0·69) with similar RRs in patients with and without diabetes. In the four chronic kidney disease trials, RRs were similar irrespective of primary kidney diagnosis. SGLT2 inhibitors reduced the risk of acute kidney injury by 23% (0·77, 0·70-0·84) and the risk of cardiovascular death or hospitalisation for heart failure by 23% (0·77, 0·74-0·81), again with similar effects in those with and without diabetes. SGLT2 inhibitors also reduced the risk of cardiovascular death (0·86, 0·81-0·92) but did not significantly reduce the risk of non-cardiovascular death (0·94, 0·88-1·02). For these mortality outcomes, RRs were similar in patients with and without diabetes. For all outcomes, results were broadly similar irrespective of trial mean baseline eGFR. Based on estimates of absolute effects, the absolute benefits of SGLT2 inhibition outweighed any serious hazards of ketoacidosis or amputation. INTERPRETATION In addition to the established cardiovascular benefits of SGLT2 inhibitors, the randomised data support their use for modifying risk of kidney disease progression and acute kidney injury, not only in patients with type 2 diabetes at high cardiovascular risk, but also in patients with chronic kidney disease or heart failure irrespective of diabetes status, primary kidney disease, or kidney function. FUNDING UK Medical Research Council and Kidney Research UK.
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Hropot T, Battelino T, Dovc K. Sodium-Glucose Co-Transporter-2 Inhibitors in Type 1 Diabetes: A Scoping Review. Horm Res Paediatr 2022; 96:620-630. [PMID: 36279850 PMCID: PMC10652647 DOI: 10.1159/000527653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 08/30/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND With recent developments in diabetes technology, attaining adequate glucose control is more achievable than ever. Despite these improvements, a significant proportion of individuals with type 1 diabetes do not reach recommended glycaemic goals. Sodium-glucose co-transporter-2 (SGLT2) inhibitors are glucose-lowering agents that inhibit the reabsorption of filtered glucose in the kidneys, thus promoting glucosuria. Because the glucose-lowering effect of SGLT2 inhibitors is achieved independently of insulin secretion, it has been speculated whether they could bridge the gap towards achieving glycaemic targets in individuals with type 1 diabetes. SUMMARY Our main goal was to systematically map the current knowledge on the efficacy and safety of SGLT2 inhibitor use in adults with type 1 diabetes and present recent studies regarding the use of SGLT2 inhibitors in youth with type 1 diabetes. Using a scoping review approach, we searched MEDLINE to identify relevant clinical trials of SGLT2 inhibitors as adjunctive therapy to insulin in type 1 diabetes published from January 31, 2012, to January 31, 2022. We included the most relevant, large-scale, and long placebo-controlled clinical trials of SGLT2 inhibitors as an add-on therapy to insulin in adults with type 1 diabetes. Additionally, we included all relevant pilot studies evaluating the use of SGLT2 inhibitors as add-on therapy to insulin in youth with type 1 diabetes. We identified eight placebo-controlled clinical trials in adults with type 1 diabetes meeting our inclusion criteria and two relevant pilot studies in youth with type 1 diabetes. The clinical trials in adults with type 1 diabetes confirmed the efficacy of SGLT2 inhibitors as add-on therapy to insulin. However, this was associated with an increased incidence of diabetic ketoacidosis (DKA) versus placebo in all identified clinical trials. The two relevant pilot studies in youth with type 1 diabetes showed promising results of SGLT2 inhibitor use as an add-on therapy to insulin, especially when combined with a fully closed-loop system. KEY MESSAGES SGLT2 inhibitors, as an add-on therapy to insulin, improve glycaemic outcomes in adults with type 1 diabetes with a potential cost of increasing DKA risk. The use of add-on SGLT2 inhibitors to insulin shows promising results in youth with type 1 diabetes. Moreover, SGLT2 inhibitors as add-on therapy in combination with closed-loop insulin therapy could provide additional benefits in improving glycaemic control. The current role of SGLT2 inhibitors as an adjunct therapy to insulin in individuals with type 1 diabetes is yet to be determined.
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Affiliation(s)
- Tim Hropot
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Tadej Battelino
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, University Children's Hospital, Ljubljana, Slovenia
| | - Klemen Dovc
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, University Children's Hospital, Ljubljana, Slovenia
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Bloomgarden Z, Schatz D. Small steps forward: Adjunctive therapy for T1D. J Diabetes 2022; 14:642-645. [PMID: 36205524 PMCID: PMC9574725 DOI: 10.1111/1753-0407.13326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Zachary Bloomgarden
- Department of Medicine, Division of Endocrinology, Diabetes and Bone DiseaseIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Desmond Schatz
- Diabetes Institute, University of Florida College of MedicineGainesvilleFloridaUSA
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Cao X, Du X, Jiao H, An Q, Chen R, Fang P, Wang J, Yu B. Carbohydrate-based drugs launched during 2000 -2021. Acta Pharm Sin B 2022; 12:3783-3821. [PMID: 36213536 PMCID: PMC9532563 DOI: 10.1016/j.apsb.2022.05.020] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/18/2022] [Accepted: 05/12/2022] [Indexed: 01/09/2023] Open
Abstract
Carbohydrates are fundamental molecules involved in nearly all aspects of lives, such as being involved in formating the genetic and energy materials, supporting the structure of organisms, constituting invasion and host defense systems, and forming antibiotics secondary metabolites. The naturally occurring carbohydrates and their derivatives have been extensively studied as therapeutic agents for the treatment of various diseases. During 2000 to 2021, totally 54 carbohydrate-based drugs which contain carbohydrate moities as the major structural units have been approved as drugs or diagnostic agents. Here we provide a comprehensive review on the chemical structures, activities, and clinical trial results of these carbohydrate-based drugs, which are categorized by their indications into antiviral drugs, antibacterial/antiparasitic drugs, anticancer drugs, antidiabetics drugs, cardiovascular drugs, nervous system drugs, and other agents.
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Affiliation(s)
- Xin Cao
- Zhongshan Hospital Institute of Clinical Science, Fudan University Shanghai Medical College, Shanghai 200032, China
| | - Xiaojing Du
- Zhongshan Hospital Institute of Clinical Science, Fudan University Shanghai Medical College, Shanghai 200032, China
| | - Heng Jiao
- Zhongshan Hospital Institute of Clinical Science, Fudan University Shanghai Medical College, Shanghai 200032, China
| | - Quanlin An
- Zhongshan Hospital Institute of Clinical Science, Fudan University Shanghai Medical College, Shanghai 200032, China
| | - Ruoxue Chen
- Zhongshan Hospital Institute of Clinical Science, Fudan University Shanghai Medical College, Shanghai 200032, China
| | - Pengfei Fang
- State Key Laboratory of Bio-organic and Natural Products Chemistry, Center for Excellence in Molecular Synthesis, Shanghai Institute of Organic Chemistry, Chinese Academy of Sciences, Shanghai 200032, China
| | - Jing Wang
- State Key Laboratory of Bio-organic and Natural Products Chemistry, Center for Excellence in Molecular Synthesis, Shanghai Institute of Organic Chemistry, Chinese Academy of Sciences, Shanghai 200032, China
| | - Biao Yu
- State Key Laboratory of Bio-organic and Natural Products Chemistry, Center for Excellence in Molecular Synthesis, Shanghai Institute of Organic Chemistry, Chinese Academy of Sciences, Shanghai 200032, China
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Abiru N, Shoji S, Kosakai Y, Snijder R, Asakawa K, Rokuda M. Demographic and clinical characteristics of patients with type 1 diabetes mellitus initiating sodium-glucose cotransporter 2 inhibitors in Japan: A real-world administrative database analysis. Diabetes Res Clin Pract 2022; 190:109973. [PMID: 35760156 DOI: 10.1016/j.diabres.2022.109973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/10/2022] [Accepted: 06/20/2022] [Indexed: 11/03/2022]
Abstract
AIMS To investigate the baseline demographic and clinical characteristics of patients with type 1 diabetes mellitus (T1DM) newly treated with a sodium-glucose cotransporter 2 inhibitor (SGLT2i) as an add-on to insulin, or treated with insulin alone or in combination with oral anti-diabetic drugs other than an SGLT2i. METHODS Retrospective study using data from the JMDC database (December 21, 2018, to October 31, 2020). Included patients with T1DM treated with an SGLT2i (add-on to insulin) (n = 1027) or with insulin (n = 4320). Baseline demographic and clinical characteristics were summarized, and change in insulin dose and efficacy outcomes, including hemoglobin A1c (HbA1c) and body mass index (BMI), before and after the first SGLT2i or insulin prescription were evaluated. RESULTS The SGLT2i add-on group had higher HbA1c and BMI than the insulin group. Daily insulin doses decreased from immediately before to after the first SGLT2i prescription. HbA1c and BMI improved from baseline to after the first SGLT2i prescription. CONCLUSIONS This large real-world study reported the baseline demographic and clinical characteristics of patients with T1DM newly treated with an SGLT2i in Japan. The findings may guide the appropriate use of SGLT2i and support large-scale database studies in T1DM research.
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Affiliation(s)
- Norio Abiru
- Department of Endocrinology and Metabolism, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Shingo Shoji
- Medical Affairs, Astellas Pharma Inc., 2-5-1, Nihonbashi-Honcho, Chuo-ku, Tokyo 103-8411, Japan.
| | - Yoshinori Kosakai
- Medical Affairs, Astellas Pharma Inc., 2-5-1, Nihonbashi-Honcho, Chuo-ku, Tokyo 103-8411, Japan.
| | - Robert Snijder
- Advanced Informatics & Analytics, Astellas Pharma Europe B.V, Sylviusweg 62, 2333 BE Leiden, The Netherlands.
| | - Keiko Asakawa
- Medical Affairs, Astellas Pharma Inc., 2-5-1, Nihonbashi-Honcho, Chuo-ku, Tokyo 103-8411, Japan.
| | - Mitsuhiro Rokuda
- Medical Affairs, Astellas Pharma Inc., 2-5-1, Nihonbashi-Honcho, Chuo-ku, Tokyo 103-8411, Japan.
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Stougaard EB, Rossing P, Cherney D, Vistisen D, Persson F. Sodium-glucose cotransporter 2 inhibitors as adjunct therapy for type 1 diabetes and the benefit on cardiovascular and renal disease evaluated by Steno risk engines. J Diabetes Complications 2022; 36:108257. [PMID: 35840519 DOI: 10.1016/j.jdiacomp.2022.108257] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/28/2022] [Accepted: 07/01/2022] [Indexed: 11/23/2022]
Abstract
AIMS Sodium-glucose cotransporter inhibitors (SGLTi) have beneficial cardiovascular and renal effects in persons with type 2 diabetes. No studies have shown whether this can be demonstrated in type 1 diabetes (T1D). We aimed to estimate the risk of cardiovascular disease (CVD) and end-stage kidney disease (ESKD) in persons with T1D with and without treatment with SGLTi. METHODS The study is based on 3660 adults with T1D. The Steno Type 1 Risk Engines were used to calculate 5-year risks of ESKD and 5- and 10-year risk of CVD. The effect of SGLTi was simulated by changing the HbA1c and systolic blood pressure values in accordance with results from the DEPICT studies with mean (standard deviation (SD)) of -3.6 (0.9) mmol/mol (-2.5 % (2.2)) and -1.12 (2.8) mmHg. eGFR and albuminuria were changed in accordance with results from the Tandem studies; no change in eGFR and mean (SD) %-change in albuminuria of -23.7 (12.9). RESULTS We found a 5-year CVD relative risk reduction of 6.1 % (95%CI 5.9,6.3) and 11.1 % (10.0,12.2) in the subgroup with albuminuria with similar results for the 10-year CVD risk. For the estimated 5-year risk of ESKD, we found a relative risk reduction of 5.3 % (5.1,5.4) with 7.6 % (6.9,8.4) in the subgroup with albuminuria. CONCLUSION We found a significant CVD and ESKD risk reduction, especially in the subgroup with albuminuria.
