151
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Danne T, Cariou B, Banks P, Brandle M, Brath H, Franek E, Kushner JA, Lapuerta P, McGuire DK, Peters AL, Sawhney S, Strumph P. HbA 1c and Hypoglycemia Reductions at 24 and 52 Weeks With Sotagliflozin in Combination With Insulin in Adults With Type 1 Diabetes: The European inTandem2 Study. Diabetes Care 2018; 41:1981-1990. [PMID: 29937431 DOI: 10.2337/dc18-0342] [Citation(s) in RCA: 118] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 05/17/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The objective of this study was to evaluate the efficacy and safety of the dual sodium-glucose cotransporter 1 and 2 inhibitor sotagliflozin compared with placebo when combined with optimized insulin in adults with type 1 diabetes (T1D). RESEARCH DESIGN AND METHODS In a double-blind, 52-week, international phase 3 trial, adults with T1D were randomized to placebo (n = 258) or once-daily oral sotagliflozin 200 mg (n = 261) or 400 mg (n = 263) after 6 weeks of insulin optimization. The primary outcome was change in HbA1c from baseline to 24 weeks. The first secondary end point was a composite of the proportion of patients with HbA1c <7.0%, no episode of severe hypoglycemia, and no episode of diabetic ketoacidosis (DKA) at week 24. Fasting glucose, weight, insulin dose, and safety end points were assessed through 52 weeks. RESULTS At 24 weeks, placebo-adjusted changes in HbA1c from baseline (7.8%) were -0.37% and -0.35% with sotagliflozin 200 and 400 mg, respectively (P < 0.001), and differences were maintained at 52 weeks. At 52 weeks, greater proportions of sotagliflozin-treated patients (200 mg: 25.67%; 400 mg: 26.62%) than placebo-treated patients (14.34%; P ≤ 0.001) met the composite end point, and sotagliflozin 400 mg reduced fasting plasma glucose (-0.87 mmol/L; P = 0.008), weight (-2.92 kg; P < 0.001), and total daily insulin dose (-8.2%; P = 0.001). In a 24-week continuous glucose monitoring (CGM) substudy, postprandial glucose decreased (P ≤ 0.009) and CGM demonstrated up to 3 h more time in the target range of 3.9-10.0 mmol/L with sotagliflozin. Treatment satisfaction increased and diabetes distress decreased with sotagliflozin (P < 0.05 vs. placebo). The frequency of documented hypoglycemia was lower with sotagliflozin, and severe hypoglycemia occurred by week 52 in 13 patients (5.0%), 13 patients (5.0%), and 6 patients (2.3%) treated with placebo and sotagliflozin 200 and 400 mg, respectively. DKA occurred in 0 of 258 patients, 6 of 261 patients (2.3%), and 9 of 263 patients (3.4%) in these respective groups. CONCLUSIONS In a 1-year study, sotagliflozin was associated with statistically significant HbA1c reductions. More episodes of DKA and fewer episodes of documented and severe hypoglycemia were observed in patients using sotagliflozin relative to those receiving placebo (ClinicalTrials.gov, NCT02421510).
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Affiliation(s)
- Thomas Danne
- Department of Diabetes, Endocrinology, and Clinical Research, Children's and Youth Hospital Auf der Bult, Hannover Medical School, Hannover, Germany
| | - Bertrand Cariou
- L'institut du thorax, Department of Endocrinology, CHU Nantes, CIC 1413, INSERM, Nantes, France
| | | | - Michael Brandle
- Department of Internal Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Helmut Brath
- Diabetes Outpatient Clinic, Health Center South, Vienna, Austria
| | - Edward Franek
- Mossakowski Medical Research Center, Polish Academy of Sciences, Warsaw, Poland
| | - Jake A Kushner
- Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | | | - Darren K McGuire
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Anne L Peters
- University of Southern California Keck School of Medicine, Los Angeles, CA
| | | | - Paul Strumph
- Lexicon Pharmaceuticals, Inc., The Woodlands, TX
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152
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van Niekerk C, Wallace J, Takata M, Yu R. Euglycaemic diabetic ketoacidosis in bariatric surgery patients with type 2 diabetes taking canagliflozin. BMJ Case Rep 2018; 2018:bcr-2017-221527. [PMID: 30131409 DOI: 10.1136/bcr-2017-221527] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 52-year-old type 2 diabetic man previously on canagliflozin developed severe anion gap metabolic acidosis and markedly elevated beta-hydroxybutyrate on postoperative day (POD) 2 status post laparoscopic Roux-en-Y gastric bypass. An insulin drip and aggressive intravenous fluid repletion were initiated, and electrolytes were monitored and repleted. His anion gap closed, and he was discharged on POD 4. This euglycaemic diabetic ketoacidosis prolonged his hospital stay by 2 days.
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Affiliation(s)
- Christoffel van Niekerk
- Department of Internal Medicine, Scripps Clinic - Scripps Green Hospital, La Jolla, California, USA
| | - James Wallace
- Department of Internal Medicine, Scripps Clinic - Scripps Green Hospital, La Jolla, California, USA
| | - Mark Takata
- Department of Internal Medicine, Scripps Clinic - Scripps Green Hospital, La Jolla, California, USA
| | - Roger Yu
- Department of Internal Medicine, Scripps Clinic - Scripps Green Hospital, La Jolla, California, USA
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153
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Blunck JR, Newman JW, Fields RK, Croom JE. Therapeutic augmentation of ketogenic diet with a sodium-glucose cotransporter 2 inhibitor in a super-refractory status epilepticus patient. EPILEPSY & BEHAVIOR CASE REPORTS 2018; 10:61-64. [PMID: 30073144 PMCID: PMC6068319 DOI: 10.1016/j.ebcr.2018.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 05/18/2018] [Accepted: 05/29/2018] [Indexed: 01/01/2023]
Abstract
Background A ketogenic diet (KD) may have a role in treating patients in super-refractory status epilepticus (SRSE). Sodium-glucose cotransporter 2 (SGLT2) inhibitors have a risk of ketoacidosis that could facilitate induction of KD. Case summary A 42-year-old with a history of drug resistant epilepsy developed SRSE requiring several pharmacological interventions during her hospital course including the initiation of KD that failed. SGLT2 inhibitor therapy was initiated in a successful attempt to augment ketone production. Conclusion SGLT2 inhibitors may have a therapeutic value in SRSE patients who cannot achieve ketosis with KD alone. Super-refractory status epilepticus (SRSE) carries a high risk of morbidity and mortality despite both pharmacologic and non-pharmacologic interventions. The ketogenic diet can play an important role as an adjunct treatment for these patients, but delaying ketosis could negate those benefits. Sodium-glucose cotransporter 2 inhibitors can carry an increased risk of ketoacidosis that may benefit patients in SRSE who do not achieve ketosis on the ketogenic diet alone.
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Affiliation(s)
- Joseph R Blunck
- Saint Luke's Hospital, 4401 Wornall Rd., 64111 Kansas City, MO, United States of America
| | - Joseph W Newman
- Saint Luke's Hospital, 4401 Wornall Rd., 64111 Kansas City, MO, United States of America
| | - Ronald K Fields
- Saint Luke's Hospital, 4401 Wornall Rd., 64111 Kansas City, MO, United States of America
| | - John E Croom
- Saint Luke's Hospital, 4401 Wornall Rd., 64111 Kansas City, MO, United States of America
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154
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Sloan G, Kakoudaki T, Ranjan N. Prolonged diabetic ketoacidosis associated with canagliflozin. Endocrinol Diabetes Metab Case Rep 2018; 2018:EDM170177. [PMID: 29899991 PMCID: PMC5993060 DOI: 10.1530/edm-17-0177] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 05/10/2018] [Indexed: 01/11/2023] Open
Abstract
We report a case of a 63-year-old man who developed diabetic ketoacidosis (DKA) associated with canagliflozin, a sodium glucose co-transporter 2 (SGLT-2) inhibitor. He presented acutely unwell with a silent myocardial infarction, diverticulitis and DKA with a minimally raised blood glucose level. Standard therapy for DKA was initiated. Despite this, ketonaemia persisted for a total of 12 days after discontinuation of canagliflozin. Glucosuria lasting for several days despite discontinuation of the medications is a recognised phenomenon. However, this is the longest duration of ketonaemia to be reported. The cause of prolonged SGLT-2 inhibition remains uncertain. Deviation from the normal DKA treatment protocol and use of personalised regimens may be required in order to prevent relapse into ketoacidosis while avoiding hypoglycaemia in those that develop this condition. Learning points Diabetic ketoacidosis (DKA) may develop in the presence of lower-than-expected blood glucose levels in patients treated with a sodium glucose co-transporter 2 (SGLT-2) inhibitor.Certain individuals prescribed with SGLT-2 inhibitors may be more at risk of DKA, for example, those with a low beta cell function reserve, excessive alcohol consumption and a low carbohydrate diet.In order to reduce the risk of SGLT-2 inhibitor-associated DKA, all patients must be carefully selected before prescription of the medication and appropriately educated.Increased serum ketone levels and glucosuria have been reported to persist for several days despite discontinuation of their SGLT-2 inhibitor.Physicians should consider individualised treatment regimens for subjects with prolonged DKA in the presence of SGLT-2 inhibition.
