Effects of SGLT2 inhibitors on UTIs and genital infections in type 2 diabetes mellitus: a systematic review and meta-analysis

Poor adherence and persistence to sodium glucose co-transporter 2 inhibitors in real-world settings: Evidence from a systematic review and meta-analysis

AIMS

Despite increasing prescription of sodium glucose co-transporter 2 (SGLT2) inhibitors, there is limited insight of the patterns of use among patients with diabetes prescribed these drugs. This study aimed to summarize available real-world data on the adherence and persistence to SGLT2 inhibitors.

MATERIALS AND METHODS

A systematic review for observational studies reporting the adherence and persistence to SGLT2 inhibitors was performed in Medline, Embase, and Web of Science from their inception to October 2019. Data were analysed via random-effects meta-analysis.

RESULTS

A total of 22 studies (31 cohorts) comprising 123 854 individuals prescribed SGLT2 inhibitors from eight countries were included. The pooled mean proportions of days covered [PDC] at six months and one year were 0.77 (95% confidence interval [CI] 0.72-0.82) and 0.72 (95% CI 0.66-0.77), respectively. The pooled proportions adherent (PDC ≥0.80) at six months and one year were 59.5% (95% CI 52.9-65.9) and 49.0% (95% CI 42.3-55.8), respectively. The pooled proportions of people persistent at six months, one year, and two years were 80.1% (95% CI 75.8-84.0), 61.8% (95% CI 57.8-65.7), and 45.9% (95% CI 35.5-56.5), respectively. When persistence was defined as the absence of ≥90-days gap, the equivalent pooled proportions persistent were 81.5% (95% CI 73.1-88.6), 58.9% (95% CI 53.1-64.6), and 34.7% (95% CI 33.6-35.8). Adherence and persistence appeared to vary across different SGLT2 inhibitors.

CONCLUSIONS

Real-world adherence and persistence to SGLT2 inhibitors is poor. Hence, targets for improving treatment adherence and persistence need to be identified and appropriate interventions implemented.

Does treatment with sodium-glucose co-transporter-2 inhibitors have an effect on sleep quality, quality of life, and anxiety levels in people with Type 2 diabetes mellitus?

Background/aim

To evaluate the impact of treatment with sodium-glucose co-transporter-2 (SGLT2) Inhibitors on quality of life (QoL), sleep quality (SQ), and anxiety levels in patients with Type 2 diabetes mellitus (T2DM).

Materials and methods

Ninety-seven patients with type 2 diabetes admitted to tertiary care hospital diabetes clinic were included. Fifty patients were randomized to receive SGLT2 inhibitors in addition to baseline treatment (Group A), 47 subjects continued with their baseline treatment or were added other medications as needed (Group B). Thirty healthy controls (HC) were recruited (Group C). All groups were subjected to the Turkish version of Short Form-36 (SF-36), Pittsburgh Sleep Quality (PSQ), and Beck Anxiety Inventory (BAI) scales both at baseline and final visit.

Results

Physical function, emotional role limitation, vitality, mental health, pain, general health perception scores of SF-36 were significantly improved in Group A, at the end of the follow-up period. There was no significant change in terms of PSQ, BAI scores, and hypoglycaemia documented in all groups. The intervention-related change in HbA1c level, body weight, and body mass index were significantly higher in Group A.

Conclusion

The QoL was improved in people with diabetes who were taking SGLT2 inhibitors. This may be explained by weight loss observed in participants.

[Urinary tract infections in patients with type 2 diabetes mellitus with pharmacological glucosuria]

Selective inhibitors of sodium-glucose cotransporter belong to a new class of drugs for the treatment of type 2 diabetes mellitus. The mechanism of their action is based on insulin-independent reduction of glucose reabsorption in the proximal renal tubules, which leads to stimulation of its excretion in the urine and, accordingly, to a decrease in the concentration of glucose in the blood plasma. Drugs of this group demonstrate effectiveness in the treatment of type 2 diabetes, but their use may be associated with an increased frequency of urinary tract infections. Pharmacological glucosuria, which leads to a decrease in the concentration of glucose in the blood, creates the preconditions for the occurrence of urinary tract infections. Urinary tract and genital infections are the most common adverse events associated with the use of sodium-glucose cotransporter inhibitors. In the presented literature review for 20162019, the relationship between urinary tract infections in patients with type 2 diabetes mellitus and therapy with sodium-glucose cotransporter inhibitors was analyzed.

Evaluating the Evidence behind the Novel Strategy of Early Combination from Vision to Implementation

Type 2 diabetes mellitus (T2DM) is a complex and progressive chronic disease characterised by elevating hyperglycaemia and associated need to gradually intensify therapy in order to achieve and maintain glycaemic control. Treating hyperglycaemia with sequential therapy is proposed to allow holistic assessment of the efficacy and risk-to-benefit ratio of each added component. However, there is an array of evidence supporting the scientific rationale for using synergistic, earlier, modern drug combinations to achieve glycaemic goals, delay the deterioration of glycaemic control, and, therefore, potentially preserve or slow down the declining β-cell function. Additionally, implementation of early combination(s) may lead to opportunities to combat clinical inertia and other hurdles to optimised disease management outcomes. This review aims to discuss the latest empirical evidence for long-term clinical benefits of this novel strategy of early combination in people with newly diagnosed T2DM versus the current widely-implemented treatment paradigm, which focuses on control of hyperglycaemia using lifestyle interventions followed by sequentially intensified (mostly metformin-based) monotherapy. The recent reported Vildagliptin Efficacy in combination with metfoRmin For earlY treatment of T2DM (VERIFY) study results have provided significant new evidence confirming long-term glycaemic durability and tolerability of a specific early combination in the management of newly diagnosed, treatment-naïve patients worldwide. These results have also contributed to changes in clinical treatment guidelines and standards of care while clinical implementation and individualised treatment decisions based on VERIFY results might face barriers beyond the existing scientific evidence.

Overview of Atypical Diabetes

Although type 1 diabetes mellitus and, to a lesser extent, type 2 diabetes mellitus, are the prevailing forms of diabetes in youth, atypical forms of diabetes are not uncommon and may require etiology-specific therapies. By some estimates, up to 6.5% of children with diabetes have monogenic forms. Mitochondrial diabetes and cystic fibrosis related diabetes are less common but often noted in the underlying disease. Atypical diabetes should be considered in patients with a known disorder associated with diabetes, aged less than 25 years with nonautoimmune diabetes and without typical characteristics of type 2 diabetes mellitus, and/or with comorbidities associated with atypical diabetes.

Where Does Metformin Stand in Modern Day Management of Type 2 Diabetes?

Metformin is the most commonly used glucose-lowering therapy (GLT) worldwide and remains the first-line therapy for newly diagnosed individuals with type 2 diabetes (T2D) in management algorithms and guidelines after the UK Prospective Diabetes Study (UKPDS) showed cardiovascular mortality benefits in the overweight population using metformin. However, the improved Major Adverse Cardiovascular Events (MACE) realised in some of the recent large cardiovascular outcomes trials (CVOTs) using sodium-glucose co-transporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) have challenged metformin's position as a first-line agent in the management of T2D. Many experts now advocate revising the existing treatment algorithms to target atherosclerotic cardiovascular disease (ASCVD) and improving glycaemic control as a secondary aim. In this review article, we will revisit the major cardiovascular outcome data for metformin and include a critique of the UKPDS data. We then review additional factors that might be pertinent to metformin's status as a first-line agent and finally answer key questions when considering metformin's role in the modern-day management of T2D.

Efficacy and Safety of SGLT-2 Inhibitors for Treatment of Diabetes Mellitus among Kidney Transplant Patients: A Systematic Review and Meta-Analysis

BACKGROUND

The objective of this systematic review was to evaluate the efficacy and safety profiles of sodium-glucose co-transporter 2 (SGLT-2) inhibitors for treatment of diabetes mellitus (DM) among kidney transplant patients.

METHODS

We conducted electronic searches in Medline, Embase, Scopus, and Cochrane databases from inception through April 2020 to identify studies that investigated the efficacy and safety of SGLT-2 inhibitors in kidney transplant patients with DM. Study results were pooled and analyzed utilizing random-effects model.