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Affiliation(s)
| | - Peter Rossing
- Complication Research, Steno Diabetes Center Copenhagen, Capital Region, Denmark; Department of Clinical Medicine, University of Copenhagen, Capital Region, Denmark
| | - David Cherney
- Department of Medicine, University of Toronto, Division of Nephrology, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Dorte Vistisen
- Clinical Epidemiology, Steno Diabetes Center Copenhagen, Capital Region, Denmark; Department of Public Health, University of Copenhagen, Capital Region, Denmark
| | - Frederik Persson
- Complication Research, Steno Diabetes Center Copenhagen, Capital Region, Denmark
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Liu H, Sridhar VS, Perkins BA, Rosenstock J, Cherney DZI. SGLT2 Inhibition in Type 1 Diabetes with Diabetic Kidney Disease: Potential Cardiorenal Benefits Can Outweigh Preventable Risk of Diabetic Ketoacidosis. Curr Diab Rep 2022; 22:317-332. [PMID: 35633439 DOI: 10.1007/s11892-022-01471-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/29/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to summarize existing research investigating the use of sodium glucose cotransporter-2 (SGLT2) inhibitors in patients with type 1 diabetes mellitus (T1DM) while highlighting potential strategies to mitigate the risk of diabetic ketoacidosis (DKA). RECENT FINDINGS SGLT2 inhibitors have been studied in patients with T1DM in phase 3 clinical trials such as the inTandem, DEPICT, and EASE trials, which demonstrated consistent reductions in HbA1c. Secondary analyses of these trials have also reported potential kidney protective effects that are independent of improved glycemic control. However, trials in patients with type 2 diabetes mellitus (T2DM) have found an increased risk of DKA with SGLT2 inhibitors, a serious concern in patients with T1DM. SGLT2 inhibitors provide cardiovascular benefits and kidney protection in patients with T2DM and are a promising therapeutic option for patients with T1DM due to overlapping pathophysiological mechanisms. However, SGLT2 inhibitors increase the risk of DKA, and there is currently a lack of research investigating the beneficial effects of SGLT2 inhibitors in patients with T1DM. Preventative measure for DKA would have to be implemented and the risks would need to be carefully balanced with the benefits offered by SGLT2 inhibitors. Additional research will also be required to determine the kidney protective effects of SGLT2 inhibitors in patients with T1DM and diabetic kidney disease and to quantify the risk of DKA after the implementation of preventative measures, proper patient education, and ketone monitoring.
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Affiliation(s)
- Hongyan Liu
- Department of Medicine, Division of Nephrology, University Health Network, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Vikas S Sridhar
- Department of Medicine, Division of Nephrology, University Health Network, Toronto, ON, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Bruce A Perkins
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Julio Rosenstock
- Dallas Diabetes Research Center at Medical City, Dallas, TX, USA
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, University Health Network, Toronto, ON, Canada.
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada.
- Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada.
- Department of Medicine, University of Toronto, Toronto, ON, Canada.
- Toronto General Hospital, 585 University Ave, Toronto, ON, 8N-845M5G 2N2, Canada.
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Garcia-Tirado J, Farhy L, Nass R, Kollar L, Clancy-Oliveri M, Basu R, Kovatchev B, Basu A. Automated Insulin Delivery with SGLT2i Combination Therapy in Type 1 Diabetes. Diabetes Technol Ther 2022; 24:461-470. [PMID: 35255229 PMCID: PMC9464084 DOI: 10.1089/dia.2021.0542] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background: Use of sodium-glucose cotransporter 2 inhibitors (SGLT2i) as adjunct therapy to insulin in type 1 diabetes (T1D) has been previously studied. In this study, we present data from the first free-living trial combining low-dose SGLT2i with commercial automated insulin delivery (AID) or predictive low glucose suspend (PLGS) systems. Methods: In an 8-week, randomized, controlled crossover trial, adults with T1D received 5 mg/day empagliflozin (EMPA) or no drug (NOEMPA) as adjunct to insulin therapy. Participants were also randomized to sequential orders of AID (Control-IQ) and PLGS (Basal-IQ) systems for 4 and 2 weeks, respectively. The primary endpoint was percent time-in-range (TIR) 70-180 mg/dL during daytime (7:00-23:00 h) while on AID (NCT04201496). Findings: A total of 39 subjects were enrolled, 35 were randomized, 34 (EMPA; n = 18 and NOEMPA n = 16) were analyzed according to the intention-to-treat principle, and 32 (EMPA; n = 16 and NOEMPA n = 16) completed the trial. On AID, EMPA versus NOEMPA had higher daytime TIR 81% versus 71% with a mean estimated difference of +9.9% (confidence interval [95% CI] 0.6-19.1); p = 0.04. On PLGS, the EMPA versus NOEMPA daytime TIR was 80% versus 63%, mean estimated difference of +16.5% (95% CI 7.3-25.7); p < 0.001. One subject on SGLT2i and AID had one episode of diabetic ketoacidosis with nonfunctioning insulin pump infusion site occlusion contributory. Interpretation: In an 8-week outpatient study, addition of 5 mg daily empagliflozin to commercially available AID or PLGS systems significantly improved daytime glucose control in individuals with T1D, without increased hypoglycemia risk. However, the risk of ketosis and ketoacidosis remains. Therefore, future studies with SGLT2i will need modifications to closed-loop control algorithms to enhance safety.
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Affiliation(s)
- Jose Garcia-Tirado
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Leon Farhy
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Ralf Nass
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Laura Kollar
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Mary Clancy-Oliveri
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Rita Basu
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Boris Kovatchev
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Ananda Basu
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
- Address correspondence to: Ananda Basu, MD, Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia, Charlottesville, VA 22908, USA
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Aberer F, Pieber TR, Eckstein ML, Sourij H, Moser O. Glucose-Lowering Therapy beyond Insulin in Type 1 Diabetes: A Narrative Review on Existing Evidence from Randomized Controlled Trials and Clinical Perspective. Pharmaceutics 2022; 14:pharmaceutics14061180. [PMID: 35745754 PMCID: PMC9229408 DOI: 10.3390/pharmaceutics14061180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/18/2022] [Accepted: 05/30/2022] [Indexed: 12/10/2022] Open
Abstract
Background: In Type 1 diabetes (T1D), according to the most recent guidelines, the everyday glucose-lowering treatment is still restricted to the use of subcutaneous insulin, while multiple therapeutic options exist for Type 2 diabetes (T2D). Methods: For this narrative review we unsystematically screened PubMed and Embase to identify clinical trials which investigated glucose-lowering agents as an adjunct to insulin treatment in people with T1D. Published studies up to March 2022 were included. We discuss the safety and efficacy in modifying cardiovascular risk factors for each drug, the current status of research, and provide a clinical perspective. Results: For several adjunct agents, in T1D, the scientific evidence demonstrates improvements in HbA1c, reductions in the risk of hypoglycemia, and achievements of lower insulin requirements, as well as positive effects on cardiovascular risk factors, such as blood lipids, blood pressure, and weight. As the prevalence of obesity, the major driver for double diabetes, is rising, weight and cardiovascular risk factor management is becoming increasingly important in people with T1D. Conclusions: Adjunct glucose-lowering agents, intended to be used in T2D, bear the potential to beneficially impact on cardiovascular risk factors when investigated in the T1D population and are suggested to be more extensively considered as potentially disease-modifying drugs in the future and should be investigated for hard cardiovascular endpoints.
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Affiliation(s)
- Felix Aberer
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (F.A.); (T.R.P.); (O.M.)
- Division of Exercise Physiology and Metabolism, Institute of Sport Science, University of Bayreuth, 95447 Bayreuth, Germany;
| | - Thomas R. Pieber
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (F.A.); (T.R.P.); (O.M.)
| | - Max L. Eckstein
- Division of Exercise Physiology and Metabolism, Institute of Sport Science, University of Bayreuth, 95447 Bayreuth, Germany;
| | - Harald Sourij
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (F.A.); (T.R.P.); (O.M.)
- Correspondence: ; Tel.: +43-316-385-86113
| | - Othmar Moser
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (F.A.); (T.R.P.); (O.M.)
- Division of Exercise Physiology and Metabolism, Institute of Sport Science, University of Bayreuth, 95447 Bayreuth, Germany;
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Haidar A, Lovblom LE, Cardinez N, Gouchie-Provencher N, Orszag A, Tsoukas MA, Falappa CM, Jafar A, Ghanbari M, Eldelekli D, Rutkowski J, Yale JF, Perkins BA. Empagliflozin add-on therapy to closed-loop insulin delivery in type 1 diabetes: a 2 × 2 factorial randomized crossover trial. Nat Med 2022; 28:1269-1276. [PMID: 35551290 DOI: 10.1038/s41591-022-01805-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 03/28/2022] [Indexed: 11/09/2022]
Abstract
There is a need to optimize closed-loop automated insulin delivery in type 1 diabetes. We assessed the glycemic efficacy and safety of empagliflozin 25 mg d-1 as add-on therapy to insulin delivery with a closed-loop system. We performed a 2 × 2 factorial randomized, placebo-controlled, crossover two-center trial in adults, assessing 4 weeks of closed-loop delivery versus sensor-augmented pump (SAP) therapy and empagliflozin versus placebo. The primary outcome was time spent in the glucose target range (3.9-10.0 mmol l-1). Primary comparisons were empagliflozin versus placebo in each of closed-loop or SAP therapy; the remaining comparisons were conditional on its significance. Twenty-four of 27 randomized participants were included in the final analysis. Compared to placebo, empagliflozin improved time in target range with closed-loop therapy by 7.2% and in SAP therapy by 11.4%. Closed-loop therapy plus empagliflozin improved time in target range compared to SAP therapy plus empagliflozin by 6.1% but by 17.5% for the combination of closed-loop therapy and empagliflozin compared to SAP therapy plus placebo. While no diabetic ketoacidosis or severe hypoglycemia occurred during any intervention, uncomplicated ketosis events were more common on empagliflozin. Empagliflozin 25 mg d-1 added to automated insulin delivery improves glycemic control but increases ketone concentration and ketosis compared to placebo.
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Affiliation(s)
- Ahmad Haidar
- Department of Biomedical Engineering, McGill University, Montreal, Quebec, Canada.,The Research Institute of McGill University Health Centre, Montreal, Quebec, Canada.,Division of Endocrinology, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Leif Erik Lovblom
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Nancy Cardinez
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | | | - Andrej Orszag
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Michael A Tsoukas
- The Research Institute of McGill University Health Centre, Montreal, Quebec, Canada.,Division of Endocrinology, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - C Marcelo Falappa
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Adnan Jafar
- Department of Biomedical Engineering, McGill University, Montreal, Quebec, Canada
| | - Milad Ghanbari
- Department of Biomedical Engineering, McGill University, Montreal, Quebec, Canada
| | - Devrim Eldelekli
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Joanna Rutkowski
- Department of Biomedical Engineering, McGill University, Montreal, Quebec, Canada
| | - Jean-François Yale
- The Research Institute of McGill University Health Centre, Montreal, Quebec, Canada.,Division of Endocrinology, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Bruce A Perkins
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada. .,Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Wallace AS, Chang AR, Shin JI, Reider J, Echouffo-Tcheugui JB, Grams ME, Selvin E. Obesity and Chronic Kidney Disease in US Adults With Type 1 and Type 2 Diabetes Mellitus. J Clin Endocrinol Metab 2022; 107:1247-1256. [PMID: 35080610 PMCID: PMC9016431 DOI: 10.1210/clinem/dgab927] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Obesity is a global public health challenge and strongly associated with type 2 diabetes (T2D), but its burden and effects are not well understood in people with type 1 diabetes (T1D). Particularly, the link between obesity and chronic kidney disease (CKD) in T1D is poorly characterized. RESEARCH DESIGN AND METHODS We included all T1D and, for comparison, T2D in the Geisinger Health System from 2004 to 2018. We evaluated trends in obesity (body mass index ≥ 30 kg/m2), low estimated glomerular filtration rate (eGFR) (≤60 mL/min/1.73m2), and albuminuria (urine albumin-to-creatinine ratio ≥ 30 mg/g). We used multivariable logistic regression to evaluate the independent association of obesity with CKD in 2018. RESULTS People with T1D were younger than T2D (median age 39 vs 62 years). Obesity increased in T1D over time (32.6% in 2004 to 36.8% in 2018), while obesity in T2D was stable at ~60%. The crude prevalence of low eGFR was higher in T2D than in T1D in all years (eg, 30.6% vs 16.1% in 2018), but after adjusting for age differences, prevalence was higher in T1D than T2D in all years (eg, 16.2% vs 9.3% in 2018). Obesity was associated with increased odds of low eGFR in T1D [adjusted odds ratio (AOR) = 1.52, 95% CI 1.12-2.08] and T2D (AOR = 1.29, 95% CI 1.23-1.35). CONCLUSIONS Obesity is increasing in people with T1D and is associated with increased risk of CKD. After accounting for age, the burden of CKD in T1D exceeded the burden in T2D, suggesting the need for increased vigilance and assessment of kidney-protective medications in T1D.