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Affiliation(s)
- Gordon Sloan
- Diabetes and Endocrinology Department, Barnsley District General Hospital, Barnsley, UK
| | - Tania Kakoudaki
- Diabetes and Endocrinology Department, Barnsley District General Hospital, Barnsley, UK
| | - Nishant Ranjan
- Diabetes and Endocrinology Department, Barnsley District General Hospital, Barnsley, UK
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155
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Abdelsameea AA, Kabil SL. Mitigation of cisplatin-induced peripheral neuropathy by canagliflozin in rats. Naunyn Schmiedebergs Arch Pharmacol 2018; 391:945-952. [PMID: 29862426 DOI: 10.1007/s00210-018-1521-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 05/28/2018] [Indexed: 01/27/2023]
Abstract
Peripheral nervous system neurotoxicity is the most problematic complication of cisplatin treatment. In this study, we have addressed the possible neuroprotective effect of canagliflozin on cisplatin-induced peripheral neurotoxicity in rats. Rats were randomly allocated into the following: control (vehicle) group, received hydhroxypropyl methyl cellulose; cisplatin group, injected cisplatin 2 mg/kg intraperitoneal, twice a week for 5 consecutive weeks; canagliflozin-cisplatin of received canagliflozin, 10 mg/kg/day by gavage and cisplatin in the same schedule like cisplatin group. Thermal nociception and rotarod performance were assessed. Malondialdehyde (MDA), reduced glutathione (GSH), tumor necrosis factor-α (TNF-α), and caspase 3 were determined in serum. Hematoxylin and eosin (H&E) and immunohistochemical stained sciatic nerve sections were examined. Cisplatin induced thermal hypoalgesia and decreased rotarod performance as well as GSH serum level while increased MDA, TNF-α, and caspase-3 serum levels with atrophy and fragmentation of the nerve fibers with decreased expression of myelin basic protein. Canagliflozin prevented thermal hypoalgesia and improved rotarod performance with increment in GSH serum level while decreased MDA, TNF-α, and caspase-3 levels as well as prevented fragmentation of the nerve fibers and enhanced myelin basic protein expression in relation to cisplatin group. Canagliflozin attenuates the neurotoxic effect of cisplatin through anti-inflammatory and anti-oxidant actions as well as inhibition of apoptosis.
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Affiliation(s)
- Ahmed A Abdelsameea
- Department of Pharmacology, Faculty of Medicine-Zagazig University, Zagazig, Egypt.
| | - Soad L Kabil
- Department of Pharmacology, Faculty of Medicine-Zagazig University, Zagazig, Egypt
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156
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157
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Hallberg SJ, McKenzie AL, Williams PT, Bhanpuri NH, Peters AL, Campbell WW, Hazbun TL, Volk BM, McCarter JP, Phinney SD, Volek JS. Effectiveness and Safety of a Novel Care Model for the Management of Type 2 Diabetes at 1 Year: An Open-Label, Non-Randomized, Controlled Study. Diabetes Ther 2018; 9:583-612. [PMID: 29417495 PMCID: PMC6104272 DOI: 10.1007/s13300-018-0373-9] [Citation(s) in RCA: 212] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Carbohydrate restriction markedly improves glycemic control in patients with type 2 diabetes (T2D) but necessitates prompt medication changes. Therefore, we assessed the effectiveness and safety of a novel care model providing continuous remote care with medication management based on biometric feedback combined with the metabolic approach of nutritional ketosis for T2D management. METHODS We conducted an open-label, non-randomized, controlled, before-and-after 1-year study of this continuous care intervention (CCI) and usual care (UC). Primary outcomes were glycosylated hemoglobin (HbA1c), weight, and medication use. Secondary outcomes included fasting serum glucose and insulin, HOMA-IR, blood lipids and lipoproteins, liver and kidney function markers, and high-sensitivity C-reactive protein (hsCRP). RESULTS 349 adults with T2D enrolled: CCI: n = 262 [mean (SD); 54 (8) years, 116.5 (25.9) kg, 40.4 (8.8) kg m2, 92% obese, 88% prescribed T2D medication]; UC: n = 87 (52 (10) years, 105.6 (22.15) kg, 36.72 (7.26) kg m2, 82% obese, 87% prescribed T2D medication]. 218 participants (83%) remained enrolled in the CCI at 1 year. Intention-to-treat analysis of the CCI (mean ± SE) revealed HbA1c declined from 59.6 ± 1.0 to 45.2 ± 0.8 mmol mol-1 (7.6 ± 0.09% to 6.3 ± 0.07%, P < 1.0 × 10-16), weight declined 13.8 ± 0.71 kg (P < 1.0 × 10-16), and T2D medication prescription other than metformin declined from 56.9 ± 3.1% to 29.7 ± 3.0% (P < 1.0 × 10-16). Insulin therapy was reduced or eliminated in 94% of users; sulfonylureas were entirely eliminated in the CCI. No adverse events were attributed to the CCI. Additional CCI 1-year effects were HOMA-IR - 55% (P = 3.2 × 10-5), hsCRP - 39% (P < 1.0 × 10-16), triglycerides - 24% (P < 1.0 × 10-16), HDL-cholesterol + 18% (P < 1.0 × 10-16), and LDL-cholesterol + 10% (P = 5.1 × 10-5); serum creatinine and liver enzymes (ALT, AST, and ALP) declined (P ≤ 0.0001), and apolipoprotein B was unchanged (P = 0.37). UC participants had no significant changes in biomarkers or T2D medication prescription at 1 year. CONCLUSIONS These results demonstrate that a novel metabolic and continuous remote care model can support adults with T2D to safely improve HbA1c, weight, and other biomarkers while reducing diabetes medication use. CLINICALTRIALS. GOV IDENTIFIER NCT02519309. FUNDING Virta Health Corp.
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Affiliation(s)
- Sarah J Hallberg
- Medically Supervised Weight Loss, Indiana University Health Arnett, Lafayette, IN, USA
- Virta Health, San Francisco, CA, USA
| | | | | | | | - Anne L Peters
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Wayne W Campbell
- Department of Nutrition Science, Purdue University, West Lafayette, IN, USA
| | - Tamara L Hazbun
- Medically Supervised Weight Loss, Indiana University Health Arnett, Lafayette, IN, USA
| | | | - James P McCarter
- Virta Health, San Francisco, CA, USA
- Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Jeff S Volek
- Virta Health, San Francisco, CA, USA
- Department of Human Sciences, The Ohio State University, Columbus, OH, USA
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158
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Meyer EJ, Gabb G, Jesudason D. SGLT2 Inhibitor-Associated Euglycemic Diabetic Ketoacidosis: A South Australian Clinical Case Series and Australian Spontaneous Adverse Event Notifications. Diabetes Care 2018; 41:e47-e49. [PMID: 29440112 DOI: 10.2337/dc17-1721] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 01/02/2018] [Indexed: 02/03/2023]
Affiliation(s)
- Emily J Meyer
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia .,Discipline of Medicine, University of Adelaide, Adelaide, Australia.,Department of Endocrinology and Diabetes, The Queen Elizabeth Hospital, Woodville, Australia
| | - Genevieve Gabb
- Discipline of Medicine, University of Adelaide, Adelaide, Australia.,Department of General Medicine, Royal Adelaide Hospital, Adelaide, Australia
| | - David Jesudason
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, Australia.,Department of Endocrinology and Diabetes, The Queen Elizabeth Hospital, Woodville, Australia
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159
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Isaacs M, Tonks KT, Greenfield JR. Euglycaemic diabetic ketoacidosis in patients using sodium-glucose co-transporter 2 inhibitors. Intern Med J 2018; 47:701-704. [PMID: 28580740 DOI: 10.1111/imj.13442] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 02/04/2017] [Accepted: 02/12/2017] [Indexed: 12/01/2022]
Abstract
Sodium-glucose co-transporter 2 inhibitors (SGLT2i) are an increasingly prescribed class of medication for type 2 diabetes mellitus. Euglycaemic diabetic ketoacidosis (euDKA) has been reported in association with SGLT2i use. Clinicians need to understand how to recognise and treat this complication. We describe three cases of euDKA in patients treated with SGLT2i.