RESULTS

Eight studies with 132 patients (baseline estimated glomerular filtration rate (eGFR) of 64.5 ± 19.9 mL/min/1.73m2) treated with SGLT-2 inhibitors were included in our meta-analysis. SGLT-2 inhibitors demonstrated significantly lower hemoglobin A1c (HbA1c) (WMD = -0.56% [95%CI: -0.97, -0.16]; p = 0.007) and body weight (WMD = -2.16 kg [95%CI: -3.08, -1.24]; p < 0.001) at end of study compared to baseline level. There were no significant changes in eGFR, serum creatinine, urine protein creatinine ratio, and blood pressure. By subgroup analysis, empagliflozin demonstrated a significant reduction in body mass index (BMI) and body weight. Canagliflozin revealed a significant decrease in HbA1C and systolic blood pressure. In terms of safety profiles, fourteen patients had urinary tract infection. Only one had genital mycosis, one had acute kidney injury, and one had cellulitis. There were no reported cases of euglycemic ketoacidosis or acute rejection during the treatment.

CONCLUSION

Among kidney transplant patients with excellent kidney function, SGLT-2 inhibitors for treatment of DM are effective in lowering HbA1C, reducing body weight, and preserving kidney function without reporting of serious adverse events, including euglycemic ketoacidosis and acute rejection.

Clinical Adverse Events of High-Dose vs Low-Dose Sodium-Glucose Cotransporter 2 Inhibitors in Type 2 Diabetes: A Meta-Analysis of 51 Randomized Clinical Trials

AIMS

The aims of this work are to assess the clinical adverse events (AEs) of high-dose vs low-dose sodium-glucose cotransporter 2 inhibitors (SGLT2 inhibitors) in patients with type 2 diabetes mellitus (T2DM).

METHODS

We searched MEDLINE, EMBASE, and Cochrane Library from January 1, 2006 to March 10, 2020, for identifying eligible randomized clinical trials (RCTs) that reported AEs by high-dose and low-dose SGLT2 inhibitors in T2DM patients. Random-effects models was used to obtain summary relative risks (RRs) with associated 95% CIs. Prespecified subgroup analyses according to individual SGLT2 inhibitors and follow-up duration, and leave-one-out sensitivity analysis were conducted.

RESULTS

A total of 51 RCTs involving 24 371 patients (12 208 received high-dose and 12 163 received low-dose SGLT2 inhibitors) were included. Overall, the heterogeneity among included studies was relatively low (I2 < 50% for each outcome). No significant differences between high-dose and low-dose SGLT2 inhibitors were observed for overall safety (including any AEs, serious AEs, AEs leading to discontinuation, and death) and specified safety (including infections and infestations, musculoskeletal disorders, gastrointestinal disorders, osmotic diuresis-related AEs, volume-related AEs, renal-related AEs, and metabolism and nutrition), except for a mild increase in risk for AEs related to study drugs (RR: 1.08; 95% CI, 1.01-1.16) that mainly derived from canagliflozin (RR: 1.17; 95% CI, 1.05-1.30). Subgroup analyses were consistent with the primary outcomes.

CONCLUSIONS

This study provided substantial evidence that AEs of SGLT2 inhibitors were not dose related.

Potential Safety Issues with Use of Sodium-Glucose Cotransporter 2 Inhibitors, Particularly in People with Type 2 Diabetes and Chronic Kidney Disease

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a major advance in the fields of diabetology, nephrology, and cardiology. The cardiovascular and renal benefits of SGLT2 inhibitors are likely largely independent of their glycaemic effects, and this understanding is central to the use of these agents in the high-risk population of people with type 2 diabetes and chronic kidney disease. There are a number of potential safety issues associated with the use of SGLT2 inhibitors. These include the rare but serious risks of diabetic ketoacidosis and necrotising fasciitis of the perineum. The data regarding a possibly increased risk of lower limb amputation and fracture with SGLT2 inhibitor therapy are conflicting. This article aims to explore the potential safety issues associated with the use of SGLT2 inhibitors, with a particular focus on the safety of these drugs in people with type 2 diabetes and chronic kidney disease. We discuss strategies that clinicians can implement to minimise the risk of adverse effects including diabetic ketoacidosis and volume depletion. Risk mitigation strategies with respect to SGLT2 inhibitor-associated diabetic ketoacidosis are of particular importance during the current coronavirus disease 2019 (COVID-19) pandemic.

Cardiovascular Effects of Hypoglycemic Agents in Diabetes Mellitus

BACKGROUND

Despite substantial improvements over the years, diabetes mellitus is still associated with cardiovascular disease, heart failure, and excess mortality.

OBJECTIVE

The objective of this article is to examine existing data on the reduction of cardiovascular morbidity and mortality in diabetes. Control of glycemia, lipid levels, and blood pressure are described in brief. The main scope of this article is, however, to review the glucose-independent cardiovascular effect of antidiabetic pharmacological agents (mainly other than insulin).

METHODS

The article is a narrative review based on recently published reviews and meta-analyses complemented with data from individual trials, when relevant.

RESULTS AND DISCUSSION

Older data suggest a cardioprotective role of metformin (an inexpensive and safe drug); a role to date not convincingly challenged. The cardiovascular effects of thiazolidinediones, sulphonylurea, and glinides are debatable. Recent large-scale cardiovascular outcome trials suggest a neutral profile of dipeptidyl peptidase 4 inhibitors, yet provide compelling evidence of cardioprotective effects of glucagon-like 1 receptor antagonists and sodium-glucose transporter 2 inhibitors.

CONCLUSION

Metformin may have a role in primary and secondary prevention of cardiovascular disease; glucagon-like 1 receptor antagonists and sodium-glucose co-transporter 2 inhibitors play a role in secondary prevention of atherosclerotic cardiovascular disease. Sodium-glucose transporter 2 inhibitors have a role to play in both primary and secondary prevention of heart failure; yet, they carry a small risk of the potentially dangerous adverse effect, euglycemic diabetic ketoacidosis.

SGLT2 inhibitors and atrial fibrillation in type 2 diabetes: a systematic review with meta-analysis of 16 randomized controlled trials

BACKGROUND

Type 2 diabetes is closely related to an increased risk of atrial fibrillation (AF) and atrial flutter (AFL). Whether sodium-glucose cotransporter 2 (SGLT2) inhibitors can attenuate AF/AFL progression remains unclear.

METHODS

We searched electronic databases (PubMed, Embase and ClinicalTrials.gov) from their inception to January 2020 for trials evaluating the AF outcomes of SGLT2 inhibitors in patients with type 2 diabetes. The data search and extraction were conducted with a standardized data form and any conflicts were resolved by consensus. Relative risks (RRs) with 95% confidence intervals (CIs) were used for binary variables, and the weighed mean differences (WMDs) with the standard deviation (SDs) were applied for continuous variables.

RESULTS

We included data from 16 identified trials consisting of 38,335 patients with type 2 diabetes. Incorporated data demonstrated that compared to placebo, SGLT2 inhibitors significantly reduced AF/AFL (RR: 0.76; 95% CI 0.65-0.90; p = 0.001) and all-cause mortality (RR: 0.91; 95% CI 0.83-0.99; p = 0.03). AF/AFL reductions were not modified by age, body weight, glycated haemoglobin (HbA1c), or systolic blood pressure (SBP) at baseline (all p-interactions > 0.3). SGLT2 inhibitors also significantly reduced heart failure events (RR: 0.73; 95% CI 0.64-0.84; p < 0.00001), HbA1c (WMD: - 0.62%; 95% CI - 0.89 to - 0.34; p < 0.00001), body weight (WMD: - 2.12 kg; 95% CI - 2.91 to - 1.34; p < 0.00001), SBP (WMD: - 3.34 mmHg; 95% CI - 4.12 to - 2.56; p < 0.00001), and diastolic blood pressure (DBP) (WMD: - 1.11 mmHg; 95% CI - 1.62 to - 0.60; p < 0.0001). Of note, cerebrovascular events and myocardial infarction did not increase in patients taking SGLT2 inhibitors.

CONCLUSION

SGLT2 inhibitors may confer a specific AF/AFL-reduction benefit in the susceptible type 2 diabetes population, regardless of age, body weight, HbA1c, and systolic blood pressure at baseline. Such an AF/AFL-reduction benefit may be partly attributed to pharmacological effects on reductions in HbA1c, body weight, blood pressure, and the occurrence of heart failure.