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Affiliation(s)
- Amelia S Wallace
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
| | - Alex R Chang
- Department of Population and Health Sciences, Geisinger, Danville, PA, USA
- Kidney Health Research Institute, Geisinger, Danville, PA, USA
- Department of Nephrology, Geisinger, Danville, PA, USA
| | - Jung-Im Shin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
| | - Jodie Reider
- Endocrinology, Diabetes & Metabolism, Internal Medicine, Geisinger, Danville, PA, USA
| | - Justin B Echouffo-Tcheugui
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Morgan E Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
- Department of Internal Medicine, Division of Nephrology, Johns Hopkins University, Baltimore, MD, USA
| | - Elizabeth Selvin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
- Correspondence: Elizabeth Selvin, PhD, MPH, Department of Epidemiology, Welch Center for Prevention, Epidemiology and Clinical Research and the Johns Hopkins Bloomberg School of Public Health; 2024 E Monument St, Ste 2-639; Baltimore, MD 21287, USA.
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Dos Santos SS, Ramaldes LA, Gabbay MAL, Moises RCS, Dib SA. Use of a Sodium-Glucose Cotransporter 2 Inhibitor, Empagliflozin, in a Patient with Rabson-Mendenhall Syndrome. Horm Res Paediatr 2022; 94:313-316. [PMID: 34551418 DOI: 10.1159/000519613] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 09/12/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Among the insulin resistance syndromes that lead to diabetes mellitus in young people, Rabson-Mendenhall syndrome (RMS; OMIM # 262190) is an autosomal recessive inherited disease caused by an insulin receptor mutation (INSR; 147,670). Due to the rarity and complexity of the disease, we have few therapeutic alternatives other than insulin with clinical studies with robust evidence. Some reports suggest the adjunct use of metreleptin, metformin, and pioglitazone with improved glycemic control, however, with results still unsatisfactory for the desirable glycemic targets for this age group. CASE PRESENTATION We report a case of an 11-year-old patient who was diagnosed with RMS at 6 years of age, confirmed through genetic sequencing, with unsatisfactory glycemic control despite the use of >5 IU/kg/day of insulin, pioglitazone, and metformin. To optimize therapy, we used empagliflozin (SGLT2i) to correct hyperglycemia. With the use of the drug, we obtained a decrease of almost 3% in the value of glycated hemoglobin (HbA1c) and about 30% reduction in the total daily dose of insulin. DISCUSSION/CONCLUSION In this specific case, considering the glycosuric effects independent of the functionality of insulin receptors (which in this case had partial activity due to the INSR gene mutation), an improvement in glycemic control was obtained, with optimization of HbA1c without documented or reported adverse effects. From this isolated case and understanding the pharmacokinetics of this drug class, the question remains whether it would be possible to use this treatment in other situations of SIR where we also have few therapeutic perspectives.
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Affiliation(s)
- Sarah Simaan Dos Santos
- Department of Medicine, Discipline of Endocrinology, Diabetes Center, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Luana Aparecida Ramaldes
- Department of Medicine, Discipline of Endocrinology, Diabetes Center, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Monica Andrade Lima Gabbay
- Department of Medicine, Discipline of Endocrinology, Diabetes Center, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Regina Celia Santiago Moises
- Department of Medicine, Discipline of Endocrinology, Diabetes Center, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Sergio Atala Dib
- Department of Medicine, Discipline of Endocrinology, Diabetes Center, Universidade Federal de São Paulo, São Paulo, Brazil
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SGLT2 Inhibitors in Type 2 Diabetes Mellitus and Heart Failure-A Concise Review. J Clin Med 2022; 11:jcm11061470. [PMID: 35329796 PMCID: PMC8952302 DOI: 10.3390/jcm11061470] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 02/28/2022] [Accepted: 03/06/2022] [Indexed: 01/25/2023] Open
Abstract
The incidence of both diabetes mellitus type 2 and heart failure is rapidly growing, and the diseases often coexist. Sodium-glucose co-transporter 2 inhibitors (SGLT2i) are a new antidiabetic drug class that mediates epithelial glucose transport at the renal proximal tubules, inhibiting glucose absorption—resulting in glycosuria—and therefore improving glycemic control. Recent trials have proven that SGLT2i also improve cardiovascular and renal outcomes, including reduced cardiovascular mortality and fewer hospitalizations for heart failure. Reduced preload and afterload, improved vascular function, and changes in tissue sodium and calcium handling may also play a role. The expected paradigm shift in treatment strategies was reflected in the most recent 2021 guidelines published by the European Society of Cardiology, recommending dapagliflozin and empagliflozin as first-line treatment for heart failure patients with reduced ejection fraction. Moreover, the recent results of the EMPEROR-Preserved trial regarding empagliflozin give us hope that there is finally an effective treatment for patients with heart failure with preserved ejection fraction. This review aims to assess the efficacy and safety of these new anti-glycemic oral agents in the management of diabetic and heart failure patients.
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Palanca A, van Nes F, Pardo F, Ampudia Blasco FJ, Mathieu C. Real-world Evidence of Efficacy and Safety of SGLT2 Inhibitors as Adjunctive Therapy in Adults With Type 1 Diabetes: A European Two-Center Experience. Diabetes Care 2022; 45:650-658. [PMID: 35061022 DOI: 10.2337/dc21-1584] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 12/19/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate real-world efficacy and safety of sodium-glucose cotransporter 2 inhibitor (SGLT2i) use in combination with insulin in people with type 1 diabetes. RESEARCH DESIGN AND METHODS We conducted a retrospective cohort European two-center study. Data on demographics, HbA1c, weight, insulin use, renal function, and adverse events were collected for 199 adults with type 1 diabetes who initiated a SGLT2i adjunct to insulin. Subgroup analyses were performed to identify who benefited most and who was more at risk for adverse events. RESULTS Overall, significant reductions in mean HbA1c (-0.5%), weight (-2.9 kg), and daily insulin (-8.5%) were achieved after 12 months. The greatest reduction in HbA1c was obtained in individuals with baseline HbA1c >8% (-0.7% [64 mmol/mol]). The most weight loss was observed in subjects with BMI >27 kg/m2 (-3.5 kg). Individuals with baseline estimated glomerular filtration rate (eGFR) <90 mL/min/1.73 m2 showed an increase in eGFR (4.5 mL/min/1.73 m2), whereas those with urinary albumin-to-creatinine ratio (UACR) >15 mg/g showed a decrease in UACR (-16.6 mg/g). Fifty-seven individuals (28.6%) reported adverse events: 45 with genital infections (22.6%), 5 ketosis episodes (2.5%), and 7 diabetic ketoacidosis (DKA) (3.5%). No severe hypoglycemia events were reported. CONCLUSIONS Our real-world data on SGLT2i showed promising results in reductions in HbA1c, weight, and insulin requirements in type 1 diabetes. Benefits were more pronounced in individuals with higher baseline HbA1c and BMI. DKA remained a major concern, despite educational measures. Further real-life evidence is still required for evaluation of SGLT2i longer-term effects and their impact on reno-cardiovascular outcomes.
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Affiliation(s)
- Ana Palanca
- Endocrinology and Nutrition Department, University Hospital of Valencia, Valencia, Spain.,INCLIVA Biomedical Research Institute, Valencia, Spain
| | - Falco van Nes
- Clinical and Experimental Endocrinology, KU Leuven, Leuven, Belgium
| | - Felipe Pardo
- Endocrinology and Nutrition Department, University Hospital of Valencia, Valencia, Spain
| | - F Javier Ampudia Blasco
- Endocrinology and Nutrition Department, University Hospital of Valencia, Valencia, Spain.,INCLIVA Biomedical Research Institute, Valencia, Spain.,Department of Medicine, Medicine Faculty, University of Valencia, Valencia, Spain
| | - Chantal Mathieu
- Clinical and Experimental Endocrinology, KU Leuven, Leuven, Belgium
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Matthews JR, Schlaich MP, Rakoczy EP, Matthews VB, Herat LY. The Effect of SGLT2 Inhibition on Diabetic Kidney Disease in a Model of Diabetic Retinopathy. Biomedicines 2022; 10:biomedicines10030522. [PMID: 35327323 PMCID: PMC8944990 DOI: 10.3390/biomedicines10030522] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 02/18/2022] [Accepted: 02/18/2022] [Indexed: 02/04/2023] Open
Abstract
Diabetic kidney disease (DKD) is a chronic disorder characterized by elevated urine albumin excretion, reduced glomerular filtration rate, or both. At present, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers are the standard care for the treatment of DKD, resulting in improved outcomes. However, alternative treatments may be required because although the standard treatments have been found to slow the progression of DKD, they have not been found to halt the disease. In the past decade, sodium glucose co-transporter 2 (SGLT2) inhibitors have been widely researched in the area of cardiovascular disease and diabetes and have been shown to improve cardiovascular outcomes. SGLT2 inhibitors including canagliflozin and dapagliflozin have been shown to slow the progression of kidney disease. There is currently an omission of literature where three SGLT2 inhibitors have been simultaneously compared in a rodent diabetic model. After diabetic Akimba mice were treated with SGLT2 inhibitors for 8 weeks, there was not only a beneficial impact on the pancreas, signified by an increase in the islet mass and increased plasma insulin levels, but also on the kidneys, signified by a reduction in average kidney to body weight ratio and improvement in renal histology. These findings suggest that SGLT2 inhibition promotes improvement in both pancreatic and kidney health.
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Affiliation(s)
- Jennifer Rose Matthews
- Dobney Hypertension Centre, School of Biomedical Sciences—Royal Perth Hospital Unit, University of Western Australia, Crawley, WA 6009, Australia; (J.R.M.); (V.B.M.)
| | - Markus P. Schlaich
- Dobney Hypertension Centre, Medical School—Royal Perth Hospital Unit, University of Western Australia, Crawley, WA 6009, Australia;
- Department of Cardiology and Department of Nephrology, Royal Perth Hospital, Perth, WA 6000, Australia
| | - Elizabeth Piroska Rakoczy
- Department of Molecular Ophthalmology, University of Western Australia, Crawley, WA 6009, Australia;
| | - Vance Bruce Matthews
- Dobney Hypertension Centre, School of Biomedical Sciences—Royal Perth Hospital Unit, University of Western Australia, Crawley, WA 6009, Australia; (J.R.M.); (V.B.M.)
| | - Lakshini Yasaswi Herat
- Dobney Hypertension Centre, School of Biomedical Sciences—Royal Perth Hospital Unit, University of Western Australia, Crawley, WA 6009, Australia; (J.R.M.); (V.B.M.)