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Affiliation(s)
- Michelle Isaacs
- Department of Endocrinology and Diabetes, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Katherine T Tonks
- Department of Endocrinology and Diabetes, St Vincent's Hospital, Sydney, New South Wales, Australia.,Diabetes and Metabolism Division, Garvan Institute of Medical Research, Sydney, New South Wales, Australia.,Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Jerry R Greenfield
- Department of Endocrinology and Diabetes, St Vincent's Hospital, Sydney, New South Wales, Australia.,Diabetes and Metabolism Division, Garvan Institute of Medical Research, Sydney, New South Wales, Australia.,Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
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160
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Milder DA, Milder TY, Kam PCA. Sodium-glucose co-transporter type-2 inhibitors: pharmacology and peri-operative considerations. Anaesthesia 2018. [DOI: 10.1111/anae.14251] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- D. A. Milder
- Concord Repatriation Hospital, Hospital Road; Concord NSW Australia
| | - T. Y. Milder
- St. Vincent's Hospital; Darlinghurst NSW Australia
| | - P. C. A. Kam
- University of Sydney; Royal Prince Alfred Hospital; Camperdown NSW Australia
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161
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Jabbour S, Seufert J, Scheen A, Bailey CJ, Karup C, Langkilde AM. Dapagliflozin in patients with type 2 diabetes mellitus: A pooled analysis of safety data from phase IIb/III clinical trials. Diabetes Obes Metab 2018; 20:620-628. [PMID: 28950419 PMCID: PMC5836959 DOI: 10.1111/dom.13124] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 09/13/2017] [Accepted: 09/21/2017] [Indexed: 12/30/2022]
Abstract
AIM To evaluate the safety and tolerability of dapagliflozin, a highly selective sodium-glucose co-transporter-2 inhibitor, in patients with type 2 diabetes mellitus (T2DM). METHODS Data were pooled from 13 placebo-controlled trials of up to 24 weeks' duration (dapagliflozin, n = 2360; placebo, n = 2295). Larger placebo-/comparator-controlled pools of 21 (≤208 weeks; dapagliflozin, n = 5936; control, n = 3403) and 30 trials (≥12 weeks; dapagliflozin, n = 9195; control, n = 4629) assessed the rare adverse events (AEs) of diabetic ketoacidosis (DKA) and lower limb amputation, respectively. RESULTS Over 24 weeks, the overall incidence of AEs and serious AEs (SAEs) was similar for dapagliflozin and placebo: 60.0% vs 55.7% and 5.1% vs 5.4%, respectively. Rates of hypoglycaemia, volume depletion AEs, urinary tract infections (UTIs) and fractures were balanced between the groups. Genital infections were more frequent with dapagliflozin (5.5%) vs placebo (0.6%) and renal function AEs occurred in 3.2% vs 1.8% of patients (the most common renal AE was decreased creatinine clearance: 1.1% vs 0.7%). In the 21-study pool, 1 SAE of DKA and 3 AEs of ketonuria/metabolic acidosis occurred with dapagliflozin vs none with control; estimated combined incidence for these events was 0.03% (95% confidence interval 0.010-0.089). In the 30-study pool, lower limb amputation occurred in 8 (0.1%) and 7 (0.2%) patients receiving dapagliflozin and control, respectively. CONCLUSION The overall incidence rates of AEs and SAEs were similar in the dapagliflozin and placebo/control groups, including the incidence of hypoglycaemia, volume depletion, fractures, UTIs, amputations and DKA. Genital infections were more frequent with dapagliflozin than placebo.
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Affiliation(s)
- Serge Jabbour
- Department of Endocrinology, Sidney Kimmel Medical College at Thomas Jefferson UniversityPhiladelphiaPennsylvania
| | - Jochen Seufert
- Division of Endocrinology and Diabetology, Department of Internal Medicine IIUniversity Hospital of Freiburg, Medical Faculty, University of FreiburgFreiburgGermany
| | - Andre Scheen
- Department of Medicine, University of LiègeLiègeBelgium
| | | | - Cathrina Karup
- Department of AZ Global Regulatory Affairs, Patient Safety and QA (GRAPSQA), AstraZeneca GothenburgMölndalSweden
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162
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Chacko B, Whitley M, Beckmann U, Murray K, Rowley M. Postoperative Euglycaemic Diabetic Ketoacidosis Associated with Sodium–Glucose Cotransporter-2 Inhibitors (Gliflozins): A Report of Two Cases and Review of the Literature. Anaesth Intensive Care 2018. [DOI: 10.1177/0310057x1804600212] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Sodium–glucose cotransporter-2 inhibitor (SGLT2i)-associated euglycaemic diabetic ketoacidosis (euDKA) is a serious and increasingly recognised complication of treatment with this class of oral hypoglycaemic agents and can present a diagnostic challenge, resulting in delayed recognition, inappropriate treatment and potentially life-threatening acidosis. We present two cases of patients developing SGLT2i-associated euDKA in the early postoperative period. We support ceasing SGLT2i for 72 hours preoperatively and would suggest continuing to withhold the medication until oral intake is restored, and recommend a wider awareness of SGLT2i-associated diabetic ketoacidosis (DKA) amongst patients and their healthcare providers with an emphasis on checking ketone levels irrespective of blood glucose levels in the postoperative setting.