Rationale for Timely Insulin Therapy in Type 2 Diabetes Within the Framework of Individualised Treatment: 2020 Update

Type 2 diabetes is characterised by chronic hyperglycaemia and variable degrees of insulin deficiency and resistance. Hyperglycaemia and elevated fatty acids exert harmful effects on β-cell function, regeneration and apoptosis (gluco-lipotoxicity). Furthermore, chronic hyperglycaemia triggers a vicious cycle of insulin resistance, low-grade inflammation and a cascade of pro-atherogenic processes. Thus, timely near to normal glucose control is of utmost importance in the management of type 2 diabetes and prevention of micro- and macroangiopathy. The majority of patients are multimorbid and obese, with critical comorbidities such as cardiovascular disease, heart failure and chronic kidney disease. Recently published guidelines therefore recommend patient-centred risk/benefit-balanced use of oral glucose-lowering drugs or a glucagon-like peptide 1 (GLP-1) receptor agonist, or switching to insulin with glycated haemoglobin (HbA1c) out of target. This article covers the indications of early insulin treatment to prevent diabetes-related complications, particularly in subgroups with severe insulin deficit, and to achieve recovery of residual β-cell function. Furthermore, the individualised, risk/benefit-balanced, timely initiation of insulin as second and third option is analysed. Timely insulin initiation may prevent diabetes progression, reduce diabetes-related complications and has less serious adverse effects. Basal insulin is the preferred option in most clinical situations with consequences of undertreatment of chronic hyperglycaemia.

Kidney and cardiovascular protection with SGLT2 inhibitors: lessons from cardiovascular outcome trials and CREDENCE

The burden of diabetic kidney disease is rising rapidly worldwide, and new therapies are of vital importance to reduce the risk of kidney failure and major cardiovascular events. Of the newer glucose-lowering agents, sodium-glucose co-transporter 2 (SGLT2) inhibitors have shown exciting potential in preventing these adverse events. The results of several large cardiovascular outcome trials, a single dedicated kidney outcome trial and a dedicated heart failure trial, demonstrate substantial clinical benefits for several different SGLT2 inhibitors. Emerging evidence raises the possibility that these benefits may extend to those with non-diabetic chronic kidney disease. This review summarises the current evidence for SGLT2 inhibitor benefits and harms, and examines which patients are most likely to gain from these therapies.

Patient Preferences for Medications in Managing Type 2 Diabetes Mellitus: A Discrete Choice Experiment

OBJECTIVES

To quantify patients' maximum acceptable risk (MAR) of urinary and genital tract infections (UGTI) in exchange for benefits associated with treatments for managing type 2 diabetes mellitus (T2DM).

METHODS

In a discrete choice experiment, adult patients with T2DM and currently on metformin and/or sulphonylurea (first-line treatments) were asked to choose between 2 hypothetical medications defined by 6 attributes: years of medication effectiveness in controlling blood glucose, weight reduction, UGTI risk, risk of hospitalization from heart failure, all-cause mortality risk, and out-of-pocket medication cost. We used latent class logistic regression parameters to estimate the conditional relative importance of treatment attributes and MAR of UGTI for various treatment benefits.

RESULTS

A 2-class latent class model was identified as the best fit for the responses from 147 patients. The first class (49% of sample), termed as "survival-conscious," stated that they were willing to accept 46% (95% confidence interval [CI]: 2%-90%) UGTI risk in exchange for a reduction from 6% to 1% in all-cause mortality risk. The second class (51% of sample), termed as "UGTI/cost-conscious" were willing to accept significantly lower (6%; CI: 2%-11%, and 5%; CI: 2%-8%) UGTI risk in exchange for the same reduction in all-cause mortality and hospitalization risks, respectively.

CONCLUSIONS

On average, patients were willing to trade higher UGTI risk for a more effective medication. Our findings suggest that physicians should present the benefits and potential side effects of all available treatments and consider patient preferences in their treatment recommendations.

The association of sodium-glucose cotransporter 2 inhibitors with cancer: An overview of quantitative systematic reviews

AIMS

To summarize reported cancer events associated with SGLT-2 inhibitors used in patients with type 2 diabetes mellitus, as well as assess the quality of included reviews.

MATERIALS AND METHODS

In May 2019, we searched PubMed, Embase and the Cochrane Library for quantitative systematic reviews assessing the safety of SGLT-2 inhibitors. Data were abstracted using a standardized form, and methodological quality was assessed using the AMSTAR 2 tool. Main outcome measures included total cancer events and specific cancers such as breast cancer, bladder cancer, gastrointestinal cancer, prostate cancer, respiratory cancer, renal cancer and skin cancer. Pooled treatment effects from included reviews were summarized for SGLT-2 inhibitors as a class and for individual SGLT-2 inhibitors commonly used worldwide (canagliflozin, dapagliflozin and empagliflozin).

RESULTS

We screened 1248 unique citations, of which eight quantitative systematic reviews meta-analysed results from studies reporting the association between an SGLT-2 inhibitor and any cancer. Only one review was rated as high quality according to AMSTAR 2 assessment. In total, data from 170 cancer-related point estimates (PE) were reported. As a class, SGLT-2 inhibitors were not associated with an increased risk of any cancer event versus placebo and active comparators. Most point estimates (7/143) were nonsignificant for individual cancers except for two associations. Empagliflozin was associated with an increased risk of bladder cancer versus placebo and active comparators in two reviews, while canagliflozin appeared protective for gastrointestinal cancer versus placebo and active comparators in one review.

CONCLUSIONS

It appears that SGLT-2 inhibitors are not associated with an increased risk of total cancer or specific cancers in patients with type 2 diabetes. However, higher quality evidence is needed to derive confident conclusions.

Candida sepsis from local infection in a patient with a urostomy on SGLT2 inhibitor therapy

Sodium-glucose co-transporter 2 (SGLT2) inhibitors exhibit impressive cardio-renal benefits in patients with a high cardiovascular risk. Genital yeast infections are important side effects of this class of drugs. We report a case of Candida glabrata sepsis secondary to a Candida infection of the urostomy of a patient on SGLT2 inhibitor therapy. In urostomy patients, one should critically evaluate the risk of mycotic infections against the cardiovascular and glycaemic benefits of SGLT2 inhibition. Urostomy patients without a high cardiovascular risk should not be treated with SGLT2 inhibitors.

Safety of Ertugliflozin in Patients with Type 2 Diabetes Mellitus: Pooled Analysis of Seven Phase 3 Randomized Controlled Trials

INTRODUCTION

The sodium-glucose cotransporter 2 (SGLT2) inhibitor ertugliflozin is approved for the treatment of adults with type 2 diabetes mellitus (T2DM). This analysis was conducted on safety data pooled from phase 3 studies using ertugliflozin 5 mg or 15 mg versus placebo or an active comparator.

METHODS

The placebo pool (n = 1544) comprised data from three similarly designed 26-week placebo-controlled studies. The broad pool (n = 4849) comprised these three placebo-controlled studies plus four placebo- or active-controlled studies with treatment durations of up to 104 weeks.

RESULTS

In the placebo pool, there were no notable differences across groups in the incidence of adverse events (AEs), serious AEs, or AEs resulting in discontinuation from study medication, while associations were observed with genital mycotic infection in both females (3.0%, 9.1%, and 12.2% in the placebo, ertugliflozin 5 mg, and ertugliflozin 15 mg groups, respectively) and males (0.4%, 3.7%, 4.2%), thirst (0.2%, 1.3%, 1.0%), and increased urination (1.0%, 2.7%, 2.4%). In the broad pool, volume depletion was increased with ertugliflozin in patients with estimated glomerular filtration rate < 60 ml/min/1.73 m², aged ≥ 65 years, or who were taking diuretics. Ertugliflozin was not associated with increased urinary tract infection, fracture, hypoglycemia, pancreatitis, renal or hepatic injury, hypersensitivity, malignancy, or venous thromboembolism. Small numbers of patients were reported with lower limb amputation [0.1% (non-ertugliflozin group), 0.2% (ertugliflozin 5 mg), 0.5% (ertugliflozin 15 mg)]. There were three cases of ketoacidosis (all ertugliflozin 15 mg) and no cases of Fournier's gangrene.

CONCLUSION

This pooled analysis showed that ertugliflozin was generally well tolerated in a large population of patients with T2DM with and without moderate renal impairment who were taking a range of background diabetes medications including insulin and insulin secretagogs, with results that are generally consistent with those for other SGLT2 inhibitors.

TRIAL REGISTRATION

Clinicaltrials.gov indentifier, NCT02033889, NCT01958671, NCT02036515, NCT01986855, NCT02099110, NCT02226003, NCT01999218.

Effect of the Sodium-Glucose Cotransporter 2 Inhibitor, Dapagliflozin, on Genitourinary Infection in an Animal Model of Type 2 Diabetes

Purpose

To investigate the effect of dapagliflozin, a sodium-glucose cotransporter 2 inhibitor, on inflammatory cytokines of urogenital tissue in a rat model of type 2 diabetes (T2DM) to infer pharmaceutical influence of dapagliflozin on genitourinary infection or inflammation.