- Correspondence: ; Tel.: +61-8-9224-0239
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Fallatah W, Brema I, Alobedallah A, Alkhathami R, Zaheer S, AlMalki E, Almehthel M, Alzahrani S, AlMalki MH. Efficacy and Safety of SGLT2 Inhibitors as Adjunctive Treatment in Type 1 Diabetes in a Tertiary Care Center in Saudi Arabia. Avicenna J Med 2022; 12:10-15. [PMID: 35586391 PMCID: PMC9110106 DOI: 10.1055/s-0041-1742196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background
Adjunctive treatment with sodium-glucose co-transporters 2 inhibitors (SGLT2- I) has been successfully used in patients with type 1 diabetes mellitus (T1DM) in recent years to improve glycemic control and reduce body weight without increasing the risk of hypoglycemia; however, there is a scarcity of evidence for real-world experience in their use in T1DM Saudi patients. The purpose of this study was to evaluate the efficacy and safety of empagliflozin as off-label adjunctive therapy in Saudi patients with T1DM.
Methods
This study was a retrospective study for T1DM patients, who were prescribed empagliflozin as an adjunctive therapy. Baseline characteristics including age, changes in HbA1c, body weight, total daily insulin dose, lipid profile, and well as side effects such as urinary tract infections (UTIs) and diabetes ketoacidosis (DKA) were evaluated before and after initiation empagliflozin in 37 T1DM patients.
Results
The mean age was 25.8 ± 8.0 years, mean weight was 75.3 ± 14.8 kg, mean body mass index (BMI) was 28.1 ± 6.7 kg/m
2
, mean duration of diabetes was 10.1 ± 6.5 years, and mean HbA1c was 9.4 ± 1.4%. After a mean follow-up duration of 15.8 ± 6.0 months, the mean reduction in the HbA1c% from baseline was 0.82% (
p
= 0.001) and mean weight reduction from baseline was 1.7 kg (
p
= 0.097). The total daily insulin dose was decreased by 2.9 units. UTIs and DKA episodes were reported among 2.7% and 10.8% of the participants, respectively.
Conclusion
Empagliflozin in combination with insulin in overweight Saudi T1DM subjects resulted in a significant improvement in glycemic control, mild non-significant reduction in body weight, and a small but statistically significant reduction in the total daily insulin dose with a slight increase in the risk of DKA and UTIs. Further larger prospective studies are needed for better evaluation of the efficacy and safety of these agents in Saudi T1DM patients.
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Affiliation(s)
- Walla Fallatah
- Obesity, Endocrine and Metabolism Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Imad Brema
- Obesity, Endocrine and Metabolism Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ahmed Alobedallah
- King Fahad Medical City, College of Medicine, King Saud Bin Abdul Aziz University for Health Science, Riyadh, Saudi Arabia
| | - Reem Alkhathami
- Obesity, Endocrine and Metabolism Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Shawana Zaheer
- Obesity, Endocrine and Metabolism Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Eyad AlMalki
- Colleague of medicine, Shaqra University, Shaqra, Saudi Arabia
| | - Mohammed Almehthel
- Obesity, Endocrine and Metabolism Center, King Fahad Medical City, Riyadh, Saudi Arabia
- Division of Endocrinology, University of British Columbia
| | - Saad Alzahrani
- Obesity, Endocrine and Metabolism Center, King Fahad Medical City, Riyadh, Saudi Arabia
- King Fahad Medical City, College of Medicine, King Saud Bin Abdul Aziz University for Health Science, Riyadh, Saudi Arabia
| | - Mussa H. AlMalki
- Obesity, Endocrine and Metabolism Center, King Fahad Medical City, Riyadh, Saudi Arabia
- King Fahad Medical City, College of Medicine, King Saud Bin Abdul Aziz University for Health Science, Riyadh, Saudi Arabia
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Hafidh K, Abdella NA. Glycemic control of adult patients with type 1 diabetes mellitus in Arabian Gulf Countries; PREDICT. BMC Endocr Disord 2022; 22:32. [PMID: 35101023 PMCID: PMC8805329 DOI: 10.1186/s12902-022-00946-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 01/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Optimum glycemic control is necessary to reduce and even prevent the risk of micro- and macrovascular complications of type 1 diabetes mellitus (T1DM). The main aim of this study was to assess the prevalence of T1DM patients with adequate glycemic control in 4 Arabian Gulf countries. METHODS This study was a multicenter, observational, cross-sectional disease registry. Data were collected from adult T1DM patients who were treated with insulin within 6 months prior to the study visit. RESULTS Out of 241 patients whose data were eligible for primary endpoint analysis, 27.4% had adequate glycemic control (HbA1c < 7%). The patients' age ranged from 18 to 64 years, and 53% were males. The mean (SD) duration of diabetes was 14.6 (9) years and the mean HbA1c was 8.11 (1.8) %. At the time of T1DM diagnosis, mean HbA1c was 10.7 (2.17) %. About 98% of the patients were normotensive and the lipid profile of patients was found to be optimal. The main variables associated with adequate glycemic control were low HbA1c at diagnosis (P < 0.001) and absence of a family history of diabetes (P = 0.002). CONCLUSIONS We found that the glycemic control of T1DM adult patients in Kuwait, UAE, Oman and Bahrain is suboptimal. More efforts are necessary to pinpoint the causes of inadequate control in this population.
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Affiliation(s)
- Khadija Hafidh
- Department of Medicine, Rashid Hospital, Dubai Health Authority, Rashid Hospital, P.0.Box 4545, Dubai, UAE.
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75
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Varthya S, Dutta S, Kumar T, Singh S, Ambwani S, Charan J. Euglycemic diabetic ketoacidosis associated with SGLT2 inhibitors: A systematic review and quantitative analysis. J Family Med Prim Care 2022; 11:927-940. [PMID: 35495849 PMCID: PMC9051698 DOI: 10.4103/jfmpc.jfmpc_644_21] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/15/2021] [Accepted: 07/16/2021] [Indexed: 11/04/2022] Open
Abstract
Background: Methods: Results: Conclusion:
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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77
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Hamaguchi M, Yoshimura Y, Nakajima H, Tanaka T, Hasegawa G, Ishii M, Okada H, Mitsuhashi K, Kitagawa N, Okamura T, Hashimoto Y, Majima S, Senmaru T, Ushigome E, Nakanishi N, Asano M, Yamazaki M, Fukui M. Insulin dose reduction in dapagliflozin combination therapy for type 1 diabetes mellitus: the RISING-STAR study. J Clin Biochem Nutr 2022; 71:158-164. [PMID: 36213793 PMCID: PMC9519412 DOI: 10.3164/jcbn.22-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 01/29/2022] [Indexed: 12/03/2022] Open
Abstract
To clarify the frequency of hypoglycemia in patients with type 1 diabetes mellitus receiving dapagliflozin combination therapy to reduce their basal insulin dose. Sixty subjects were assigned to two groups according to their basal insulin-to-total daily dose (TDD) ratio: group A (basal insulin/TDD <40%) and group B (≥40%). Reduction of the basal insulin dose was instituted in group B, but not in group A. The number of hypoglycemic events per day and ketosis frequency were the primary and secondary endpoints, respectively. The hypoglycemia frequency before and after the intervention was 0.23 and 0.26 times/day in group A and 0.19 and 0.23 times/day in group B, respectively, with no significant difference between the groups. The total insulin dose reduction was approximately 10% in both groups. Ketosis frequency increased significantly after the intervention (from 0.013 to 0.086 times/day in group A and 0.013 to 0.059 times/day in group B). Time-in-range, mean amplitude of glycemic excursion, and glycated hemoglobin A1c improved in both groups. No significant difference in hypoglycemia frequency was observed between patients with and without reduction of the basal insulin dose. The combination therapy improved glycemic control and patient satisfaction regarding hyperglycemia. Nevertheless, adequate attention to ketosis is crucial.
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Affiliation(s)
- Masahide Hamaguchi
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine
| | - Yuta Yoshimura
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine
| | - Hanako Nakajima
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine
| | - Toru Tanaka
- Department of Diabetes and Endocrinology, Japanese Red Cross Kyoto Daiichi Hospital
| | - Goji Hasegawa
- Division of Metabolism, Nephrology and Rheumatology, Japanese Red Cross Kyoto Daini Hospital
| | | | - Hiroshi Okada
- Department of Diabetes and Endocrinology, Matsushita Memorial Hospital
| | | | | | - Takuro Okamura
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine
| | - Yoshitaka Hashimoto
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine
| | - Saori Majima
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine
| | - Takafumi Senmaru
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine
| | - Emi Ushigome
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine
| | - Naoko Nakanishi
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine
| | - Mai Asano
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine
| | - Masahiro Yamazaki
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine
| | - Michiaki Fukui
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine
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Hughes MS, Bailey R, Calhoun P, Shah VN, Lyons SK, DeSalvo DJ. Off-label use of sodium glucose co-transporter inhibitors among adults in type 1 diabetes exchange registry. Diabetes Obes Metab 2022; 24:171-173. [PMID: 34545988 DOI: 10.1111/dom.14556] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/10/2021] [Accepted: 09/17/2021] [Indexed: 12/11/2022]
Affiliation(s)
| | - Ryan Bailey
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Peter Calhoun
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Viral N Shah
- Barbara Davis Center for Diabetes, University of Colorado, Denver, Colorado, USA
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Shimoda M, Mashiko A, Katakura Y, Sanada J, Fushimi Y, Obata A, Kimura T, Kohara K, Tatsumi F, Nakanishi S, Mune T, Kaku K, Kaneto H. Efficacy and safety of adding ipragliflozin to insulin in Japanese patients with type 1 diabetes mellitus: a retrospective study. Endocr J 2021; 68:1455-1461. [PMID: 34334532 DOI: 10.1507/endocrj.ej21-0161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Advances in insulin preparations and administration methods have produced a gradual improvement in glycemic control in patients with type 1 diabetes mellitus (DM). Nevertheless, glycated hemoglobin (HbA1c) levels in patients with type 1 DM are still poor compared to those in patients with type 2 DM. Here, we sought to assess the efficacy and safety of the sodium-glucose cotransporter 2 (SGLT2) inhibitor ipragliflozin (IPRA) in patients with type 1 DM. This study was retrospectively conducted with data from type 1 DM patients who had a history of IPRA therapy. The primary endpoint was HbA1c level at 24 weeks. The baseline characteristics of a total of 12 subjects were as follows: age, 50.1 ± 13.2 years; diabetes duration, 17.3 ± 10.5 years; body mass index (BMI), 22.9 ± 2.1 kg/m2; HbA1c, 8.8 ± 1.3%; and daily insulin dose, 0.60 ± 0.21 units/kg. IPRA decreased HbA1c levels to 8.2 ± 1.2% (p < 0.05) and reduced insulin dose to 0.52 ± 0.17 units/kg (p < 0.01) after 24 weeks. HbA1c value was particularly reduced in subjects with preserved C-peptide index. IPRA significantly reduced body weight by -1.4 ± 1.4 kg (p < 0.01) 16 weeks after starting treatment, with no further weight loss after 24 weeks. There were no instances of diabetic ketoacidosis or severe hypoglycemia. IPRA exerted beneficial effects on glycemic control without any severe adverse effects, and should be safe and effective when used in patients with type 1 DM with understanding of correspondence in sick day.
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Affiliation(s)
- Masashi Shimoda
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki 701-0192, Japan
| | - Akiko Mashiko
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki 701-0192, Japan
| | - Yukino Katakura
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki 701-0192, Japan
| | - Junpei Sanada
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki 701-0192, Japan
| | - Yoshiro Fushimi
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki 701-0192, Japan
| | - Atsushi Obata
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki 701-0192, Japan
| | - Tomohiko Kimura
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki 701-0192, Japan
| | - Kenji Kohara
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki 701-0192, Japan
| | - Fuminori Tatsumi
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki 701-0192, Japan
| | - Shuhei Nakanishi
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki 701-0192, Japan
| | - Tomoatsu Mune
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki 701-0192, Japan
| | - Kohei Kaku
- Kawasaki Medical School, Kurashiki 701-0192, Japan
| | - Hideaki Kaneto
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki 701-0192, Japan
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Ribeiro J. Diastolic dysfunction and type 1 diabetes: A sweet link? Rev Port Cardiol 2021; 40:767-769. [PMID: 34857115 DOI: 10.1016/j.repce.2021.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- José Ribeiro
- Cardiology Department, Gaia/Espinho Hospital Center, Vila Nova de Gaia, Portugal.