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Affiliation(s)
- B. Chacko
- Nephrologist, Newcastle Private Hospital; Senior Staff Specialist, Nephrology and Transplantation unit, John Hunter Hospital; Conjoint Senior Lecturer, School of Medicine and Public Health, University of Newcastle; Newcastle, New South Wales
| | - M. Whitley
- Intensive Care Unit, Newcastle Private Hospital, Newcastle, New South Wales
| | - U. Beckmann
- Intensivist, Newcastle Private Hospital; Senior Staff Specialist, Intensive Care Unit, John Hunter Hospital; Conjoint Senior Lecturer, School of Medicine and Public Health, University of Newcastle; Newcastle, New South Wales
| | - K. Murray
- Endocrinologist, Newcastle Private Hospital; Senior Staff Specialist, Endocrine and Diabetes Unit, John Hunter Hospital; Newcastle, New South Wales
| | - M. Rowley
- Intensivist, Newcastle Private Hospital; Senior Staff Specialist, Intensive Care Unit, John Hunter Hospital; Conjoint Lecturer, School of Medicine and Public Health, University of Newcastle; Newcastle, New South Wales
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163
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The Good, the Bad, and the Ugly: Sodium–Glucose Cotransporter-2 Inhibitors (Gliflozins) and Perioperative Diabetes. Anaesth Intensive Care 2018. [DOI: 10.1177/0310057x1804600202] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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164
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Barengolts E. “The Proof is in the Pudding”: Do SGLT2 Inhibitors Cause Diabetic Ketoacidosis? AACE Clin Case Rep 2018. [DOI: 10.4158/accr-2017-0091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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165
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Abstract
BACKGROUND Sodium-glucose co-transporter 2 inhibitors have been shown to reduce body weight. However, little is known about whether a reduction in body weight affects glycemic and non-glycemic parameters. OBJECTIVES The aim of this study was to investigate the link between the changes in body weight and those in metabolic parameters in drug-naïve subjects with type 2 diabetes mellitus (T2DM) receiving ipragliflozin monotherapy. METHODS Subjects received ipragliflozin monotherapy 25-50 mg/day for 3 months (n = 33). They were then divided into two groups: group L ('lost'; n = 17) comprised patients who lost weight (change [Δ] in body mass index [BMI] ≤ -0.75, p < 0.00001), and group N ('neutral'; n = 16) comprised patients who did not lose weight (ΔBMI > -0.75, not significant [NS]). RESULTS In these two groups, similar reductions were observed in glycated hemoglobin (HbA1c) levels (group L: 9.76-8.02%, p < 0.00001; group N: 10.07-8.36%, p < 0.0005). Homeostasis model assessment (HOMA)-B levels increased in both groups, with inter-group differences (p < 0.05; +38.91 vs. +96.83% in group L and N, respectively). However, some parameters showed distinct regulatory patterns. For instance, in group L, reductions were observed in HOMA-R (-20.18%, p < 0.04) and uric acid (UA; -8.91%, p < 0.02) levels. Correlations were seen between the change in HOMA-R and those in fasting blood glucose (FBG) levels (R = 0.557, p < 0.02). Non-significant increases in free fatty acid (FFA) levels and decreases in non-high-density lipoprotein cholesterol (non-HDL-C) or low-density lipoprotein cholesterol (LDL-C) levels were also noted. In group N, reductions in FFA levels (-17.07%, p < 0.05) were observed, and negative correlations were seen between ΔHOMA-B and ΔFBG (R = -0.4781, p < 0.05) and between Δ FFA and Δ HOMA-B levels (R = -0.4305, p < 0.05). Non-significant increases in non-HDL-C and LDL-C levels were also noted. Inter-group differences existed between group L and group N in the changes in non-HDL-C and LDL-C levels (both p < 0.05). CONCLUSIONS These results indicate that ipragliflozin may possess distinct dual glucose-lowering mechanisms depending on body weight changes. Degrees of insulin resistance decrease in subjects who lose weight. Conversely, ipragliflozin reduces lipotoxicity (FFA levels), thereby activating beta-cell function, in subjects who do not lose weight. Similar glycemic efficacies were observed in both cases. In patients who lost weight, ipragliflozin was associated with improvements in the levels of metabolic parameters related to cardiovascular risk factors, including UA and atherogenic lipid levels (non-HDL-C and LDL-C) compared with those who did not lose weight.
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Woo VC, Berard LD, Bajaj HS, Ekoé JM, Senior PA. Considerations for Initiating a Sodium-Glucose Co-Transporter 2 Inhibitor in Adults With Type 2 Diabetes Using Insulin. Can J Diabetes 2018; 42:88-93. [DOI: 10.1016/j.jcjd.2017.01.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 01/25/2017] [Accepted: 01/27/2017] [Indexed: 01/11/2023]
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167
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Dandona P, Ghanim H, Chaudhuri A. Incretins: Beyond type 2 diabetes. Diabetes Obes Metab 2018; 20 Suppl 1:59-67. [PMID: 29364583 DOI: 10.1111/dom.13153] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 11/01/2017] [Accepted: 11/02/2017] [Indexed: 12/11/2022]
Abstract
While the use of incretins, including GLP-1 receptor agonists and PDD-IV inhibitors, is well established in the treatment of type 2 diabetes, many other aspects of these agents are yet to be discovered and utilized for their potential clinical benefit. These include the potential role of GLP-1 receptor agonists in the induction of weight loss, blood pressure reduction, anti-inflammatory and nephro- and cardio-protective actions. Their potential benefit in type 1 diabetes is also being investigated. This review will attempt to comprehensively describe novel discoveries in the field of incretin pathophysiology and pharmacology beyond their classical role in the treatment of type 2 diabetes.
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Affiliation(s)
- Paresh Dandona
- Diabetes-Endocrinology Center of Western NY, State University of New York at Buffalo, Buffalo, New York
| | - Husam Ghanim
- Diabetes-Endocrinology Center of Western NY, State University of New York at Buffalo, Buffalo, New York
| | - Ajay Chaudhuri
- Diabetes-Endocrinology Center of Western NY, State University of New York at Buffalo, Buffalo, New York
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168
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Diabetes mellitus tipo LADA y cetoacidosis: reflexiones a partir de un caso clínico. Semergen 2018; 44:64-66. [DOI: 10.1016/j.semerg.2017.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 04/25/2017] [Accepted: 05/03/2017] [Indexed: 11/22/2022]
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169
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Upadhyay J, Polyzos SA, Perakakis N, Thakkar B, Paschou SA, Katsiki N, Underwood P, Park KH, Seufert J, Kang ES, Sternthal E, Karagiannis A, Mantzoros CS. Pharmacotherapy of type 2 diabetes: An update. Metabolism 2018; 78:13-42. [PMID: 28920861 DOI: 10.1016/j.metabol.2017.08.010] [Citation(s) in RCA: 128] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 08/24/2017] [Accepted: 08/26/2017] [Indexed: 12/22/2022]
Abstract
Type 2 diabetes (T2DM) is a leading cause of morbidity and mortality worldwide and a major economic burden. The prevalence of T2DM is rising, suggesting more effective prevention and treatment strategies are necessary. The aim of this narrative review is to summarize the pharmacologic treatment options available for patients with T2DM. Each therapeutic class is presented in detail, outlining medication effects, side effects, glycemic control, effect on weight, indications and contraindications, and use in selected populations (heart failure, renal insufficiency, obesity and the elderly). We also present representative cost for each antidiabetic category. Then, we provide an individualized guide for initiation and intensification of treatment and discuss the considerations and rationale for an individualized glycemic goal.
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Affiliation(s)
- Jagriti Upadhyay
- Section of Endocrinology, Diabetes and Metabolism, Boston VA Healthcare System, Boston, MA, USA; Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Stergios A Polyzos
- First Department of Pharmacology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nikolaos Perakakis
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Divisions of Endocrinology and Diabetology, Department of Internal Medicine II, University Hospital of Freiburg, Freiburg, Germany
| | - Bindiya Thakkar
- Section of Endocrinology, Diabetes and Metabolism, Boston VA Healthcare System, Boston, MA, USA
| | - Stavroula A Paschou
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Niki Katsiki
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, Thessaloniki, Greece
| | - Patricia Underwood
- Section of Endocrinology, Diabetes and Metabolism, Boston VA Healthcare System, Boston, MA, USA
| | - Kyung-Hee Park
- Department of Family Medicine, Hallym University Sacred Heart Hospital, Gyeonggi-do, Republic of Korea
| | - Jochen Seufert
- Divisions of Endocrinology and Diabetology, Department of Internal Medicine II, University Hospital of Freiburg, Freiburg, Germany
| | - Eun Seok Kang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Elliot Sternthal
- Section of Endocrinology, Diabetes and Metabolism, Boston VA Healthcare System, Boston, MA, USA
| | - Asterios Karagiannis
- First Department of Pharmacology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christos S Mantzoros
- Section of Endocrinology, Diabetes and Metabolism, Boston VA Healthcare System, Boston, MA, USA; Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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170
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Esteban-Jiménez O, Navarro-Pemán C, Urieta-González L. Seguridad de los iSGLT-2. Revisión de las reacciones adversas notificadas a nivel nacional. Semergen 2018; 44:23-29. [DOI: 10.1016/j.semerg.2017.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 08/06/2017] [Accepted: 10/19/2017] [Indexed: 12/14/2022]
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Otto-Buczkowska E, Jainta N. Pharmacological Treatment in Diabetes Mellitus Type 1 - Insulin and What Else? Int J Endocrinol Metab 2018; 16:e13008. [PMID: 29696037 PMCID: PMC5903388 DOI: 10.5812/ijem.13008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 09/18/2017] [Accepted: 10/31/2017] [Indexed: 12/19/2022] Open
Abstract
The basis of treatment in autoimmune diabetes is insulin therapy; however, many clinical cases have proven that this method does not solve all problems. Trials of causal treatment including blocking the autoimmune processes and insulin-producing cells transplants were carried out. Those methods require more research to be concerned as efficient and safe ways of treatment in type 1 diabetes. The use of non-insulin adjunct treatment is a new trend. It has been successfully used in laboratories as well as clinical trials. Metformin is the most widely used drug, together with sodium-glucose co-transporters 2 (SGLT2) inhibitors, amylin analogues, glucagon-like peptide 1 (GLP-1) receptor agonists, and dipeptidyl peptidase-4 (DPP-4) inhibitors. The results of administration of these medicaments give good outcomes in patients with diabetes mellitus type 1. Most likely, in the near future, they will progressively be used in both adult and adolescent patients with type 1 diabetes. Further multicenter, randomized studies are required to evaluate the efficacy of treatment and long term safety of these drugs.