Methods

Study animals were divided into the following 4 groups of 10 animals each: (1) the Otsuka Long-Evans Tokushima Fatty (OLETF)-DA group treated with dapagliflozin at 1.0 mg/kg/day, (2) the OLETF-VO group treated with voglibose at 0.6 mg/kg/day, (3) the control group (OLETF-CO) given water, and (4) the Long-Evans Tokushima Otsuka (LETO) rats were included as nondiabetic control group. Changes in blood glucose, 24-hour urine volume, and urine glucose were measured. The interleukin-1β (IL-1β) and interleukin-18 (IL-18) levels in the bladder and the urethra were quantified, respectively.

Results

The urine glucose level and the 24-hour urine volume at 12 weeks of treatment were significantly higher in the OLETF-DA group than that in any other group (P<0.05). The cytokine analysis of the bladder and urethra showed higher IL-18 and IL-1β in the OLETF-DA and the OLETF-CO groups than that in the OLETF-VO and LETO groups (P<0.05). The cytokine levels did not differ between the OLETF-DA and the OLETF-CO groups, and the level of IL-18 in the OLETF-DA group was higher in the urethra than in the bladder.

Conclusions

This study revealed that dapagliflozin increased the urine glucose concentration, resulting in an inflammatory response remain in the urogenital tract as the untreated diabetic rats. Therefore, when treating patients with T2DM with dapagliflozin, careful attention should be paid to genitourinary infection or inflammation.

What have we learned about renal protection from the cardiovascular outcome trials and observational analyses with SGLT2 inhibitors?

Over the past 5 years, sodium-glucose cotransport 2 (SGLT2) inhibitors have been increasingly regarded as glycaemic agents with cardiovascular (CV) and renal protective effects. The CV benefits of SGLT2 inhibitors have been well established in patients with type 2 diabetes (T2D) and a range of CV comorbidities at baseline. Subsequently, the renal benefits of SGLT2 inhibitors were established in the CREDENCE trial, a dedicated renal outcome trial where canagliflozin reduced the primary composite renal outcome by 30%. In light of these trials, clinical practice guidelines have rapidly evolved, recommending the use of SGLT2 inhibitors as renal and cardioprotective agents in appropriate patient populations. Accordingly, it is important to have an in-depth understanding of the evidence underlying the use of SGLT2 inhibitors in patients with T2D based on published clinical trials and real-world evidence (RWE) studies, as well as information related to potential safety concerns. To accomplish this, we reviewed the evidence for renal protection and safety with SGLT2 inhibitors in the EMPA-REG OUTCOME, CANVAS Program and DECLARE-TIMI 58 CV safety trials, and in the growing body of evidence emerging from real-world studies. This body of work has shown that SGLT2 inhibitors reduce the risk of surrogate renal endpoints such as albuminuria and mitigate the risk of hard renal endpoints including doubling of serum creatinine and end-stage kidney disease in patients with T2D.

Chrysophyllum cainito: A Tropical Fruit with Multiple Health Benefits

Chrysophyllum cainito is a tropical fruit tree with multiple benefits to human health. C. cainito possesses strong antioxidant properties either in vitro or in vivo. Extracts from the leaves, stem bark, fruits, peel, pulp, or seed of C. cainito are promising candidates in traditional medicine for curing diabetes and fighting against bacterial, fungal, and viral infections. C. cainito leaf extract alone or in a complex formula exhibits anti-inflammatory responses by reducing hypersensitivity, acts as inflammatory markers, and has antinociceptive effects. The leaf extract also increases wound healing speed and assists in regulating fat uptake. In addition, the C. cainito fruit shows anticancer activity against osteosarcoma. In conclusion, the aerial parts of C. cainito have strong beneficial biological effects on human health.

Efficacy and Safety of SGLT2 Inhibitors in Type 1 Diabetes After the Introduction of an Off-Label Use Protocol for Clinical Practice

Aims: We evaluated the real-life efficacy and safety of empagliflozin in combination with optimized insulin therapy in patients with type 1 diabetes (T1D). Methods: This was a prospective study, including 27 patients with T1D treated with insulin therapy to whom empagliflozin was added according to an off-label protocol approved for use in clinical practice. The primary end point was the change in HbA_1c 52 weeks after the addition of empagliflozin to insulin therapy. Blood pressure (BP), weight, and safety were also assessed. Results: At week 52, the addition of empagliflozin significantly reduced HbA_1c from 8.0% ± 0.7% to 7.2% ± 0.8% (P < 0.001). The mean percentage of time in range for capillary glucose monitoring increased from 50% to 62% (P = 0.008) in parallel to a -0.08 IU/(kg·day) reduction in insulin requirements (P = 0.031). There was also a reduction in the body weight (-8 kg) and in systolic BP from 134 to 127 mmHg (P < 0.001). The most commonly reported adverse events were genitourinary infections (10 episodes in 52 weeks of follow-up). One patient developed an episode of mild diabetic ketoacidosis that motivated empagliflozin withdrawal. No severe hypoglycemic events were registered. Conclusions: Our results suggested that the use of empagliflozin following a strict off-label protocol may represent an effective and safe option in real life among patients with T1D, improving metabolic control, and ameliorating some cardiovascular risk factors.

Assessing the Risk for Gout With Sodium-Glucose Cotransporter-2 Inhibitors in Patients With Type 2 Diabetes: A Population-Based Cohort Study

BACKGROUND

Hyperuricemia is common in patients with type 2 diabetes mellitus and is known to cause gout. Sodium-glucose cotransporter-2 (SGLT2) inhibitors prevent glucose reabsorption and lower serum uric acid levels.

OBJECTIVE

To compare the rate of gout between adults prescribed an SGLT2 inhibitor and those prescribed a glucagon-like peptide-1 (GLP1) receptor agonist.

DESIGN

Population-based new-user cohort study.

SETTING

A U.S. nationwide commercial insurance database from March 2013 to December 2017.

PATIENTS

Persons with type 2 diabetes newly prescribed an SGLT2 inhibitor were 1:1 propensity score matched to patients newly prescribed a GLP1 agonist. Persons were excluded if they had a history of gout or had received gout-specific treatment previously.

MEASUREMENTS

The primary outcome was a new diagnosis of gout. Cox proportional hazards regression was used to estimate hazard ratios (HRs) of the primary outcome and 95% CIs.

RESULTS

The study identified 295 907 adults with type 2 diabetes mellitus who were newly prescribed an SGLT2 inhibitor or a GLP1 agonist. The gout incidence rate was lower among patients prescribed an SGLT2 inhibitor (4.9 events per 1000 person-years) than those prescribed a GLP1 agonist (7.8 events per 1000 person-years), with an HR of 0.64 (95% CI, 0.57 to 0.72) and a rate difference of -2.9 (CI, -3.6 to -2.1) per 1000 person-years.

LIMITATION

Unmeasured confounding, missing data (namely incomplete laboratory data), and low baseline risk for gout.

CONCLUSION

Adults with type 2 diabetes prescribed an SGLT2 inhibitor had a lower rate of gout than those prescribed a GLP1 agonist. Sodium-glucose cotransporter-2 inhibitors may reduce the risk for gout among adults with type 2 diabetes mellitus, although future studies are necessary to confirm this observation.

PRIMARY FUNDING SOURCE

Brigham and Women's Hospital.

Insight Into the Perioperative Management of Type 2 Diabetes

Diabetic people are at risk of developing acute complications when exposed to stress. Surgery brings a stressful period when the patient is exposed not only to surgical stress but also the effects of medications used during that particular period. The patient's comorbidities can influence the perioperative management of diabetes. Poorly controlled diabetes can complicate the hospital course. The literature was searched through PubMed and the articles of the last 5 years, from 2014 to 2019, were looked into. The studies available as a free text, in the English language and related to humans, were included. Inclusion criteria also included adults with type 2 diabetes undergoing surgery. The perioperative management of diabetes is a challenging one. Apart from the diabetes control; comorbidities, general health, intake, and interaction of medications both anti-diabetic and non-diabetic, type and duration of surgery, are some of the factors that influence the outcome of the surgery. With a variety of options available to manage diabetes currently, it is important to have a good insight into their effects to prevent complications to occur and ensure safe discharge from the hospital. The good control of diabetes is essential in bringing favorable outcomes. The perioperative management of diabetes should be individualized. Oral anti-hyperglycemic medications, other than sulfonylureas and SGLT2 inhibitors, provide a reasonable alternative to insulin and can be continued safely perioperatively depending upon the type of surgery and the patient is expected to resume oral intake soon postoperatively.