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Dejgaard TF, von Scholten BJ, Christiansen E, Kreiner FF, Bardtrum L, von Herrath M, Mathieu C, Madsbad S. Efficacy and safety of liraglutide in type 1 diabetes by baseline characteristics in the ADJUNCT ONE and ADJUNCT TWO randomized controlled trials. Diabetes Obes Metab 2021; 23:2752-2762. [PMID: 34463425 PMCID: PMC9292057 DOI: 10.1111/dom.14532] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/10/2021] [Accepted: 08/24/2021] [Indexed: 12/21/2022]
Abstract
AIM To evaluate 26 weeks of liraglutide treatment in type 1 diabetes (T1D) by subgroups in the ADJUNCT ONE and ADJUNCT TWO trials. MATERIALS AND METHODS ADJUNCT ONE and ADJUNCT TWO were randomized controlled phase 3 trials in 1398 and 835 participants with T1D treated with liraglutide (1.8, 1.2, or 0.6 mg) or placebo (adjuncts to insulin). This post hoc analysis evaluated treatment effects by subgroups: HbA1c (< or ≥8.5%), body mass index (BMI; < or ≥27 kg/m2 ), and insulin regimen (basal bolus or continuous subcutaneous insulin infusion). RESULTS In both trials at week 26, reductions in HbA1c, body weight, and daily insulin dose did not differ significantly (P > .05) by baseline HbA1c or BMI. Risk of clinically significant hypoglycaemia or hyperglycaemia with ketosis did not differ significantly (P > .05) by baseline HbA1c, BMI, or insulin regimen. At week 26 in ADJUNCT ONE, these risks did not differ (P > .05) between treatment groups. Placebo-adjusted reductions in HbA1c, body weight, and insulin dose (-0.30%-points, -5.0 kg, and -12%, respectively, with liraglutide 1.8 mg), were significant (P < .05), greater than at week 52, and similar to those in ADJUNCT TWO (-0.35%, -4.8 kg, and -10%, respectively, with liraglutide 1.8 mg). CONCLUSIONS In ADJUNCT ONE and ADJUNCT TWO, the efficacy and glycaemic safety of liraglutide did not depend on subgroups, leaving residual beta-cell function as the only identified variable impacting the effect of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in T1D. These findings support a role for GLP-1 RAs as adjuncts to insulin in T1D, warranting further study.
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Affiliation(s)
| | | | | | | | | | | | | | - Sten Madsbad
- Hvidovre University Hospital, University of CopenhagenHvidovreDenmark
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82
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Cherney DZI, Ferrannini E, Umpierrez GE, Peters AL, Rosenstock J, Carroll AK, Lapuerta P, Banks P, Agarwal R. Efficacy and safety of sotagliflozin in patients with type 2 diabetes and severe renal impairment. Diabetes Obes Metab 2021; 23:2632-2642. [PMID: 34338408 DOI: 10.1111/dom.14513] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/27/2021] [Accepted: 07/29/2021] [Indexed: 11/28/2022]
Abstract
AIMS To assess the efficacy and safety of sotagliflozin, a dual inhibitor of sodium-glucose cotransporter-1 and -2, in adults with type 2 diabetes (T2D) and stage 4 chronic kidney disease (CKD4). MATERIALS AND METHODS This 52-week, phase 3, randomized (1:1:1), placebo-controlled trial evaluated sotagliflozin 200 mg and sotagliflozin 400 mg once daily in 277 patients with T2D and estimated glomerular filtration rate (eGFR) 15 to 30 mL/min/1.73 m2 . The primary endpoint was glycated haemoglobin (HbA1c) reduction with sotagliflozin 400 mg versus placebo at 26 weeks. A hierarchical statistical testing approach was used. RESULTS The baseline mean HbA1c was 65 ± 12 mmol/mol (8.1% ± 1.1%), systolic blood pressure (SBP) was 144 ± 15 mmHg, and eGFR was 24 ± 4 mL/min/1.73m2 . Placebo-adjusted changes with sotagliflozin 400 mg were -3 mmol/mol (-0.3%; 95% confidence interval -7 to 0.6 [-0.6 to 0.05]; P = 0.096) and -8 mmol/mol (-0.7%; -13 to -3 [-1.2 to -0.2]; P = 0.003) in HbA1c at Weeks 26 and 52, respectively, -1.5 kg (-3.0 to -0.1) in body weight at Week 26, -5.4 mmHg (-9.4 to -1.3) in SBP at Week 12, and -0.3 mL/min/1.73 m2 (-2.1 to 1.6; P = 0.776) in eGFR at Week 52. Over 52 weeks, 11.8%, 5.4% and 3.3% of patients receiving placebo and sotagliflozin 200 and 400 mg, respectively, required rescue therapy for hyperglycaemia. Adverse events (AEs) occurred in 82.8%, 86.2% and 81.1% of patients and serious cardiovascular AEs occurred in 12.9%, 3.2% and 4.4% of patients in the placebo and sotagliflozin 200 and 400 mg groups, respectively. CONCLUSIONS After 26 weeks, HbA1c reductions with sotagliflozin were not statistically significant versus placebo in adults with T2D and CKD4. The 52-week safety profile was consistent with results of the SCORED outcomes trial (NCT03242018).
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Affiliation(s)
| | | | | | - Anne L Peters
- Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Julio Rosenstock
- Dallas Diabetes Research Center at Medical City, Dallas, Texas, USA
| | - Amy K Carroll
- Lexicon Pharmaceuticals, Inc., The Woodlands, Texas, USA
| | - Pablo Lapuerta
- Lexicon Pharmaceuticals, Inc., The Woodlands, Texas, USA
| | - Phillip Banks
- Lexicon Pharmaceuticals, Inc., The Woodlands, Texas, USA
| | - Rajiv Agarwal
- Indiana University School of Medicine, Indianapolis, Indiana, USA
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Pietschner R, Kolwelter J, Bosch A, Striepe K, Jung S, Kannenkeril D, Ott C, Schiffer M, Achenbach S, Schmieder RE. Effect of empagliflozin on ketone bodies in patients with stable chronic heart failure. Cardiovasc Diabetol 2021; 20:219. [PMID: 34753480 PMCID: PMC8579532 DOI: 10.1186/s12933-021-01410-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 10/27/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Recent studies indicated that sodium glucose cotransporter (SGLT)2 inhibition increases levels of ketone bodies in the blood in patients with type 1 and 2 diabetes. Other studies suggested that in patients with chronic heart failure (CHF), increased myocardial oxygen demand can be provided by ketone bodies as a fuel substrate. Experimental studies reported that ketone bodies, specifically beta-hydroxybutyrate (β-OHB) may increase blood pressure (BP) by impairing endothelium-dependant relaxation, thereby leading to increased vascular stiffness. In our study we assessed whether the SGLT 2 inhibition with empagliflozin increases ketone bodies in patients with stable CHF and whether such an increase impairs BP and vascular function. METHODS In a prospective, double blind, placebo controlled, parallel-group single centre study 75 patients with CHF (left ventricular ejection fraction 39.0 ± 8.2%) were randomised (2:1) to the SGLT-2 inhibitor empagliflozin 10 mg orally once daily or to placebo, 72 patients completed the study. After a run-in phase we evaluated at baseline BP by 24 h ambulatory blood pressure (ABP) monitoring, vascular stiffness parameters by the SphygmoCor system (AtCor Medical, Sydney, NSW, Australia) and fasting metabolic parameters, including β-OHB by an enzymatic assay (Beckman Coulter DxC 700 AU). The same measurements were repeated 12 weeks after treatment. In 19 of the 72 patients serum levels of β-OHB were beneath the lower border of our assay (< 0.05 mmol/l) therefore being excluded from the subsequent analysis. RESULTS In patients with stable CHF, treatment with empagliflozin (n = 36) was followed by an increase of β-OHB by 33.39% (p = 0.017), reduction in 24 h systolic (p = 0.038) and diastolic (p = 0.085) ABP, weight loss (p = 0.003) and decrease of central systolic BP (p = 0.008) and central pulse pressure (p = 0.008). The increase in β-OHB was related to an attenuated decrease of empagliflozin-induced 24 h systolic (r = 0.321, p = 0.069) and diastolic (r = 0.516, p = 0.002) ABP and less reduction of central systolic BP (r = 0.470, p = 0.009) and central pulse pressure (r = 0.391, p = 0.033). No significant changes were seen in any of these parameters after 12 weeks of treatment in the placebo group (n = 17). CONCLUSION In patients with stable CHF ketone bodies as assessed by β-OHB increased after treatment with empagliflozin. This increase led to an attenuation of the beneficial effects of empagliflozin on BP and vascular parameters. Trial registration The study was registered at http://www.clinicaltrials.gov (NCT03128528).
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Affiliation(s)
- R Pietschner
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany
| | - J Kolwelter
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany
- Department of Cardiology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - A Bosch
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany
| | - K Striepe
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany
| | - S Jung
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany
- Department of Cardiology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - D Kannenkeril
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany
| | - C Ott
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany
- Department of Nephrology and Hypertension, Paracelsus Medical University, Nuremberg, Germany
| | - M Schiffer
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany
| | - S Achenbach
- Department of Cardiology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - R E Schmieder
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany.
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Pinnaro CT, Tansey MJ. The Evolution of Insulin Administration in Type 1 Diabetes. JOURNAL OF DIABETES MELLITUS 2021; 11:249-277. [PMID: 37745178 PMCID: PMC10516284 DOI: 10.4236/jdm.2021.115021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
Insulin has been utilized in the treatment of type 1 diabetes (T1D) for 100 years. While there is still no cure for T1D, insulin administration has undergone a remarkable evolution which has contributed to improvements in quality of life and life expectancy in individuals with T1D. The advent of faster-acting and longer-acting insulins allowed for the implementation of insulin regimens more closely resembling normal insulin physiology. These improvements afforded better glycemic control, which is crucial for limiting microvascular complications and improving T1D outcomes. Suspension of insulin delivery in response to actual and forecasted hypoglycemia has improved quality of life and mitigated hypoglycemia without compromising glycemic control. Advances in continuous glucose monitoring (CGM) and insulin pumps, efforts to model glucose and insulin kinetics, and the application of control theory to T1D have made the automation of insulin delivery a reality. This review will summarize the past, present, and future of insulin administration in T1D.
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Affiliation(s)
- Catherina T Pinnaro
- University of Iowa Stead Family Department of Pediatrics
- Fraternal Order of Eagles Diabetes Research Center
| | - Michael J Tansey
- University of Iowa Stead Family Department of Pediatrics
- Fraternal Order of Eagles Diabetes Research Center
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Abstract
Automated insulin delivery (AID) is the most recent advance in type 1 diabetes (T1D) management. It has the potential to achieve glycemic targets without disabling hypoglycemia, to improve quality of life and reduce diabetes distress and burden associated with self-management. Several AID systems are currently licensed for use by people with T1D in Europe, United States, and the rest of the world. Despite AID becoming a reality in routine clinical practice over the last few years, the commercially hybrid AID and other systems, are still far from a fully optimized automated diabetes management tool. Implementation of AID systems requires education and support of healthcare professionals taking care of people with T1D, as well as users and their families. There is much to do to increase usability, portability, convenience and to reduce the burden associated with the use of the systems. Co-design, involvement of people with lived experience of T1D and robust qualitative assessment is critical to improving the real-world use of AID systems, especially for those who may have greater need. In addition to this, information regarding the psychosocial impact of the use of AID systems in real life is needed. The first commercially available AID systems are not the end of the development journey but are the first step in learning how to optimally automate insulin delivery in a way that is equitably accessible and effective for people living with T1D.