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Affiliation(s)
- Ewa Otto-Buczkowska
- Medical Specialist Centre in Gliwice, Poland
- Corresponding author: Ewa Otto-Buczkowska MD PhD, Jasnogorska 16/2144-100 Gliwice, Poland. E-mail:
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172
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Bonora BM, Avogaro A, Fadini GP. Sodium-glucose co-transporter-2 inhibitors and diabetic ketoacidosis: An updated review of the literature. Diabetes Obes Metab 2018; 20:25-33. [PMID: 28517913 DOI: 10.1111/dom.13012] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 05/12/2017] [Accepted: 05/13/2017] [Indexed: 12/15/2022]
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT2is) are increasingly used for the treatment of type 2 diabetes (T2D) and can improve glucose control also in type 1 diabetes (T1D). In May 2015, regulatory agencies issued a warning that SGLT2is may cause diabetic ketoacidosis (DKA). We report details on 2 new cases of SGLT2i-associated DKA and review the literature for similar cases within randomized controlled trials (RCTs), cohort studies and single reports. We searched the medical literature for reports of SGLT2i-associated DKA cases. A quantitative analysis of frequency and clinical characteristics is reported. The 2 narrative cases illustrate that SGLT2i-associated DKA can occur in patients with T1D incorrectly diagnosed as T2D, perhaps without the presence of obvious DKA precipitating factors. The incidence of SGLT2i-associated DKA was less than 1/1000 in randomized controlled trials and 1.6/1000 person-years in cohort studies. We retrieved detailed data on 105 SGLT2i-associated DKA case reports, wherein 35% showed glucose levels of less than 200 mg/dL and 22% were not associated with typical triggers. In case reports and in pharmacovigilance databases, duration of SGLT2i treatment before DKA onset was extremely variable. Fatal SGLT2i-associated DKA episodes were found only in pharmacovigilance databases and represented 1.6% of all reported cases. DKA is a rare adverse event during SGLT2i therapy. Predisposing and precipitating factors are still incompletely understood, although a minority of cases lacked typical DKA triggers. More narrative case series and cohort studies are needed to better understand the true risk and the spectrum of this adverse event.
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Affiliation(s)
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Padova, Italy
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173
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Garg SK, Henry RR, Banks P, Buse JB, Davies MJ, Fulcher GR, Pozzilli P, Gesty-Palmer D, Lapuerta P, Simó R, Danne T, McGuire DK, Kushner JA, Peters A, Strumph P. Effects of Sotagliflozin Added to Insulin in Patients with Type 1 Diabetes. N Engl J Med 2017; 377:2337-2348. [PMID: 28899222 DOI: 10.1056/nejmoa1708337] [Citation(s) in RCA: 284] [Impact Index Per Article: 40.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND In most patients with type 1 diabetes, adequate glycemic control is not achieved with insulin therapy alone. We evaluated the safety and efficacy of sotagliflozin, an oral inhibitor of sodium-glucose cotransporters 1 and 2, in combination with insulin treatment in patients with type 1 diabetes. METHODS In this phase 3, double-blind trial, which was conducted at 133 centers worldwide, we randomly assigned 1402 patients with type 1 diabetes who were receiving treatment with any insulin therapy (pump or injections) to receive sotagliflozin (400 mg per day) or placebo for 24 weeks. The primary end point was a glycated hemoglobin level lower than 7.0% at week 24, with no episodes of severe hypoglycemia or diabetic ketoacidosis after randomization. Secondary end points included the change from baseline in glycated hemoglobin level, weight, systolic blood pressure, and mean daily bolus dose of insulin. RESULTS A significantly larger proportion of patients in the sotagliflozin group than in the placebo group achieved the primary end point (200 of 699 patients [28.6%] vs. 107 of 703 [15.2%], P<0.001). The least-squares mean change from baseline was significantly greater in the sotagliflozin group than in the placebo group for glycated hemoglobin (difference, -0.46 percentage points), weight (-2.98 kg), systolic blood pressure (-3.5 mm Hg), and mean daily bolus dose of insulin (-2.8 units per day) (P≤0.002 for all comparisons). The rate of severe hypoglycemia was similar in the sotagliflozin group and the placebo group (3.0% [21 patients] and 2.4% [17], respectively). The rate of documented hypoglycemia with a blood glucose level of 55 mg per deciliter (3.1 mmol per liter) or below was significantly lower in the sotagliflozin group than in the placebo group. The rate of diabetic ketoacidosis was higher in the sotagliflozin group than in the placebo group (3.0% [21 patients] and 0.6% [4], respectively). CONCLUSIONS Among patients with type 1 diabetes who were receiving insulin, the proportion of patients who achieved a glycated hemoglobin level lower than 7.0% with no severe hypoglycemia or diabetic ketoacidosis was larger in the group that received sotagliflozin than in the placebo group. However, the rate of diabetic ketoacidosis was higher in the sotagliflozin group. (Funded by Lexicon Pharmaceuticals; inTandem3 ClinicalTrials.gov number, NCT02531035 .).
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Affiliation(s)
- Satish K Garg
- From the University of Colorado Denver, Aurora (S.K.G.); the University of California at San Diego, San Diego (R.R.H.); Lexicon Pharmaceuticals, The Woodlands (P.B., D.G.-P., P.L., P.S.), the University of Texas Southwestern Medical Center, Dallas (D.K.M.), and Baylor College of Medicine and Texas Children's Hospital, Houston (J.A.K.) - all in Texas; the Diabetes Research Center, University of North Carolina School of Medicine, Durham (J.B.B.); the University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, United Kingdom (M.J.D.); the University of Sydney, Sydney (G.R.F.); University Campus Bio-Medico of Rome, Rome (P.P.); Vall d'Hebron Research Institute, Barcelona, and CIBERDEM-Instituto de Salud Carlos III, Madrid (R.S.); Diabetes Center Auf der Bult, Hannover Medical School, Hannover, Germany (T.D.); and the University of Southern California, Los Angeles (A.P.)
| | - Robert R Henry
- From the University of Colorado Denver, Aurora (S.K.G.); the University of California at San Diego, San Diego (R.R.H.); Lexicon Pharmaceuticals, The Woodlands (P.B., D.G.-P., P.L., P.S.), the University of Texas Southwestern Medical Center, Dallas (D.K.M.), and Baylor College of Medicine and Texas Children's Hospital, Houston (J.A.K.) - all in Texas; the Diabetes Research Center, University of North Carolina School of Medicine, Durham (J.B.B.); the University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, United Kingdom (M.J.D.); the University of Sydney, Sydney (G.R.F.); University Campus Bio-Medico of Rome, Rome (P.P.); Vall d'Hebron Research Institute, Barcelona, and CIBERDEM-Instituto de Salud Carlos III, Madrid (R.S.); Diabetes Center Auf der Bult, Hannover Medical School, Hannover, Germany (T.D.); and the University of Southern California, Los Angeles (A.P.)
| | - Phillip Banks
- From the University of Colorado Denver, Aurora (S.K.G.); the University of California at San Diego, San Diego (R.R.H.); Lexicon Pharmaceuticals, The Woodlands (P.B., D.G.-P., P.L., P.S.), the University of Texas Southwestern Medical Center, Dallas (D.K.M.), and Baylor College of Medicine and Texas Children's Hospital, Houston (J.A.K.) - all in Texas; the Diabetes Research Center, University of North Carolina School of Medicine, Durham (J.B.B.); the University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, United Kingdom (M.J.D.); the University of Sydney, Sydney (G.R.F.); University Campus Bio-Medico of Rome, Rome (P.P.); Vall d'Hebron Research Institute, Barcelona, and CIBERDEM-Instituto de Salud Carlos III, Madrid (R.S.); Diabetes Center Auf der Bult, Hannover Medical School, Hannover, Germany (T.D.); and the University of Southern California, Los Angeles (A.P.)