Fournier's gangrene and sodium-glucose co-transporter-2 inhibitors: A meta-analysis of randomized controlled trials

Fournier's gangrene (FG) is a rare, life-threatening necrotizing fasciitis of the perineum. The US Food and Drug Administration (FDA) released a Drug Safety Communication regarding the risk of FG associated with sodium-glucose co-transporter-2 inhibitors (SGLT2i), relying on the FDA Adverse Event Reporting System. To verify this association, we performed a meta-analysis of all randomized controlled trials enrolling patients with type 2 diabetes, comparing SGLT2i with placebo or different therapies, collecting cases of FG reported as a serious adverse event. Risk of abscess, cellulitis and erysipela were secondary outcomes. We retrieved 84 trials enrolling 42 415 patients in the SGLT2i group and 27 158 patients in comparator groups. No difference was observed between SGLT2i and comparators in the risk of FG (Mantel-Haenzel odds ratio [MH-OR] 0.41 [0.09, 1.82]), abscess (MH-OR 0.94 [0.54, 1.65]), cellulitis (MH-OR 0.90 [0.71, 1.13] or erysipela (MH-OR 0.89 [0.45, 1.77]). The number of events was small, leading to a wide confidence interval that does not allow ruling out an increase in FG or skin and subcutaneous tissue infections.

Outcomes of SGLT2 Inhibitors Use in Diabetic Renal Transplant Patients

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are newly introduced hypoglycemic drugs that work by inhibiting glucose reabsorption at proximal renal tubules. The use of SGLT2 inhibitors in nontransplant diabetic patients with or without cardiovascular disease has well-established efficacy and safety. The risks of renal graft dysfunction and urinary tract infections might be the limiting factors for their use in renal transplant patients. Data regarding the safety and long-term efficacy of SGLT2 inhibitors use in diabetic renal transplant patients is scanty. The aim of the study is to report our experience with use of SGLT2 inhibitors in 8 diabetic renal transplant patients supported by literature review. Eight diabetic renal transplant patients were recruited from Tawam hospital during the period between June 2016 and January 2019. Demographic, clinical, and laboratory data were collected and analyzed. Adding SGLT2 resulted in significant decrease in hemoglobin A1c and body mass index after 12 months of treatment. There was significant negative correlation between the duration of treatment with SGLT2 and hemoglobin A1c. Diabetic renal transplant patients with stable kidney function had better glycemic control with use of SGLT2 inhibitors. There was no deterioration of kidney function and risk of recurrent urinary tract infection was low.

The use of sodium-glucose co-transporter 2 inhibitors in the inpatient setting: Is the risk worth taking?

WHAT IS KNOWN AND OBJECTIVE

In the outpatient setting, sodium-glucose co-transporter 2 inhibitors (SGLT2i) are recognized as effective agents to optimize glycaemia and also developing robust evidence for cardiovascular (CV) and renal protection in people with type 2 diabetes, particularly those at higher risk. However, data on the safety and efficacy of these drugs in hospitalized patients remain limited. The purpose of this review is to discuss the balance between risks and benefits of SGLT2i use in the inpatient setting.

METHODS

PubMed, Embase and Google Scholar databases were searched to identify relevant published work. Available evidence on the mechanisms of action and the safety profile of SGLT2i in the context of their use in hospitalized individuals are summarized and discussed in this narrative review.

RESULTS AND DISCUSSION

The rationale behind the use of these agents in the inpatient setting is based on the low risk of hypoglycaemia, the practical dosing scheme and the potential to decrease subsequent heart failure admission rates. In addition, data from animal studies indicate the ability of SGLT2i to ameliorate oxidative stress, suppress sympathetic activity, enhance autophagy and promote cardiac remodelling, when administered in the acute phase of CV episodes. On the other hand, these drugs have been linked to specific adverse events related to their mechanism of action, including an increased risk of euglycaemic diabetic ketoacidosis and volume depletion, which raises concerns over their usefulness in inpatients, particularly individuals with multimorbidities.

WHAT IS NEW AND CONCLUSION

Potential benefits deriving from the use of SGLT2i in the inpatient setting cannot mitigate possible risks, at least until robust evidence on their efficacy in hospitalized individuals become available. The concept of administering these agents in the acute phase of CV episodes, in people with or without diabetes, requires further evaluation in appropriately designed clinical studies.

How Do the Recent Major Randomized Controlled Trials Inform Best Use of the Novel Glucose-Lowering Agents?

<b><i>Background:</i></b> Type 2 diabetes mellitus (T2DM) is frequently associated with the development of cardiovascular disease and chronic kidney disease (CKD). Some newer glucose-lowering agents confer both cardiac and kidney benefits, as supported by robust data from recent high-quality randomized controlled trials. The decision-making process when selecting glucose-lowering medications for T2DM now extends beyond glycaemia and metabolic effects, and towards additional benefits such as prevention of other complications. <b><i>Summary:</i></b> We review the evidence for efficacy in 3 new classes of medication for T2DM and additionally discuss relevant safety issues when considering optimal agents. <b><i>Key Messages:</i></b> Clinicians have multiple efficacy and safety factors to consider when selecting agents for glucose lowering in T2DM, and this should help direct individualized selection of pharmacotherapy for patients. New medications offer an opportunity to prevent cardiac and renal complications in people with T2DM.

Safety of Ertugliflozin in Patients with Type 2 Diabetes Mellitus Inadequately Controlled with Conventional Therapy at Different Periods: A Meta-Analysis of Randomized Controlled Trials

AIMS

To assess the safety of ertugliflozin in patients with type 2 diabetes mellitus (T2DM) inadequately controlled with conventional therapy at different periods.

METHODS

We searched PubMed, Embase, and The Cochrane Library from inception to September 23, 2020. A total of six studies involving 4120 patients were included.

RESULTS

Compared with the control group, 15 mg and 5 mg of ertugliflozin were associated with higher risks of genital mycotic infections (GMIs) at 26 weeks (p < 0.0001 and p < 0.0001, respectively), 52 weeks (p < 0.00001 and p < 0.0001, respectively), and 104 weeks (p < 0.00001 and p < 0.0001, respectively). Moreover, females had a higher risk of GMIs than males in the 15 mg group at 26 weeks (p = 0.0008), 52 weeks (p < 0.0001), and 104 weeks (p = 0.02). At 104 weeks, 15 mg and 5 mg of ertugliflozin showed beneficial effects on symptomatic hypoglycemia (p < 0.00001 and p = 0.004, respectively) compared with the effects observed in the control group. Compared with the control group, 15 mg and 5 mg of ertugliflozin were associated with higher risks of drug-related adverse events at 26 weeks (p = 0.002 and p = 0.002, respectively); 15 mg of ertugliflozin was associated with a higher risk of discontinuation related to adverse events at 104 weeks (p = 0.03). No significant differences were found in the remaining safety outcomes.

CONCLUSION

This meta-analysis of randomized controlled trials indicates that ertugliflozin is tolerated by T2DM, but the risk of GMIs is noteworthy, especially among females in the high-dose group.

Safety of Sodium-Glucose Co-Transporter 2 Inhibitors

Sodium-glucose co-transporter 2 (SGLT2) inhibitors have a well-defined safety profile based on data obtained from numerous clinical trials, including cardiovascular outcomes trials (CVOTs) and postmarketing pharmacovigilance reporting. Adverse events including risk of genital mycotic infection and volume depletion-related events are consistent with the mechanism of action of this drug class. However, several emergent (albeit infrequent) serious safety issues have also been reported. In their respective CVOTs, the proportion of patients with reported diabetic ketoacidosis was similar in empagliflozin or canagliflozin compared with their placebo groups, but it was higher for dapagliflozin. Canagliflozin may be associated with an increased risk of bone fracture and lower limb amputation; however, data are inconclusive. There is no evidence linking SGLT2 inhibitors with an increased risk of cancer, but these agents, particularly dapagliflozin, should be used with caution in patients with hematuria or a history of bladder cancer. Postmarketing reports of acute kidney injury have occurred in patients receiving SGLT2 inhibitors, and cases identified in recent CVOTs occurred with similar frequency in SGLT2 inhibitor and placebo groups. Common adverse events associated with SGLT2 inhibitors (such as genital infections or volume depletion) are generally mild and manageable by patients or by primary care physicians, and the risk of rare events (such as ketoacidosis) can be minimized by appropriate patient selection and early recognition of symptoms. When selecting treatment, it is important that clinicians weigh the known risks of SGLT2 inhibitors against their proven benefits, including the reduction of adverse cardiovascular and renal outcomes.