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Affiliation(s)
- Marga Giménez
- Diabetes Unit, Endocrinology and
Nutrition Department, Hospital Clínic i Universitari, Barcelona, Spain
- CIBERDEM, Centro de Investigación
Biomédica en Red de Diabetes y Enfermedades Metabólicas, Madrid, Spain
- IDIBAPS, Institut
d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Ignacio Conget
- Diabetes Unit, Endocrinology and
Nutrition Department, Hospital Clínic i Universitari, Barcelona, Spain
- CIBERDEM, Centro de Investigación
Biomédica en Red de Diabetes y Enfermedades Metabólicas, Madrid, Spain
- IDIBAPS, Institut
d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Nick Oliver
- Department of Metabolism,
Digestion and Reproduction, Faculty of Medicine, Imperial College London,
London, UK
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86
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van Meijel LA, Tack CJ, de Galan BE. Effect of short-term use of dapagliflozin on impaired awareness of hypoglycaemia in people with type 1 diabetes. Diabetes Obes Metab 2021; 23:2582-2589. [PMID: 34338413 PMCID: PMC9292159 DOI: 10.1111/dom.14505] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 07/11/2021] [Accepted: 07/26/2021] [Indexed: 12/12/2022]
Abstract
AIM Impaired awareness of hypoglycaemia (IAH) affects about 25% of patients with type 1 diabetes (T1DM). IAH can be reversed by strict avoidance of hypoglycaemia for at least 3 weeks. Adjunctive treatment with sodium glucose cotransporter 2 inhibitors may reduce the risk of hypoglycaemia through reduction of glucose variability. We tested the hypothesis that short-term use of dapagliflozin may improve awareness of hypoglycaemia in people with T1DM and IAH. MATERIALS AND METHODS Fifteen patients with T1DM and IAH were included in this randomized double-blind, placebo-controlled cross-over trial (age 49.7 ± 14.6 years, 40% men, disease duration 24.1 ± 14.2 years, glycated haemoglobin 7.5 ± 0.8% (58.6 ± 8.4 mmol/mol). They were treated with dapagliflozin 10 mg once daily or matching placebo, with a washout period of 2 weeks. At the end of each treatment period, participants underwent a modified hyperinsulinaemic normoglycaemic-hypoglycaemic glucose clamp (glucose nadir 2.5 mmol/L). Blinded continuous glucose monitors were used in the final treatment weeks. RESULTS Treatment with dapagliflozin significantly improved glycated haemoglobin [-0.32 ± 0.10 vs. 0.22 ± 0.13% (-4.1 ± 0.9 vs. 2.3 ± 1.4 mmol/mol), dapagliflozin vs. placebo, p = .007] and glucose variability (standard deviation, 2.6 ± 0.2 vs. 3.1 ± 0.3 mmol/L, p = .029), but did not affect the frequency of hypoglycaemia. During the hypoglycaemic clamp, dapagliflozin did not affect symptom responses (8.0 ± 3.4 vs. 5.2 ± 1.6, p = .31), but significantly reduced the need for exogenous glucose to maintain hypoglycaemia (3.2 ± 0.3 vs. 4.1 ± 0.4 mg/kg/min, p = .022). CONCLUSIONS Eight weeks of treatment with dapagliflozin did not restore hypoglycaemic awareness in people with T1DM and impaired awareness of hypoglycaemia, but ameliorated some clinical aspects.
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Affiliation(s)
- Lian A. van Meijel
- Department of Internal MedicineRadboud University Medical CenterNijmegenThe Netherlands
- Department of Internal MedicineMaxima Medical CenterVeldhovenThe Netherlands
| | - Cees J. Tack
- Department of Internal MedicineRadboud University Medical CenterNijmegenThe Netherlands
| | - Bastiaan E. de Galan
- Department of Internal MedicineRadboud University Medical CenterNijmegenThe Netherlands
- Department of Internal MedicineMaastricht University Medical CenterMaastrichtThe Netherlands
- CARIM School for Cardiovascular DiseasesMaastricht UniversityMaastrichtThe Netherlands
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87
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Liu H, Sridhar VS, Montemayor D, Lovblom LE, Lytvyn Y, Ye H, Kim J, Ali MT, Scarr D, Lawler PR, Perkins BA, Sharma K, Cherney DZI. Changes in plasma and urine metabolites associated with empagliflozin in patients with type 1 diabetes. Diabetes Obes Metab 2021; 23:2466-2475. [PMID: 34251085 DOI: 10.1111/dom.14489] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 07/01/2021] [Accepted: 07/01/2021] [Indexed: 02/06/2023]
Abstract
AIM To examine the impact of the sodium-glucose co-transporter-2 inhibitor, empagliflozin, on plasma and urine metabolites in participants with type 1 diabetes. MATERIAL AND METHODS Participants (n = 40, 50% male, mean age 24.3 years) with type 1 diabetes and without overt evidence of diabetic kidney disease had baseline assessments performed under clamped euglycaemia and hyperglycaemia, on two consecutive days. Participants then proceeded to an 8-week, open-label treatment period with empagliflozin 25 mg/day, followed by repeat assessments under clamped euglycaemia and hyperglycaemia. Plasma and urine metabolites were first grouped into metabolic pathways using MetaboAnalyst software. Principal component analysis was performed to create a representative value for each sufficiently represented metabolic group (false discovery rate ≤ 0.1) for further analysis. RESULTS Of the plasma metabolite groups, tricarboxylic acid (TCA) cycle (P < .0001), biosynthesis of unsaturated fatty acids (P = .0045), butanoate (P < .0001), propanoate (P = .0053), and alanine, aspartate and glutamate (P < .0050) metabolites were increased after empagliflozin treatment under clamped euglycaemia. Of the urine metabolite groups, only butanoate metabolites (P = .0005) were significantly increased. Empagliflozin treatment also attenuated the increase in a number of urine metabolites observed with acute hyperglycaemia. CONCLUSIONS Empagliflozin was associated with increased lipid and TCA cycle metabolites in participants with type 1 diabetes, suggesting a shift in metabolic substrate use and improved mitochondrial function. These effects result in more efficient energy production and may contribute to end-organ protection by alleviating local hypoxia and oxidative stress.
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Affiliation(s)
- Hongyan Liu
- Toronto General Hospital Research Institute, UHN, Toronto, Ontario, Canada
- Department of Medicine, Division of Nephrology, UHN, Toronto, Ontario, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Vikas S Sridhar
- Toronto General Hospital Research Institute, UHN, Toronto, Ontario, Canada
- Department of Medicine, Division of Nephrology, UHN, Toronto, Ontario, Canada
- Department of Medicine, Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
- Banting and Best Diabetes Centre, Toronto, Ontario, Canada
| | - Daniel Montemayor
- Center for Renal Precision Medicine, Division of Nephrology, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Leif Erik Lovblom
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Yuliya Lytvyn
- Toronto General Hospital Research Institute, UHN, Toronto, Ontario, Canada
- Department of Medicine, Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Hongping Ye
- Center for Renal Precision Medicine, Division of Nephrology, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Jiwan Kim
- Center for Renal Precision Medicine, Division of Nephrology, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Mir Tariq Ali
- Center for Renal Precision Medicine, Division of Nephrology, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Daniel Scarr
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- Ted Rogers Centre for Heart Research, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bruce A Perkins
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kumar Sharma
- Center for Renal Precision Medicine, Division of Nephrology, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - David Z I Cherney
- Toronto General Hospital Research Institute, UHN, Toronto, Ontario, Canada
- Department of Medicine, Division of Nephrology, UHN, Toronto, Ontario, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
- Banting and Best Diabetes Centre, Toronto, Ontario, Canada
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
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88
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Staplin N, Roddick AJ, Emberson J, Reith C, Riding A, Wonnacott A, Kuverji A, Bhandari S, Baigent C, Haynes R, Herrington WG. Net effects of sodium-glucose co-transporter-2 inhibition in different patient groups: a meta-analysis of large placebo-controlled randomized trials. EClinicalMedicine 2021; 41:101163. [PMID: 34765951 PMCID: PMC8571171 DOI: 10.1016/j.eclinm.2021.101163] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/17/2021] [Accepted: 09/30/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The net absolute effects of sodium-glucose co-transporter-2 (SGLT-2) inhibitors across different patient groups have not been quantified. METHODS We performed a meta-analysis of published large (>500 participants/arm) placebo-controlled SGLT-2 inhibitor trials after systematically searching MEDLINE and Embase databases from inception to 28th August 2021 (PROSPERO 2021 CRD42021240468). FINDINGS Four heart failure trials (n=15,684 participants), four trials in type 2 diabetes mellitus at high atherosclerotic cardiovascular risk (n=42,568), and three trials in chronic kidney disease (n=19,289) were included. Relative risks (RRs) for all cardiovascular, renal and safety outcomes were broadly similar across these three patient groups, and between people with or without diabetes. Overall, compared to placebo, allocation to SGLT-2 inhibition reduced risk of hospitalization for heart failure or cardiovascular death by 23% (RR=0.77, 95%CI 0.73-0.80; n=6658), cardiovascular death by 14% (0.86, 0.81-0.92; n=3962), major adverse cardiovascular events by 11% (0.89, 0.84-0.94; n=5703), kidney disease progression by 36% (0.64, 0.59-0.70; n=2275), acute kidney injury by 30% (0.70, 0.62-0.79; n=1013 events) and severe hypoglycaemia by 13% (0.87, 0.79-0.97; n=1484). There was no effect of SGLT-2 inhibition on risk of non-cardiovascular death (0.93, 0.86-1.01; n=2226), but a net 12% reduction in all-cause mortality remained evident (0.88, 0.84-0.93; n=6188). However, the risk of ketoacidosis was 2-times higher among those allocated SGLT-2 inhibitors compared to placebo (2.03, 1.41-2.93; n=159; absolute excess in people with diabetes ∼0.3/1000 patient years). A small increased risk of urinary tract infection was evident (1.07, 1.02-1.13; n=5384) alongside a known increased risk of mycotic genital infections. Overall, risk of lower limb amputations was increased by 16% (1.16, 1.02-1.31; n=1074), but this risk was largely driven by a single outlying trial (CANVAS). INTERPRETATIONS The relative effects of SGLT-2 inhibition on key safety and efficacy outcomes are consistent across the different studied groups of patient. Consequently, absolute benefits and harms are determined by the absolute baseline risk of particular outcomes, with absolute benefits on mortality and on non-fatal serious cardiac/renal outcomes substantially exceeding the risks of amputation and ketoacidosis in the main patient groups studied to date. FUNDING MRC-UK & KRUK.
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Affiliation(s)
- Natalie Staplin
- Medical Research Council Population Health Research Unit at the University of Oxford, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK
| | - Alistair J. Roddick
- Medical Research Council Population Health Research Unit at the University of Oxford, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
| | - Jonathan Emberson
- Medical Research Council Population Health Research Unit at the University of Oxford, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK
| | - Christina Reith
- Medical Research Council Population Health Research Unit at the University of Oxford, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
| | - Alex Riding
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Apexa Kuverji
- John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester, Leicester, UK
| | - Sunil Bhandari
- Hull University Teaching Hospitals NHS Trust and Hull York Medical School, Hull, UK
| | - Colin Baigent
- Medical Research Council Population Health Research Unit at the University of Oxford, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
| | - Richard Haynes
- Medical Research Council Population Health Research Unit at the University of Oxford, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
- Oxford Kidney Unit, Churchill Hospital, Oxford, UK
| | - William G Herrington
- Medical Research Council Population Health Research Unit at the University of Oxford, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
- Oxford Kidney Unit, Churchill Hospital, Oxford, UK
- Health Data Research UK, University of Oxford, Oxford, UK
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Pasqua MR, Tsoukas MA, Haidar A. Strategically Playing with Fire: SGLT Inhibitors as Possible Adjunct to Closed-Loop Insulin Therapy. J Diabetes Sci Technol 2021; 15:1232-1242. [PMID: 34558336 PMCID: PMC8655283 DOI: 10.1177/19322968211035411] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
As closed-loop insulin therapies emerge into clinical practice and evolve in medical research for type 1 diabetes (T1D) treatment, the limitations in these therapies become more evident. These gaps include unachieved target levels of glycated hemoglobin in some patients, postprandial hyperglycemia, the ongoing need for carbohydrate counting, and the lack of non-glycemic benefits (such as prevention of metabolic syndrome and complications). Multiple adjunct therapies have been examined to improve closed-loop systems, yet none have become a staple. Sodium-glucose-linked cotransporter inhibitors (SGLTi's) have been extensively researched in T1D, with average reductions in placebo-adjusted HbA1c by 0.39%, and total daily dose by approximately 10%. Unfortunately, many trials revealed an increased risk of diabetic ketoacidosis, as high as 5 times the relative risk compared to placebo. This narrative review discusses the proven benefits and risks of SGLTi in patients with T1D with routine therapy, what has been studied thus far in closed-loop therapy in combination with SGLTi, the potential benefits of SGLTi use to closed-loop systems, and what is required going forward to improve the benefit to risk ratio in these insulin systems.