| | - John B Buse
- From the University of Colorado Denver, Aurora (S.K.G.); the University of California at San Diego, San Diego (R.R.H.); Lexicon Pharmaceuticals, The Woodlands (P.B., D.G.-P., P.L., P.S.), the University of Texas Southwestern Medical Center, Dallas (D.K.M.), and Baylor College of Medicine and Texas Children's Hospital, Houston (J.A.K.) - all in Texas; the Diabetes Research Center, University of North Carolina School of Medicine, Durham (J.B.B.); the University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, United Kingdom (M.J.D.); the University of Sydney, Sydney (G.R.F.); University Campus Bio-Medico of Rome, Rome (P.P.); Vall d'Hebron Research Institute, Barcelona, and CIBERDEM-Instituto de Salud Carlos III, Madrid (R.S.); Diabetes Center Auf der Bult, Hannover Medical School, Hannover, Germany (T.D.); and the University of Southern California, Los Angeles (A.P.)
| | - Melanie J Davies
- From the University of Colorado Denver, Aurora (S.K.G.); the University of California at San Diego, San Diego (R.R.H.); Lexicon Pharmaceuticals, The Woodlands (P.B., D.G.-P., P.L., P.S.), the University of Texas Southwestern Medical Center, Dallas (D.K.M.), and Baylor College of Medicine and Texas Children's Hospital, Houston (J.A.K.) - all in Texas; the Diabetes Research Center, University of North Carolina School of Medicine, Durham (J.B.B.); the University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, United Kingdom (M.J.D.); the University of Sydney, Sydney (G.R.F.); University Campus Bio-Medico of Rome, Rome (P.P.); Vall d'Hebron Research Institute, Barcelona, and CIBERDEM-Instituto de Salud Carlos III, Madrid (R.S.); Diabetes Center Auf der Bult, Hannover Medical School, Hannover, Germany (T.D.); and the University of Southern California, Los Angeles (A.P.)
| | - Gregory R Fulcher
- From the University of Colorado Denver, Aurora (S.K.G.); the University of California at San Diego, San Diego (R.R.H.); Lexicon Pharmaceuticals, The Woodlands (P.B., D.G.-P., P.L., P.S.), the University of Texas Southwestern Medical Center, Dallas (D.K.M.), and Baylor College of Medicine and Texas Children's Hospital, Houston (J.A.K.) - all in Texas; the Diabetes Research Center, University of North Carolina School of Medicine, Durham (J.B.B.); the University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, United Kingdom (M.J.D.); the University of Sydney, Sydney (G.R.F.); University Campus Bio-Medico of Rome, Rome (P.P.); Vall d'Hebron Research Institute, Barcelona, and CIBERDEM-Instituto de Salud Carlos III, Madrid (R.S.); Diabetes Center Auf der Bult, Hannover Medical School, Hannover, Germany (T.D.); and the University of Southern California, Los Angeles (A.P.)
| | - Paolo Pozzilli
- From the University of Colorado Denver, Aurora (S.K.G.); the University of California at San Diego, San Diego (R.R.H.); Lexicon Pharmaceuticals, The Woodlands (P.B., D.G.-P., P.L., P.S.), the University of Texas Southwestern Medical Center, Dallas (D.K.M.), and Baylor College of Medicine and Texas Children's Hospital, Houston (J.A.K.) - all in Texas; the Diabetes Research Center, University of North Carolina School of Medicine, Durham (J.B.B.); the University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, United Kingdom (M.J.D.); the University of Sydney, Sydney (G.R.F.); University Campus Bio-Medico of Rome, Rome (P.P.); Vall d'Hebron Research Institute, Barcelona, and CIBERDEM-Instituto de Salud Carlos III, Madrid (R.S.); Diabetes Center Auf der Bult, Hannover Medical School, Hannover, Germany (T.D.); and the University of Southern California, Los Angeles (A.P.)
| | - Diane Gesty-Palmer
- From the University of Colorado Denver, Aurora (S.K.G.); the University of California at San Diego, San Diego (R.R.H.); Lexicon Pharmaceuticals, The Woodlands (P.B., D.G.-P., P.L., P.S.), the University of Texas Southwestern Medical Center, Dallas (D.K.M.), and Baylor College of Medicine and Texas Children's Hospital, Houston (J.A.K.) - all in Texas; the Diabetes Research Center, University of North Carolina School of Medicine, Durham (J.B.B.); the University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, United Kingdom (M.J.D.); the University of Sydney, Sydney (G.R.F.); University Campus Bio-Medico of Rome, Rome (P.P.); Vall d'Hebron Research Institute, Barcelona, and CIBERDEM-Instituto de Salud Carlos III, Madrid (R.S.); Diabetes Center Auf der Bult, Hannover Medical School, Hannover, Germany (T.D.); and the University of Southern California, Los Angeles (A.P.)
| | - Pablo Lapuerta
- From the University of Colorado Denver, Aurora (S.K.G.); the University of California at San Diego, San Diego (R.R.H.); Lexicon Pharmaceuticals, The Woodlands (P.B., D.G.-P., P.L., P.S.), the University of Texas Southwestern Medical Center, Dallas (D.K.M.), and Baylor College of Medicine and Texas Children's Hospital, Houston (J.A.K.) - all in Texas; the Diabetes Research Center, University of North Carolina School of Medicine, Durham (J.B.B.); the University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, United Kingdom (M.J.D.); the University of Sydney, Sydney (G.R.F.); University Campus Bio-Medico of Rome, Rome (P.P.); Vall d'Hebron Research Institute, Barcelona, and CIBERDEM-Instituto de Salud Carlos III, Madrid (R.S.); Diabetes Center Auf der Bult, Hannover Medical School, Hannover, Germany (T.D.); and the University of Southern California, Los Angeles (A.P.)
| | - Rafael Simó
- From the University of Colorado Denver, Aurora (S.K.G.); the University of California at San Diego, San Diego (R.R.H.); Lexicon Pharmaceuticals, The Woodlands (P.B., D.G.-P., P.L., P.S.), the University of Texas Southwestern Medical Center, Dallas (D.K.M.), and Baylor College of Medicine and Texas Children's Hospital, Houston (J.A.K.) - all in Texas; the Diabetes Research Center, University of North Carolina School of Medicine, Durham (J.B.B.); the University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, United Kingdom (M.J.D.); the University of Sydney, Sydney (G.R.F.); University Campus Bio-Medico of Rome, Rome (P.P.); Vall d'Hebron Research Institute, Barcelona, and CIBERDEM-Instituto de Salud Carlos III, Madrid (R.S.); Diabetes Center Auf der Bult, Hannover Medical School, Hannover, Germany (T.D.); and the University of Southern California, Los Angeles (A.P.)
| | - Thomas Danne
- From the University of Colorado Denver, Aurora (S.K.G.); the University of California at San Diego, San Diego (R.R.H.); Lexicon Pharmaceuticals, The Woodlands (P.B., D.G.-P., P.L., P.S.), the University of Texas Southwestern Medical Center, Dallas (D.K.M.), and Baylor College of Medicine and Texas Children's Hospital, Houston (J.A.K.) - all in Texas; the Diabetes Research Center, University of North Carolina School of Medicine, Durham (J.B.B.); the University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, United Kingdom (M.J.D.); the University of Sydney, Sydney (G.R.F.); University Campus Bio-Medico of Rome, Rome (P.P.); Vall d'Hebron Research Institute, Barcelona, and CIBERDEM-Instituto de Salud Carlos III, Madrid (R.S.); Diabetes Center Auf der Bult, Hannover Medical School, Hannover, Germany (T.D.); and the University of Southern California, Los Angeles (A.P.)