Safety of Ipragliflozin in Patients with Type 2 Diabetes Mellitus: Pooled Analysis of Phase II/III/IV Clinical Trials

INTRODUCTION

Ipragliflozin is a selective sodium-glucose cotransporter 2 (SGLT2) inhibitor approved for the treatment of type 2 diabetes mellitus (T2DM). The objective of this pooled analysis was to characterise the safety profile of ipragliflozin based on safety data from published randomised controlled trials.

METHODS

Safety data from 12 randomised, phase II/III/IV placebo-controlled, parallel group, comparative studies of ipragliflozin in patients with T2DM were pooled. Treatment-emergent adverse events (TEAEs) were analysed for patients who had received at least one dose of ipragliflozin 50 mg (n = 1209) or placebo (n = 796) in studies lasting for up to 24 weeks. TEAEs of special interest and serious adverse events (SAEs) were assessed, as well as abnormal laboratory test and vital sign measurements.

RESULTS

The overall incidences of TEAEs and SAEs between the ipragliflozin and placebo groups were similar, 63.8% vs 59.3% and 2.5% vs 3.3%, respectively. The incidence of TEAEs leading to permanent discontinuation was lower for ipragliflozin (3.6%) than placebo (6.5%). The incidences of TEAEs of special interest including those related to urinary tract infection, cardiovascular events, renal disorder, fracture, malignant tumours and hypoglycaemia were also similar between the groups. Genital infections were more frequent with ipragliflozin (2.4%) than placebo (0.6%), as were pollakiuria/polyuria (6.0% vs 2.0%), volume depletion (4.9% vs 1.8%) and skin/subcutaneous tissue disorders (7.7% vs 4.4%). There were no reported cases of diabetic ketoacidosis, fractures, lower-limb amputation or Fournier's gangrene in ipragliflozin-treated patients across the 12 studies.

CONCLUSION

In randomised, placebo-controlled trials of patients with T2DM, ipragliflozin was well tolerated, with a similar overall incidence of TEAEs to placebo. No new safety signals were observed.

TRIAL REGISTRATION NUMBERS

NCT01071850, NCT00621868, NCT01057628, NCT01117584, NCT01135433, NCT01225081, NCT01242215, NCT02175784, NCT01505426, NCT02452632, NCT02794792, NCT01316094.

FUNDING

Astellas Pharma Inc.

Sodium glucose cotransporter 2 inhibitors and risk of genital mycotic and urinary tract infection: A population-based study of older women and men with diabetes

AIMS

The objective of the study was to quantify the association between SGLT2 inhibitors and genital mycotic infection and between SGLT2 inhibitors and urinary tract infection (UTI) within 30 days of drug initiation among older women and men.

MATERIALS AND METHODS

This was a retrospective cohort study using linked administrative databases of women and men with diabetes, aged 66 years or older, in Ontario, Canada. We compared the incidence of genital mycotic infection or UTI within 30 days between new users of an SGLT2 inhibitor and of a dipeptidyl-peptidase-4 (DPP4) inhibitor.

RESULTS

We identified 21 444 incident users of SGLT2 inhibitor and 22 463 incident users of DPP4 inhibitor. Among SGLT2 inhibitor users, there were 8848 (41%) women and the mean age at index was 71.8 ± 5 (SD) years. After adjusting for propensity score, age, sex and recent UTI, there was a 2.47-fold increased risk of genital mycotic infection with incident use of SGLT2 inhibitors (adjusted hazard ratio (HR), 2.47; 95% confidence interval (CI), 2.08-2.92; P < 0.001) within 30 days compared to incident use of DPP4 inhibitors. For UTI, the adjusted HR was 0.89 (95% CI, 0.78-1.00; P = 0.05).

CONCLUSIONS

Incident use of SGLT2 inhibitors among older women and men is associated with increased risk of genital mycotic infections within 30 days; there is no associated increased risk of UTI. These findings from a real-world setting provide evidence of the potential harms of SGLT2 inhibitors.

Comparative Efficacy and Safety Among Sodium-glucose Cotransporter-2 Inhibitors in Type 2 Diabetes - Results from a Retrospective Single-centre Study

Introduction: This retrospective analysis compared the real-world effectiveness and safety of sodium-glucose cotransporter-2 inhibitors (SGLT2i) in patients with type 2 diabetes mellitus in India. Methods: All patients initiated on canagliflozin (C; 100 mg), dapagliflozin (D; 10 mg) and empagliflozin (E; 10 mg) between January and December 2016 were identified from an urban outpatient facility. Intra- and inter-group changes in glycaemic and metabolic parameters were recorded. Results: At week 48 (median follow-up), mean changes from baseline in the C (n=29), D (n=65) and E groups (n=27), respectively, were -1.3% (p=0.0002), -0.9% (p<0.0001) and -0.7% (p=0.34) for glycated haemoglobin; -60.9 mg/dL (p=0.00), -50.2 mg/dL (p=0.00) and -46.7 mg/dL (p=0.01) for fasting plasma glucose; -100.6 mg/dL (p=0.00), -79.8 mg/dL (p=0.00) and -90.2 mg/dL (p=0.00) for postprandial plasma glucose; -1.7 kg (p<0.05), -2.1 kg (p=0.0004) and -3.7 kg (p=0.002) for body weight; -5.2 mmHg (p=0.10), -5.8 mmHg (p=0.009); 0.0 mmHg (p=0.80) for systolic blood pressure and -12.2% (p=0.26), -9.2% (p=0.27) and -9.7% (p=0.50) for proportion of patients taking insulin. The incidence rate of hypoglycaemia was 2.4% for C, 1.3% for D, and 6.4% for E group. No significant inter-group differences were noted. Conclusion: Overall intra-group changes in glycaemic and metabolic parameters were significant; however, inter-group changes among SGLT2i were not significant, thereby indicating a class effect of the efficacy and safety parameters.

Cardiorenal Protection: Potential of SGLT2 Inhibitors and GLP-1 Receptor Agonists in the Treatment of Type 2 Diabetes

Recent large clinical trials on sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists, with the aim of verifying cardiovascular safety, have revealed that these medications have a preventative advantage on adverse cardiovascular outcomes, including worsening of heart failure and deterioration of nephropathy, in patients with type 2 diabetes (T2D). These observed benefits do not seem to correlate with the glucose-lowering effect, and the underlying mechanism is being intensively investigated. Given the results from recent studies, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) recommend that patients with T2D and clinical cardiovascular disease (CVD) with inadequate glucose control despite treatment with metformin should receive an SGLT2 inhibitor or GLP-1 receptor agonist. In this review we summarize the results of recent cardiovascular outcome trials and discuss the potential clinical advantage of SGLT2 inhibitors and GLP-1 receptor agonists. We also present practical implications of these glucose-lowering agents for reducing the risk of adverse cardiovascular events and progressive renal comorbidity in patients with T2D and CVD.

Efficacy and Safety of Sodium-Glucose Cotransporter 2 Inhibitors in East Asians with Type 2 Diabetes: A Systematic Review and Meta-Analysis

INTRODUCTION

The aim of this study was to assess the efficacy and safety of sodium-glucose cotransporter 2 (SGLT2) inhibitors in East Asians with type 2 diabetes mellitus (T2DM).

METHODS

A literature search that focused primarily on the PubMed, Embase, and Cochrane library databases was performed. All randomized controlled trials (RCTs) which satisfied the inclusion and exculsion criteria were eligible to be included in the meta-analysis. Risk ratios (RRs) and weighted mean differences (WMDs) were used as statistical indicators for the analysis of dichotomous data and continuous outcomes, respectively. Pooled estimates were obtained using random-effects models in RevMan version 5.3.5.

RESULTS

Thirty-three RCTs (8496 randomized patients) fulfilled the eligibility criteria for inclusion in the meta-analysis. The meta-analysis showed that, compared with the control group, the use of SGLT2 inhibitors improved both glycated hemoglobin (HbA1c) in patients (WMD - 0.73%; 95% confidence interval [CI] - 0.84, - 0.61) and the percentage of patients with HbA1c  < 7% (RR 2.33; 95% CI 1.74, 3.12); lowered both fasting plasma glucose (WMD - 28.47 mg/dl; 95% CI - 32.86, - 24.08) and postprandial glucose (WMD - 52.32 mg/dl; 95% CI - 67.67, - 39.96); reduced body weight (WMD - 1.73 kg; 95% CI - 2.28, - 1.17); and did not increase the risk of hypoglycemia (RR 1.27; 95% CI 0.89, 1.82) and urinary tract infections (RR 0.93; 95% CI 0.68, 1.27). However, SGLT2 inhibitors did increase the risk of genital tract infections (GTIs) (RR 1.73; 95% CI 1.02, 2.96). The stratified analysis showed that patients with higher HbA1c levels at baseline may achieve a greater improvement in HbA1c after taking SGLT2 inhibitors, while those with higher body weight or a longer history of diabetes may have an increased risk of developing GTIs.