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Affiliation(s)
- Melissa-Rosina Pasqua
- Division of Endocrinology, McGill
University Health Centre, Montreal, QC, Canada
- Melissa-Rosina Pasqua, MD, Mailing address:
McGill University Health Centre, 1001 boulevard de Décarie, Montreal, QC H4A
3J1, Canada.
| | - Michael A. Tsoukas
- Division of Endocrinology, McGill
University Health Centre, Montreal, QC, Canada
| | - Ahmad Haidar
- Department of Biomedical Engineering,
McGill University, Montreal, QC, Canada
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90
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Cherney DZ, Bjornstad P, Perkins BA, Rosenstock J, Neubacher D, Marquard J, Soleymanlou N. Kidney Effects of Empagliflozin in People with Type 1 Diabetes. Clin J Am Soc Nephrol 2021; 16:1715-1719. [PMID: 34535454 PMCID: PMC8729416 DOI: 10.2215/cjn.07700621] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- David Z.I. Cherney
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Petter Bjornstad
- University of Colorado Anschutz Medical Campus, Denver, Colorado
| | - Bruce A. Perkins
- Lunenfeld–Tanenbaum Research Institute, Mount Sinai Hospital and the Division of Endocrinology, University of Toronto, Toronto, Ontario, Canada
| | | | - Dietmar Neubacher
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany
| | - Jan Marquard
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut
| | - Nima Soleymanlou
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut
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91
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Comparative efficacy of empagliflozin versus placebo in the treatment of type 1 diabetes mellitus: a meta-analysis of randomized controlled trials. CURRENT ISSUES IN PHARMACY AND MEDICAL SCIENCES 2021. [DOI: 10.2478/cipms-2021-0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
The objective of this meta-analysis study was to evaluate the comparative efficacy of empagliflozin (25 mg) with placebo in the treatment and management of type 1 diabetes mellitus. This study is a meta-analysis, so an ethical statement is not required. Different databases and individual journal websites like SCOPUS, Science direct, Cochrane review library etc. were used. The articles were evaluated based on the search and eligibility criteria. A total of five RCTs were incorporated in this meta-analysis. These studies contained a total of 1058 patients, including 526 patients with placebo (or control-treated patients), and 532 patients with empagliflozin (25 mg) treated combination. The mean follow-up time ranged from 7 days to 6 months. Overall, mean reduction in placebo was -0.50% and empa-treated was -0.85%, while the pooled WMD was 3.82 995% CI 1.20 – 5.88, p=0.0001). Regarding urinary glucose excretion, that the pooled WMD was 6.67 (95% CI 4.87-10.14, p=0.001) indicated a significant increase in empa-arm compared to placebo. No heterogeneity was found (I2 – 15.03%). This meta-analysis underlined the therapeutic benefit of empagliflozin as an adjunctive therapy for patients with type 1 diabetes.
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Hamaguchi M, Hashimoto Y, Tanaka T, Hasegawa G, Ishii M, Okada H, Mitsuhashi K, Kitagawa N, Ushigome E, Yamazaki M, Fukui M. Multicenter, Open-Label, 2-Arm, Pilot Trial for Safe Reduction of Basal Insulin Dose Combined with SGLT2 Inhibitor in Type 1 Diabetes Mellitus: Study Protocol for a RISING-STAR Trial. Clin Med Insights Endocrinol Diabetes 2021; 14:11795514211040539. [PMID: 34602832 PMCID: PMC8482353 DOI: 10.1177/11795514211040539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 07/23/2021] [Indexed: 01/27/2023] Open
Abstract
Background: The safe method of instructing insulin dose reduction in combination with
SGLT2 inhibitors, dapagliflozin for patients with type 1 diabetes mellitus
has not been clarified. In this study, we conducted a stratified, 2-arm,
parallel comparative study with the primary endpoint of decreasing the
frequency of hypoglycemia by instructing basal insulin dose reduction. Methods: The study has a multicenter, open-label, 2-arm design; 60 type 1 diabetes
mellitus patients are being recruited from 7 hospitals. Study subjects have
been stratified into 2 groups based on the ratio of basal insulin daily dose
(Basal) to total daily insulin dose (TDD). The subjects whose Basal/TDD
ratio is <0.4 are instructed not to reduce Basal but to reduce bolus
insulin dose by 10% (group A), and subjects with a Basal/TDD ratio >0.4
will be instructed to reduce Basal by 10% (group B). The primary outcome is
the daily frequency of hypoglycemia during the intervention period (SGLT2
inhibitor administration), as determined by self-monitoring of blood
glucose. We aimed to confirm a greater reduction in frequency of
hypoglycemia in group B (reduced Basal), than in group A (non-reduction of
Basal and reduced insulin effect levels by 10%). Baseline hypoglycemia was
set at 7 ± 6 times/month. The minimum sample size required to achieve a
significance of .05 for a 1-sided t-test with a statistical
power at 80% is determined. When the sample size is 26 patients in 1 group,
the percentage increase in hypoglycemia exceeds 60%, and the sample size is
considered sufficient. Discussion: In this pilot study, we assumed that, given a sufficient Basal, hypoglycemia
would be more frequent in patients with type 1 diabetes when combined with
SGLT2 inhibitors, provided the Basal was not reduced.
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Affiliation(s)
- Masahide Hamaguchi
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoshitaka Hashimoto
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Toru Tanaka
- Department of Diabetes and Endocrinology, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Goji Hasegawa
- Division of Metabolism, Nephrology and Rheumatology, Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan
| | - Michiyo Ishii
- Department of Internal Medicine, Otsu City Hospital, Otsu, Japan
| | - Hiroshi Okada
- Department of Diabetes and Endocrinology, Matsushita Memorial Hospital, Moriguchi, Japan
| | - Kazuteru Mitsuhashi
- Department of Diabetes and Internal Medicine, Fukuchiyama City Hospital, Fukuchiyama, Japan
| | - Noriyuki Kitagawa
- Department of Diabetology, Kameoka Municipal Hospital, Kameoka, Japan
| | - Emi Ushigome
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masahiro Yamazaki
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Michiaki Fukui
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Kyoto, Japan
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93
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Horii T, Oikawa Y, Atsuda K, Shimada A. On-label use of sodium-glucose cotransporter 2 inhibitors might increase the risk of diabetic ketoacidosis in patients with type 1 diabetes. J Diabetes Investig 2021; 12:1586-1593. [PMID: 33448127 PMCID: PMC8409873 DOI: 10.1111/jdi.13506] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 12/16/2020] [Accepted: 01/08/2021] [Indexed: 01/10/2023] Open
Abstract
AIMS/INTRODUCTION This study aimed to investigate the risk of diabetic ketoacidosis (DKA) in insulin-treated type 1 diabetes patients administered sodium-glucose cotransporter 2 (SGLT2) inhibitors in real-world clinical practice. MATERIALS AND METHODS We carried out a real-world, retrospective, observational cohort study using Japanese Medical Data Vision, a diagnosis procedure combination database. We identified insulin-treated adult type 1 diabetes patients enrolled from December 2018 to October 2019. We assessed the incidence and risk of DKA in type 1 diabetes patients using SGLT2 inhibitors in an 'on-label' manner. Cox multivariate regression analyses were carried out to determine clinical factors linked to SGLT2 inhibitor-associated DKA. RESULTS Of 11,475 type 1 diabetes patients, 1,898 (16.5%) were prescribed SGLT2 inhibitors. DKA occurred in 139 (7.3%) of these patients, with 20.2 incidences per 100 person-years. These patients also showed significantly higher DKA rates than did those not receiving SGLT2 inhibitors (hazard ratio 1.66, 95% confidence interval 1.33-2.06; P < 0.001). The mean time until DKA onset in SGLT2 inhibitor-treated type 1 diabetes patients was 30.6 ± 30.1 days. The risk of SGLT2 inhibitor-associated DKA increased in type 1 diabetes patients irrespective of sex, age or body mass index. However, the risk did not increase in type 1 diabetes patients receiving continuous subcutaneous insulin infusion, which warrants further investigation because of the small number of type 1 diabetes patients receiving continuous subcutaneous insulin infusion. CONCLUSIONS 'On-label' SGLT2 inhibitor use might increase DKA risk among insulin-treated type 1 diabetes patients irrespective of sex, age or body mass index. Both type 1 diabetes patients and healthcare providers should be wary of DKA, especially during the first month of initiating SGLT2 inhibitors.
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Affiliation(s)
- Takeshi Horii
- Laboratory of Pharmacy Practice and Science 1Division of Clinical Pharmacy, Research and Education Center for Clinical PharmacyKitasato University School of PharmacyKanagawaJapan
| | - Yoichi Oikawa
- Department of Endocrinology and DiabetesSchool of MedicineSaitama Medical UniversitySaitamaJapan
| | - Koichiro Atsuda
- Laboratory of Pharmacy Practice and Science 1Division of Clinical Pharmacy, Research and Education Center for Clinical PharmacyKitasato University School of PharmacyKanagawaJapan
| | - Akira Shimada
- Department of Endocrinology and DiabetesSchool of MedicineSaitama Medical UniversitySaitamaJapan
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94
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Ribeiro J. Diastolic dysfunction and type 1 diabetes: A sweet link? Rev Port Cardiol 2021; 40:S0870-2551(21)00350-4. [PMID: 34462171 DOI: 10.1016/j.repc.2021.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- José Ribeiro
- Cardiology Department, Gaia/Espinho Hospital Center, Vila Nova de Gaia, Portugal.
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95
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Chen H, Birnbaum Y, Ye R, Yang HC, Bajaj M, Ye Y. SGLT2 Inhibition by Dapagliflozin Attenuates Diabetic Ketoacidosis in Mice with Type-1 Diabetes. Cardiovasc Drugs Ther 2021; 36:1091-1108. [PMID: 34448973 DOI: 10.1007/s10557-021-07243-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/19/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND SGLT2 inhibitors increase plasma ketone concentrations. It has been suggested that insulinopenia, along with an increase in the counter-regulatory hormones epinephrine, corticosterone, glucagon and growth hormone, can induce ketoacidosis, especially in type-1 diabetes (T1DM). Dehydration precipitates SGLT2 inhibitor-induced ketoacidosis in type-2 diabetes. We studied the effects of dapagliflozin and water deprivation on the development of ketoacidosis and the associated signaling pathways in T1DM mice. METHODS C57BL/6 mice were fed a high-fat diet. After 7 days, some mice received intraperitoneal injection of streptozocin + alloxan (STZ/ALX). The treatment groups were control + water at lib; control + dapagloflozin + water at lib; control + dapagloflozin + water deprivation; STZ/ALX + water at lib; STZ/ALX + water deprivation; STZ/ALX + dapagloflozin + water at lib; STZ/ALX + dapagloflozin + water deprivation. Dapagliflozin was given for 7 days. In the morning of day 18, food was removed, and water was removed in the water deprivation groups. ELISA, rt-PCR, and immunoblotting were used to assess blood, heart, liver, white and brown adipose tissues. RESULTS The T1DM mice had ketoacidosis even without water deprivation. Water deprivation increased plasma levels of β-hydroxybutyrate, acetoacetate, corticosterone, and epinephrine and reduced the levels of adiponectin in T1DM mice. Interleukin (IL) 1β, IL-6, IL-8, and TNFα were also increased in the T1DM mice with water deprivation. Dapagliflozin attenuated the changes in the T1DM mice without and with water deprivation. Likewise, water deprivation increased the activation of the inflammasome in the heart, liver, and white fat of the T1DM mice and dapagliflozin attenuated these changes. Dapagliflozin reduced the mRNA levels of glucagon receptors in the liver and the increase in GPR109a in white and brown fat. In the liver, dapagliflozin increased AMPK phosphorylation, and attenuated the phosphorylation of TBK1 and the activation of NFκB. CONCLUSIONS Dapagliflozin reduced ketone body levels and attenuated the activation of NFκB and the activation of the inflammasome in T1DM mice with ketoacidosis.