| | - Darren K McGuire
- From the University of Colorado Denver, Aurora (S.K.G.); the University of California at San Diego, San Diego (R.R.H.); Lexicon Pharmaceuticals, The Woodlands (P.B., D.G.-P., P.L., P.S.), the University of Texas Southwestern Medical Center, Dallas (D.K.M.), and Baylor College of Medicine and Texas Children's Hospital, Houston (J.A.K.) - all in Texas; the Diabetes Research Center, University of North Carolina School of Medicine, Durham (J.B.B.); the University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, United Kingdom (M.J.D.); the University of Sydney, Sydney (G.R.F.); University Campus Bio-Medico of Rome, Rome (P.P.); Vall d'Hebron Research Institute, Barcelona, and CIBERDEM-Instituto de Salud Carlos III, Madrid (R.S.); Diabetes Center Auf der Bult, Hannover Medical School, Hannover, Germany (T.D.); and the University of Southern California, Los Angeles (A.P.)
| | - Jake A Kushner
- From the University of Colorado Denver, Aurora (S.K.G.); the University of California at San Diego, San Diego (R.R.H.); Lexicon Pharmaceuticals, The Woodlands (P.B., D.G.-P., P.L., P.S.), the University of Texas Southwestern Medical Center, Dallas (D.K.M.), and Baylor College of Medicine and Texas Children's Hospital, Houston (J.A.K.) - all in Texas; the Diabetes Research Center, University of North Carolina School of Medicine, Durham (J.B.B.); the University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, United Kingdom (M.J.D.); the University of Sydney, Sydney (G.R.F.); University Campus Bio-Medico of Rome, Rome (P.P.); Vall d'Hebron Research Institute, Barcelona, and CIBERDEM-Instituto de Salud Carlos III, Madrid (R.S.); Diabetes Center Auf der Bult, Hannover Medical School, Hannover, Germany (T.D.); and the University of Southern California, Los Angeles (A.P.)
| | - Anne Peters
- From the University of Colorado Denver, Aurora (S.K.G.); the University of California at San Diego, San Diego (R.R.H.); Lexicon Pharmaceuticals, The Woodlands (P.B., D.G.-P., P.L., P.S.), the University of Texas Southwestern Medical Center, Dallas (D.K.M.), and Baylor College of Medicine and Texas Children's Hospital, Houston (J.A.K.) - all in Texas; the Diabetes Research Center, University of North Carolina School of Medicine, Durham (J.B.B.); the University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, United Kingdom (M.J.D.); the University of Sydney, Sydney (G.R.F.); University Campus Bio-Medico of Rome, Rome (P.P.); Vall d'Hebron Research Institute, Barcelona, and CIBERDEM-Instituto de Salud Carlos III, Madrid (R.S.); Diabetes Center Auf der Bult, Hannover Medical School, Hannover, Germany (T.D.); and the University of Southern California, Los Angeles (A.P.)
| | - Paul Strumph
- From the University of Colorado Denver, Aurora (S.K.G.); the University of California at San Diego, San Diego (R.R.H.); Lexicon Pharmaceuticals, The Woodlands (P.B., D.G.-P., P.L., P.S.), the University of Texas Southwestern Medical Center, Dallas (D.K.M.), and Baylor College of Medicine and Texas Children's Hospital, Houston (J.A.K.) - all in Texas; the Diabetes Research Center, University of North Carolina School of Medicine, Durham (J.B.B.); the University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, United Kingdom (M.J.D.); the University of Sydney, Sydney (G.R.F.); University Campus Bio-Medico of Rome, Rome (P.P.); Vall d'Hebron Research Institute, Barcelona, and CIBERDEM-Instituto de Salud Carlos III, Madrid (R.S.); Diabetes Center Auf der Bult, Hannover Medical School, Hannover, Germany (T.D.); and the University of Southern California, Los Angeles (A.P.)
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174
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Dull RB, Spangler ML, Knezevich EL, Lau BM. Euglycemic Diabetic Ketoacidosis Associated With Sodium–Glucose Cotransporter Type 2 Inhibitors in Patients With Type 2 Diabetes Mellitus Receiving Oral Therapy. J Pharm Pract 2017; 32:240-243. [DOI: 10.1177/0897190017748049] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction and Objective: Postmarketing reports and warnings of serious adverse events such as diabetic ketoacidosis (DKA) have raised concern regarding the safety of sodium–glucose cotransporter 2 inhibitors (SGLT2i). This report describes 2 cases of symptomatic SGLT2i-associated euglycemic DKA (euDKA) leading to hospitalization in patients with type 2 diabetes mellitus (DM) previously well controlled on oral medications. Case Reports: Subject 1 is a 55-year-old female admitted with euDKA precipitated by infection and managed with intravenous insulin. This case was notable for a delayed diagnosis of euDKA and lack of clinical improvement despite withholding dapagliflozin. Subject 2 is a 62-year-old male admitted with euDKA precipitated by infection. His clinical condition improved rapidly and euDKA responded to withdrawal of empagliflozin alone. Discussion: Applying the Naranjo adverse medication reaction probability scale to each case (subject 1 score = 3 points; subject 2 score = 4 points) suggests these are possible adverse reactions to SGLT2i. Data from randomized controlled trials suggest DKA events in adults with type 2 DM receiving SGLT2i are rare and similar to placebo. However, data from a large cohort suggest these events occur more frequently and are associated with a 2-fold increased risk of DKA. Conclusion: This class of medications may be associated with a higher real-world risk of DKA in adults with type 2 DM than previously reported. Patients prescribed these medications should receive vigilant assessment for features of traditional DKA as well as euDKA.
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Affiliation(s)
- Ryan B. Dull
- Department of Pharmacy Practice, Creighton University School of Pharmacy and Health Professions, Omaha, NE, USA
| | - Mikayla L. Spangler
- Department of Pharmacy Practice, Creighton University School of Pharmacy and Health Professions, Omaha, NE, USA
| | - Emily L. Knezevich
- Department of Pharmacy Practice, Creighton University School of Pharmacy and Health Professions, Omaha, NE, USA
| | - Britney M. Lau
- Department of Pharmacy Practice, Creighton University School of Pharmacy and Health Professions, Omaha, NE, USA
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175
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Affiliation(s)
- Ele Ferrannini
- CNR Institute of Clinical Physiology, Via Roma 67, Pisa, PI 56100, Italy
| | - Anna Solini
- University of Pisa, Department of Clinical and Experimental Medicine, Via Roma 67, Pisa, I-56126, Italy
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176
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Peacock SC, Lovshin JA. Sodium-glucose cotransporter-2 inhibitors (SGLT-2i) in the perioperative setting. Can J Anaesth 2017; 65:143-147. [PMID: 29159514 DOI: 10.1007/s12630-017-1019-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 10/23/2017] [Indexed: 10/18/2022] Open
Affiliation(s)
- Sharon C Peacock
- Department of Anesthesiology, University of Toronto, Room 1200, 12th Floor, 123 Edward Street, Toronto, ON, M5G 1E2, Canada.
| | - Julie A Lovshin
- Division of Endocrinology and Metabolism, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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177
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Cohn A, Ohri A. Diabetes mellitus in a patient with glycogen storage disease type Ia: a case report. J Med Case Rep 2017; 11:319. [PMID: 29127952 PMCID: PMC5682031 DOI: 10.1186/s13256-017-1462-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 09/19/2017] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Glycogen storage disease type Ia is a genetic disorder that is associated with persistent fasting hypoglycemia and the inability to produce endogenous glucose. The development of diabetes with glycogen storage disease is exceedingly rare. The underlying pathogenesis for developing diabetes in these patients is unclear, and there are no guidelines for treatment. CASE PRESENTATION We describe a case of a 34-year-old woman of South Asian descent with glycogen storage disease type Ia, who developed uncontrolled diabetes mellitus as a young adult. Hyperglycemia was noted after childbirth, and worsened years later. Treatment for diabetes was difficult due to risks of hypoglycemia from her underlying glycogen storage disease. With minimal hypoglycemic events, the patient's blood glucose improved with exercise in combination with a sodium-glucose co-transporter 2 inhibitor and an alpha glucosidase inhibitor. CONCLUSION We report a rare case of diabetes in the setting of glycogen storage disease-Ia. Based on the literature, there appears to be a relationship between glycogen storage disease and metabolic syndrome, which likely plays a role in the pathogenesis. The management of glycemic control remains a clinical challenge, requiring management of both fasting hypoglycemia from glycogen storage disease, as well as post-prandial hyperglycemia from diabetes mellitus.