CONCLUSION

Current research suggests that SGLT2 inhibitors have favorable efficacy and safety in East Asian patients with T2DM.

Fournier´s Gangrene Under Sodium-Glucose Cotransporter 2 Inhibitor Therapy as a Life-Threatening Adverse Event: A Case Report and Review of the Literature

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a relatively new class of oral antidiabetic drugs. The US FDA has recently published a new warning about the safety of SGLT2 inhibitor administration in type 2 diabetes mellitus patients. There is an emerging evidence of an increased risk for developing Fournier´s gangrene (FG; a life-threatening complication) while under SGLT2 therapy. However, there are only three case reports and a total of 55 patients reported by the FDA to date. Therefore, there is a lack of evidence-based treatment algorithms for clinicians. We present the case of a 39-year-old male patient with diabetes on oral dapagliflozin, metformin, and sitagliptin therapy who was admitted with FG to our hospital. Following emergency scrotal surgery, he had to be transferred to the intensive care unit due to respiratory and circulatory insufficiency. After a prolonged 27-day hospital stay with delirium, blood glucose imbalance, and five further surgical interventions, the patient was stabilized and discharged. Dapagliflozin was discontinued permanently. This case demonstrates the risks of SGLT2 inhibitor therapy and the importance of early discontinuation after the occurrence of severe adverse events such as FG. According to the evidence in the literature, deranged glucose levels before admission are a common risk factor. However, further studies are required to identify patients at risks for FG and to investigate a direct connection with SGLT2 inhibitors.

Appraisal of Non-Cardiovascular Safety for Sodium-Glucose Co-Transporter 2 Inhibitors: A Systematic Review and Meta-Analysis of Placebo-Controlled Randomized Clinical Trials

Background: Whereas the cardiovascular safety of sodium-glucose co-transporter 2 (SGLT2) inhibitors has been well reported, there is limited data from controlled clinical trials regarding the non-cardiovascular safety. This was the focus of our study.

Methods and Findings: We systematically searched MEDLINE, EMBASE, and Cochrane Library (5^th Sep 2018) for randomized controlled trials (RCTs) that reported safety data for SGLT2 inhibitors and placebo. Relative risks (RRs) and their 95% confidence intervals (CIs) were pooled using random-effects models. Seventy RCTs (83 studies enrolling 36,958 patients in 78 publications) were identified. SGLT2 inhibitors were associated with a lower risk of serious adverse events (RR 0.90, 95% CI 0.86 to 0.94, P < 0.001), death (RR 0.78, 95% CI 0.64 to 0.94, P < 0.05), gastroenteritis (RR 0.38, 95% CI 0.20 to 0.72, P < 0.05), arthralgia (RR 0.72, 95% CI 0.54 to 0.96, P < 0.05), hypertension (RR 0.61, 95% CI 0.50 to 0.75, P < 0.001), and edema/peripheral edema (RR 0.49, 95% CI 0.33 to 0.72, P < 0.001) compared to placebo. SGLT2 inhibitors were associated with higher risk of infections compared to placebo (RR 1.27, 95% CI 1.17 to 1.37, P < 0.001), especially for genital mycotic infection (GMI) (RR 3.71, 95% CI 3.19 to 4.32, P < 0.001). Other significant effects were observed for osmotic diuresis–related AEs (RR 2.73, 95% CI 2.20 to 3.40, P < 0.001), volume-related AEs (RR 1.26, 95% CI 1.08 to 1.46, P < 0.05), renal-related AEs (RR 1.36, 95% CI 1.02 to 1.80, P < 0.05), hypoglycemia (RR 1.18, 95% CI 1.10 to 1.26, P < 0.001), and increased blood ketone bodies (RR 2.00, 95% CI 1.01 to 3.97, P < 0.05). Subgroup and sensitivity analyses strengthened the robustness of primary results.

Conclusion: Results from RCTs confirmed lower risk of death, serious adverse events, hypertension, and edema associated with type 2 diabetes mellitus (T2DM) patients treated with SGLT2 inhibitors when compared with placebo. The use of SGLT2 inhibitors were associated with higher risk of infection, osmotic diuresis, volume depletion effects, renal related AEs, and higher blood ketone bodies when compared with placebo.

SGLT2 Inhibitors: A Review of Their Antidiabetic and Cardioprotective Effects

Type 2 diabetes mellitus is a chronic metabolic disease associated with high cardiovascular (CV) risk. Sodium-glucose co-transporter 2 inhibitors (SGLT2i) are the latest class of antidiabetic medication that inhibit the absorption of glucose from the proximal tubule of the kidney and hence cause glycosuria. Four SGLT2i are currently commercially available in many countries: canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin. SGLT2i reduce glycated hemoglobin by 0.5%-1.0% and have shown favorable effects on body weight, blood pressure, lipid profile, arterial stiffness and endothelial function. More importantly, SGLT2i have demonstrated impressive cardioprotective and renoprotective effects. The main mechanisms underlying their cardioprotective effects have been attributed to improvement in cardiac cell metabolism, improvement in ventricular loading conditions, inhibition of the Na+/H+ exchange in the myocardial cells, alteration in adipokines and cytokines production, as well as reduction of cardiac cells necrosis and cardiac fibrosis. The main adverse events of SGLT2i include urinary tract and genital infections, as well as euglycemic diabetic ketoacidosis. Concerns have also been raised about the association of SGLT2i with lower limb amputations, Fournier gangrene, risk of bone fractures, female breast cancer, male bladder cancer, orthostatic hypotension, and acute kidney injury.

Use of Dapagliflozin in the Management of Type 2 Diabetes Mellitus: A Real-World Evidence Study in Indian Patients (FOREFRONT)

Background: Dapagliflozin is approved in India based on a controlled clinical study. This study included type 2 diabetes mellitus (T2DM) Indian patients to determine effectiveness of dapagliflozin in the real-world setup. Methods: Data were collected retrospectively and prospectively for 3 months. Primary endpoint was mean change in glycated hemoglobin (HbA1c) from baseline to months 3 and 6. Patients were stratified by baseline HbA1c and body mass index (BMI). Paired t-test or Wilcoxon signed-rank test at 5% level of significance with two-sided 95% confidence intervals analyzed endpoints. Results: Total 98.1% (n = 1941/1978) patients completed the study, majority of them were men (57.5%), <60 years (77.8%). Mean (standard deviation [SD]) HbA1c decreased significantly from baseline (9.11% [1.44]) to month 3 (8.11% [1.22]; Δ = 1.00% [1.01]) and month 6 (7.62% [1.04]; Δ = 1.49% [1.18]), P < 0.001. Per baseline HbA1c stratification, the largest mean (SD) decrease in HbA1c was in patients with baseline HbA1c >10% (1.86% [1.32] at month 3; 2.80% [1.22] at month 6). Decrease in mean body weight was significant from baseline (78.15 kg [13.48]) to month 3 (77.01 kg [13.21]; Δ = 1.14 kg [2.21]) and month 6 (76.16 kg [13.09]; Δ = 1.86 kg [3.04]), P < 0.001, with maximum weight loss in patients with BMI >30 kg/m² (1.60 kg [2.50] and 2.56 kg [3.50] at months 3 and 6, respectively). Systolic/diastolic blood pressure also improved. Of the 58 (2.9%) patients having ≥1 adverse event (AE), 9 (0.5%) had vulvovaginitis and 4 (0.2%) each had fungal infection and urinary tract infection (UTI). One patient had a serious AE (SAE) of UTI. No patients died or discontinued the study because of AEs or SAEs. Conclusion: Dapagliflozin significantly decreased HbA1c and body weight in Indian T2DM patients. Dapagliflozin was well tolerated and no new safety signals were detected.

Antidiabetic Effects of Hydroxytyrosol: In Vitro and In Vivo Evidence

Insulin resistance, a pathological condition characterized by defects in insulin action leads to the development of Type 2 diabetes mellitus (T2DM), a disease which is currently on the rise that pose an enormous economic burden to healthcare systems worldwide. The current treatment and prevention strategies are considerably lacking in number and efficacy and therefore new targeted therapies and preventative strategies are urgently needed. Plant-derived chemicals such as metformin, derived from the French lilac, have been used to treat/manage insulin resistance and T2DM. Other plant-derived chemicals which are not yet discovered, may have superior properties to prevent and manage T2DM and thus research into this area is highly justifiable. Hydroxytyrosol is a phenolic phytochemical found in olive leaves and olive oil reported to have antioxidant, anti-inflammatory, anticancer and antidiabetic properties. The present review summarizes the current in vitro and in vivo studies examining the antidiabetic properties of hydroxytyrosol and investigating the mechanisms of its action.