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Affiliation(s)
- Huan Chen
- The Department of Biochemistry and Molecular Biology, University of Texas Medical Branch, 301 University Blvd, BSB 648, Galveston, TX, 77555, USA.,Department of Acupuncture, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yochai Birnbaum
- The Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Regina Ye
- The Department of Biochemistry and Molecular Biology, University of Texas Medical Branch, 301 University Blvd, BSB 648, Galveston, TX, 77555, USA
| | - Hsiu-Chiung Yang
- Research and Early Development Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Göteborg, Sweden
| | - Mandeep Bajaj
- Section of Endocrinology, Baylor College of Medicine, Houston, TX, USA
| | - Yumei Ye
- The Department of Biochemistry and Molecular Biology, University of Texas Medical Branch, 301 University Blvd, BSB 648, Galveston, TX, 77555, USA.
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96
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Veneti S, Tziomalos K. Sodium/glucose cotransporter 2 inhibitors for the treatment of type 1 diabetes: what are the latest developments? Expert Opin Pharmacother 2021; 22:2261-2266. [PMID: 34402702 DOI: 10.1080/14656566.2021.1967931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Despite the improvements in insulin therapy, many patients with type 1 diabetes mellitus (T1DM) do not achieve glycemic targets. Hypoglycemia and weight gain are important barriers in reaching these targets. Sodium/glucose cotransporter 2 (SGLT2) inhibitors lack these side effects and have an insulin-independent mechanism of action. Therefore, they might be useful in patients with T1DM. The authors discuss the safety and efficacy of SGLT2 inhibitors in T1DM. Several randomized controlled trials have evaluated dapagliflozin, sotagliflozin and empagliflozin in this population whereas fewer data are available for other members of this class. In these studies, SGLT2 inhibitors reduced HbA1c levels and body weight without a greater risk of hypoglycemia. However, a higher incidence of diabetic ketoacidosis (DKA) was observed in patients treated with these agents. SGLT2 inhibitors improve glycemic control in patients with T1DM but this effect is modest. Even though weight loss and the neutral effect on the incidence of hypoglycemia are advantages of these agents, the increased risk of DKA is a cause of concern. Overall, SGLT2 inhibitors should be used with caution and only in carefully selected patients with T1DM who are motivated, adherent to treatment, well-trained in recognizing DKA and are closely followed-up.
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Affiliation(s)
- Stavroula Veneti
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Konstantinos Tziomalos
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
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97
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Palmer BF, Clegg DJ. Euglycemic Ketoacidosis as a Complication of SGLT2 Inhibitor Therapy. Clin J Am Soc Nephrol 2021; 16:1284-1291. [PMID: 33563658 PMCID: PMC8455044 DOI: 10.2215/cjn.17621120] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Sodium-glucose cotransporter-2 (SGLT2) inhibitors are drugs designed to lower plasma glucose concentration by inhibiting Na+-glucose-coupled transport in the proximal tubule. Clinical trials demonstrate these drugs have favorable effects on cardiovascular outcomes to include slowing the progression of CKD. Although most patients tolerate these drugs, a potential complication is development of ketoacidosis, often with a normal or only a minimally elevated plasma glucose concentration. Inhibition of sodium-glucose cotransporter-2 in the proximal tubule alters kidney ATP turnover so that filtered ketoacids are preferentially excreted as Na+ or K+ salts, leading to indirect loss of bicarbonate from the body and systemic acidosis under conditions of increased ketogenesis. Risk factors include reductions in insulin dose, increased insulin demand, metabolic stress, low carbohydrate intake, women, and latent autoimmune diabetes of adulthood. The lack of hyperglycemia and nonspecific symptoms of ketoacidosis can lead to delays in diagnosis. Treatment strategies and various precautions are discussed that can decrease the likelihood of this complication.
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Affiliation(s)
- Biff F. Palmer
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Deborah J. Clegg
- Associate Dean for Research, College of Nursing and Health Professionals, Drexel University, Philadelphia, Pennsylvania
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98
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Herrington WG, Savarese G, Haynes R, Marx N, Mellbin L, Lund LH, Dendale P, Seferovic P, Rosano G, Staplin N, Baigent C, Cosentino F. Cardiac, renal, and metabolic effects of sodium-glucose co-transporter 2 inhibitors: a position paper from the European Society of Cardiology ad-hoc task force on sodium-glucose co-transporter 2 inhibitors. Eur J Heart Fail 2021; 23:1260-1275. [PMID: 34184823 DOI: 10.1002/ejhf.2286] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/24/2021] [Accepted: 06/25/2021] [Indexed: 11/07/2022] Open
Abstract
In 2015, the first large-scale placebo-controlled trial designed to assess cardiovascular safety of glucose-lowering with sodium-glucose co-transporter 2 (SGLT2) inhibition in type 2 diabetes mellitus raised hypotheses that the class could favourably modify not only risk of atherosclerotic cardiovascular disease, but also hospitalization for heart failure, and the development or worsening of nephropathy. By the start of 2021, results from 10 large SGLT2 inhibitor placebo-controlled clinical outcome trials randomizing ∼71 000 individuals have confirmed that SGLT2 inhibitors can provide clinical benefits for each of these types of outcome in a range of different populations. The cardiovascular and renal benefits of SGLT2 inhibitors appear to be larger than their comparatively modest effect on glycaemic control or glycosuria alone would predict, with three trials recently reporting that clinical benefits extend to individuals without diabetes mellitus who are at risk due to established heart failure, or albuminuric chronic kidney disease. This European Society of Cardiology position paper summarizes reported results from these 10 large clinical outcome trials considering separately each of the different types of cardiorenal benefit, summarizes key molecular and pathophysiological mechanisms, and provides a synopsis of metabolic effects and safety. We also describe ongoing placebo-controlled trials among individuals with heart failure with preserved ejection fraction and among individuals with chronic kidney disease.
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Affiliation(s)
- William G Herrington
- Medical Research Council Population Health Research Unit at the University of Oxford, part of the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
- Oxford Kidney Unit, Churchill Hospital, Oxford, UK
| | - Gianluigi Savarese
- Cardiology Unit, Department of Medicine, Karolinska Institute: Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Richard Haynes
- Medical Research Council Population Health Research Unit at the University of Oxford, part of the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
- Oxford Kidney Unit, Churchill Hospital, Oxford, UK
| | - Nikolaus Marx
- Department of Internal Medicine, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Linda Mellbin
- Cardiology Unit, Department of Medicine, Karolinska Institute: Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Lars H Lund
- Cardiology Unit, Department of Medicine, Karolinska Institute: Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Paul Dendale
- Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine & Life Sciences, Hasselt University, Hasselt, Belgium
| | - Petar Seferovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Giuseppe Rosano
- Department of Medical Sciences, IRCCS San Raffaele Pisana, Rome, Italy
| | - Natalie Staplin
- Medical Research Council Population Health Research Unit at the University of Oxford, part of the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
| | - Colin Baigent
- Medical Research Council Population Health Research Unit at the University of Oxford, part of the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
| | - Francesco Cosentino
- Cardiology Unit, Department of Medicine, Karolinska Institute: Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
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99
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Rao L, Ren C, Luo S, Huang C, Li X. Sodium-glucose cotransporter 2 inhibitors as an add-on therapy to insulin for type 1 diabetes mellitus: Meta-analysis of randomized controlled trials. Acta Diabetol 2021; 58:869-880. [PMID: 33651228 PMCID: PMC8187227 DOI: 10.1007/s00592-021-01686-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 02/03/2021] [Indexed: 12/11/2022]
Abstract
AIMS The aim was to systematically review the efficacy and safety of sodium-glucose cotransporter inhibitor (SGLT2i) as an adjunct to insulin at different follow-up durations in randomized, double-blind clinical trials in patients with type 1 diabetes. METHODS We conducted a search on Medline, Embase, and the Cochrane Library for relevant studies published before May 2020. According to the duration of follow-up, the subgroup analysis included four periods: 1-4, 12-18, 24-26, and 52 weeks. In the five trials included both 24-26 and 52 weeks of follow-up, we compared the efficacy by the placebo-subtracted difference and changes in SGLT2i groups. RESULTS Fifteen trials including 7109 participants were analyzed. The combination of SGLT2i and insulin improved hemoglobin A1c (HbA1c), fasting plasma glucose (FPG), daily insulin dose, body weight, and blood pressure, which varied greatly by different follow-ups. Compared with %HbA1c at 24-26 weeks, placebo-subtracted differences and changes in the SGLT2i groups slightly increased. SGLT2i plus insulin treatment showed no difference in the occurrence of urinary tract infections (UTIs), hypoglycemia, or severe hypoglycemia but increased the risk of genital tract infections (GTIs) in a duration-dependent manner. SGLT2i treatment was associated with a significantly higher rate of ketone-related SAEs and diabetic ketoacidosis (DKA) at 52 weeks. CONCLUSION SGLT2i as an add-on therapy to insulin improved glycemic control and body weight and decreased the required dose of insulin without increasing the risk of hypoglycemia. However, after 6 months the benefits of SGLT2is on glycemic control may weaken and the risks of GTIs and DKA increased.
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Affiliation(s)
- Lunwen Rao
- Huangdu Community Health Service Center, Jiading District, Anting TownShanghai, China
| | - Chenhong Ren
- Postgraduate Training Basement of Jinzhou Medical University, Taihe Hospital, Hubei University of Medical, Shiyan, China
- Department of Endocrinology, Taihe Hospital, Hubei University of Medical, Shiyan, 442000, China
| | - Shan Luo
- Department of Endocrinology, Taihe Hospital, Hubei University of Medical, Shiyan, 442000, China
| | - Chenghu Huang
- Department of Endocrinology, The People's Hospital of Bishan District, Bishan, Chongqing, 402760, China.
| | - Xuefeng Li
- Department of Endocrinology, Taihe Hospital, Hubei University of Medical, Shiyan, 442000, China.
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100
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Vitale RJ, Laffel LM. Sodium-Glucose Transporter Inhibition in Adult and Pediatric Patients with Type 1 Diabetes Mellitus. Adv Chronic Kidney Dis 2021; 28:309-317. [PMID: 34922687 DOI: 10.1053/j.ackd.2021.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/26/2021] [Accepted: 05/12/2021] [Indexed: 01/14/2023]
Abstract
Adjunctive therapies to insulin for treatment of type 1 diabetes mellitus (T1D) have gained popularity in efforts to achieve glycemic targets, and sodium-glucose transporter (SGLT) inhibitors are an appealing option due to associated weight loss, low risk of hypoglycemia, and improved cardiorenal outcomes seen in persons with type 2 diabetes mellitus. The increased risk of diabetic ketoacidosis (DKA), including euglycemic DKA, has led many to be wary of their use in T1D, especially given limited pediatric data and data regarding cardiorenal protection in this population. The phase 3 trials of these agents in T1D have yielded lower HbA1c, decreased total daily insulin dose, and small but significant weight loss with no increase in hypoglycemia. These trials also reported increased risks of genital mycotic infection and DKA. SGLT inhibitors have been approved as adjunctive therapy to insulin in adults with T1D in Europe and Japan, but the United States Food and Drug Administration has rejected similar applications. Although approaches to mitigate the risk of DKA have been developed, no randomized trials using such tools have been conducted. More research is needed to minimize the risk of DKA and to better evaluate the cardiorenal impact of these agents in persons with T1D.
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