SGLT2 inhibitors in T2D and associated comorbidities - differentiating within the class

BACKGROUND

For patients with type 2 diabetes (T2D), cardiovascular disease (CVD) is the single most common cause of mortality. In 2008 and 2012, the Federal Drug Administration (FDA) and the European Medicines Agency (EMA) respectively mandated cardiovascular outcomes trials (CVOTs) on all new anti-diabetic agents, as prospective trials statistically powered to rule out excess cardiovascular risk in patients with T2D. Unexpectedly, some of these CVOTs have demonstrated not only cardiovascular safety, but also cardioprotective effects, as was first shown for the SGLT2 inhibitor empagliflozin in EMPA-REG OUTCOME.

EXPERT OPINION

To debate newly available CVOT data and to put them into context, we convened as a group of medical experts from the Central and Eastern European Region. Here we describe our discussions, focusing on the conclusions we can draw from EMPA-REG OUTCOME and other SGLT2 inhibitor CVOTs, including when considered alongside real-world evidence.

CONCLUSION

CVOTs investigating SGLT2 inhibitors have suggested benefits beyond glucose lowering that have been confirmed in real-world evidence studies.

Quantitative Systems Pharmacology: An Exemplar Model-Building Workflow With Applications in Cardiovascular, Metabolic, and Oncology Drug Development

Quantitative systems pharmacology (QSP), a mechanistically oriented form of drug and disease modeling, seeks to address a diverse set of problems in the discovery and development of therapies. These problems bring a considerable amount of variability and uncertainty inherent in the nonclinical and clinical data. Likewise, the available modeling techniques and related software tools are manifold. Appropriately, the development, qualification, application, and impact of QSP models have been similarly varied. In this review, we describe the progressive maturation of a QSP modeling workflow: a necessary step for the efficient, reproducible development and qualification of QSP models, which themselves are highly iterative and evolutive. Furthermore, we describe three applications of QSP to impact drug development; one supporting new indications for an approved antidiabetic clinical asset through mechanistic hypothesis generation, one highlighting efficacy and safety differentiation within the sodium‐glucose cotransporter‐2 inhibitor drug class, and one enabling rational selection of immuno‐oncology drug combinations.

Recent advances in diabetes treatments and their perioperative implications

PURPOSE OF REVIEW

The implications for perioperative management of new oral antihyperglycemic medications and new insulin treatment technologies are reviewed.

RECENT FINDINGS

The preoperative period represents an opportunity to optimize glycemic control and potentially to reduce adverse outcomes. There is now general consensus that the optimal blood glucose target for hospitalized patients is approximately 106-180 mg/dl (6-10 mmol/l). Recommendations for the management of antihyperglycemic medications vary among national guidelines. It may not be necessary to cease all antihyperglycemic agents prior to surgery. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are associated with higher rates of ketoacidosis especially in acutely unwell and postsurgical patients. The clinical practice implications of new insulin formulations, and new systems for insulin delivery, are not clear. The optimal perioperative management of these will vary depending on local institutional factors such as staff skills and existing clinical practices. Improved hospital care delivery standards, quality assurance, process improvements, consistency in clinical practice, and coordinated multidisciplinary teamwork should be a major focus for improving outcomes of perioperative patients with diabetes.

SUMMARY

Sulfonylureas and SGLT2i should be ceased before moderate or major surgery. Other oral antihyperglycemic therapies may be continued or ceased. Complex patients and/or new therapies require specialized multidisciplinary management.

A safety update on sodium glucose co-transporter 2 inhibitors

Sodium glucose co-transporter 2 inhibitors (SGLT2is) are the first class of glucose lowering agent to be shown to reduce cardiovascular events. They are generally well tolerated with infrequent serious adverse events. The most frequent side effect is genital mycotic infections with candida species that are usually mild to moderate in severity, easily treated and infrequently recur. Urinary tract infections, although common in patients with diabetes, have not been shown to be increased in controlled studies with SGLT2i. Hypoglycaemia can occur when an SGLT2i is added to agents that cause hypoglycaemia, such as insulin or sulphonylureas. Volume depletion and hypotension is infrequent and can be minimized by adjusting diuretic and antihypertensive treatment in patients at risk. Acute renal failure or kidney injury was observed in early observational studies. However, in randomized controlled trials (RCTs) and in more recent observational studies a decreased incidence of acute kidney injury was observed in SGLT2-treated patients compared to those receiving either placebo or another class of glucose lowering agents. An increased incidence of amputation (largely feet and toes) was observed in the RCT with canagliflozin but not with the other SGLT2i. Observational studies have shown either an increased risk of amputation with other agents whereas another study showed no increase. Although the increased risk of amputation is very low, avoidance of SGLT2i in patients at high risk seems prudent. Increased incidence of fractures was observed with canagliflozin but not with SGLT2i nor in a meta-analysis that included canagliflozin, empagliflozin and dapagliflozin. No increased incidence of cancer has been observed in either RCTs or observational studies.

Empagliflozin in posttransplantation diabetes mellitus: A prospective, interventional pilot study on glucose metabolism, fluid volume, and patient safety

The safety and efficacy of sodium-glucose cotransporter 2 inhibitors in posttransplantation diabetes mellitus is unknown. We converted stable kidney transplant patients to 10 mg empagliflozin, aiming at replacing their insulin therapy (<40 IU/d). N = 14 participants (the required sample size) completed the study visits through 4 weeks and N = 8 through 12 months. Oral glucose tolerance test (OGTT)-derived 2-hour glucose (primary end point) increased from 232 ± 82 mg/dL (baseline) to 273 ± 116 mg/dL (4 weeks, P = .06) and to 251 ± 71 mg/dL (12 months, P = .41). Self-monitored blood glucose and hemoglobin A1c were also clinically inferior with empagliflozin monotherapy, such that insulin was reinstituted in 3 of 8 remaining participants. Five participants (2 of them dropouts) vs nine of 24 matched reference patients developed bacterial urinary tract infections (P = .81). In empagliflozin-treated participants, oral glucose insulin sensitivity decreased and beta-cell glucose sensitivity increased at the 4-week and 12-month OGTTs. Estimated glomerular filtration rate and bioimpedance spectroscopy-derived extracellular and total body fluid volumes decreased by 4 weeks, but recovered. All participants lost body weight. No participant developed ketoacidosis; 1 patient developed balanitis. In conclusion, although limited by sample size and therefore preliminary, these results suggest that empagliflozin can safely be used as add-on therapy, if posttransplant diabetes patients are monitored closely (NCT03113110).

Comparative risk of genital infections associated with sodium-glucose co-transporter-2 inhibitors

The extent to which sodium-glucose co-transporter-2 (SGLT2) inhibitors increase the risk of genital infections in routine clinical care, compared with other antidiabetic medications, is not clear, or whether the increased risk is consistent across gender or age subgroups, within individual SGLT2 agents, or if it is more pronounced at a particular time after treatment initiation. We conducted a retrospective cohort study using two US commercial claims databases (2013-2017). In the primary analysis, 1:1 propensity score-matched cohorts of female and male subjects with type 2 diabetes mellitus initiating SGLT2 versus dipeptidyl peptidase-4 inhibitors were created. The outcome was a composite of genital candidal infections, vaginitis or vulvovaginitis in women, and genital candidal infections, balanitis, balanoposthitis, phimosis or paraphimosis in men. Among propensity score-matched cohorts of 129 994 women and 156 074 men, the adjusted hazard ratio (HR) and excess risk per 1000 person-years for SGLT2 versus DPP-4 inhibitors was 2.81 (95% confidence interval [CI], 2.64, 2.99) and 87.4 (95% CI, 79.1, 96.2) respectively for women, and was 2.68 (95% CI, 2.31, 3.11) and 11.9 (95% CI, 9.3-15.0) for men. Findings were similar in the SGLT2 inhibitor versus GLP-1 agonist comparison, more pronounced in the subgroup of patients aged ≥60 (HR, 4.45 [95% CI, 3.83-5.17] in women and 3.30 [95% CI, 2.56-4.25] in men), and no meaningful difference across individual SGLT2 inhibitors was identified. This increase in risk was evident in the first month of treatment initiation and remained elevated throughout the course of therapy. SGLT2 inhibitors were associated with an approximately 3-fold increase in risk of genital infections.