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Affiliation(s)
- Aviva Cohn
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, 1 RWJ Place, MEB 486 PO Box 19, New Brunswick, NJ, 08903, USA.
| | - Anupam Ohri
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, 1 RWJ Place, MEB 486 PO Box 19, New Brunswick, NJ, 08903, USA
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178
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SGLT2 Inhibitor-associated Diabetic Ketoacidosis: Clinical Review and Recommendations for Prevention and Diagnosis. Clin Ther 2017; 38:2654-2664.e1. [PMID: 28003053 DOI: 10.1016/j.clinthera.2016.11.002] [Citation(s) in RCA: 165] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 11/02/2016] [Indexed: 12/24/2022]
Abstract
PURPOSE Sodium-glucose cotransporter 2 (SGLT2) inhibitors are the newest class of antihyperglycemic agents available on the market. Regulator warnings and concerns regarding the risk of developing diabetic ketoacidosis (DKA), however, have dampened enthusiasm for the class despite the combined glycemic, blood pressure, and occasional weight benefits of SGLT2 inhibitors. With the goal of improving patient safety, a cross-Canada expert panel and writing group were convened to review the evidence to-date on reported SGLT2 inhibitor-related DKA incidents and to offer recommendations for preventing and recognizing patients with SGLT2 inhibitor-associated DKA. METHODS Reports covering DKA events in subjects taking SGLT2 inhibitors that were published in PubMed, presented at professional conferences, or in the public domain from January 2013 to mid-August 2016 were reviewed by the group independently and collectively. Practical recommendations for diagnosis and prevention were established by the panel. FINDINGS DKA is rarely associated with SGLT2 inhibitor therapy. Patients with SGLT2 inhibitor-associated DKA may be euglycemic (plasma glucose level <14 mmol/L). DKA is more likely in patients with insulin-deficient diabetes, including those with type 2 diabetes, and is typically precipitated by insulin omission or dose reduction, severe acute illness, dehydration, extensive exercise, surgery, low-carbohydrate diets, or excessive alcohol intake. SGLT2 inhibitor-associated DKA may be prevented by withholding SGLT2 inhibitors when precipitants develop, avoiding insulin omission or inappropriate insulin dose reduction, and by following sick day protocols as recommended. IMPLICATIONS Preventive strategies should help avoid SGLT2 inhibitor-associated DKA. All SGLT2 inhibitor-treated patients presenting with signs or symptoms of DKA should be suspected to have DKA and be investigated for DKA, especially euglycemic patients. If DKA is diagnosed, SGLT2 inhibitor treatment should be stopped, and the DKA should be treated with a traditional treatment protocol.
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179
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Gomez-Peralta F, Abreu C, Lecube A, Bellido D, Soto A, Morales C, Brito-Sanfiel M, Umpierrez G. Practical Approach to Initiating SGLT2 Inhibitors in Type 2 Diabetes. Diabetes Ther 2017; 8:953-962. [PMID: 28721687 PMCID: PMC5630545 DOI: 10.1007/s13300-017-0277-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Indexed: 12/22/2022] Open
Abstract
Sodium-glucose co-transporter 2 (SGLT2) inhibitors are an attractive novel therapeutic option for the treatment of type 2 diabetes. They block the reabsorption of filtered glucose in kidneys, mainly in proximal renal tubules, resulting in increased urinary glucose excretion and correction of the diabetes-related hyperglycemia. Beyond improving glucose control, SGLT2 inhibitors offer potential benefits by reducing body weight and blood pressure. On the basis of the efficacy demonstrated in clinical trials, SGLT2 inhibitors are recommended as second- or third-line agents for the management of patients with type 2 diabetes. Beneficial effects on kidney disease progression, cardiovascular and all-cause mortality, and hospitalization for heart failure have also been demonstrated with one SGLT2 inhibitor (empagliflozin). Potential adverse events resulting from their mechanism of action or related to concomitant therapies are reviewed. A treatment algorithm for the adjustment of concomitant therapies after initiating SGLT2 inhibitors is also proposed.
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Affiliation(s)
| | - Cristina Abreu
- Endocrinology and Nutrition Unit, Segovia General Hospital, Segovia, Spain
| | - Albert Lecube
- Endocrinology and Nutrition Unit, Hospital Universitari Arnau de Vilanova de Lleida, Institut de Recerca Biomèdica de Lleida, CIBERDEM (CIBER de Diabetes y Enfermedades Metabólicas Asociadas, ISCIII), University of Lleida, Lleida, Spain
| | - Diego Bellido
- Endocrinology and Nutrition Section, Hospital Marcide, Ferrol, Spain
| | - Alfonso Soto
- Endocrinology and Nutrition Department, Hospital de La Coruña, A Coruña, Spain
| | - Cristóbal Morales
- Endocrinology and Nutrition Department, Virgen Macarena Hospital, Seville, Spain
| | - Miguel Brito-Sanfiel
- Endocrinology and Nutrition Department, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Guillermo Umpierrez
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
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180
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Affiliation(s)
- Satish K Garg
- 1 School of Medicine, University of Colorado Denver , Aurora, Colorado
- 2 Barbara Davis Center for Diabetes , Aurora, Colorado
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181
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Shlomai G, Zelenko Z, Antoniou IM, Stasinopoulos M, Tobin-Hess A, Vitek MP, LeRoith D, Gallagher EJ. OP449 inhibits breast cancer growth without adverse metabolic effects. Endocr Relat Cancer 2017; 24:519-529. [PMID: 28830934 PMCID: PMC5678946 DOI: 10.1530/erc-17-0077] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 07/21/2017] [Indexed: 12/23/2022]
Abstract
Hyperinsulinemia is associated with a decrease in breast cancer recurrence-free survival and overall survival. Inhibition of insulin receptor signaling is associated with glycemic dysregulation. SET is a direct modulator of PP2A, which negatively regulates the PI3K/AKT/mTOR pathway. OP449, a SET inhibitor, decreases AKT/mTOR activation. The effects of OP449 treatment on breast cancer growth in the setting of pre-diabetes, and its metabolic implications are currently unknown. We found that the volumes and weights of human MDA-MB-231 breast cancer xenografts were greater in hyperinsulinemic mice compared with controls (P < 0.05), and IR phosphorylation was 4.5-fold higher in these mice (P < 0.05). Human and murine breast cancer tumors treated with OP449 were 47% and 39% smaller than controls (P < 0.05, for both, respectively). AKT and S6RP phosphorylation were 82% and 34% lower in OP449-treated tumors compared with controls (P < 0.05, P = 0.06, respectively). AKT and S6RP phosphorylation in response to insulin was 30% and 12% lower in cells, pre-treated with OP449, compared with control cells (P < 0.01, P < 0.05, respectively). However, even with decreased AKT/mTOR activation, body weights and composition, blood glucose and plasma insulin, glucose tolerance, serum triglyceride and cholesterol levels were similar between OP449-treated mice and controls. Xenografts and liver tissue from OP449-treated mice showed a 64% and 70% reduction in STAT5 activation, compared with controls (P < 0.01 and P = 0.06, respectively). Our data support an anti-neoplastic effect of OP449 on human breast cancer cells in vitro and in xenografts in the setting of hyperinsulinemia. OP449 led to the inhibition of AKT/mTOR signaling, albeit, not leading to metabolic derangements.
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Affiliation(s)
- Gadi Shlomai
- Division of EndocrinologyDiabetes and Bone Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
- The Dr Pinchas Borenstein Talpiot Medical Leadership Program 2013Tel-Hashomer, Israel
| | - Zara Zelenko
- Division of EndocrinologyDiabetes and Bone Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Irini Markella Antoniou
- Division of EndocrinologyDiabetes and Bone Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Marilyn Stasinopoulos
- Division of EndocrinologyDiabetes and Bone Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Aviva Tobin-Hess
- Division of EndocrinologyDiabetes and Bone Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Michael P Vitek
- CognosciInc., Durham, North Carolina, USA
- Department of NeurologyDuke University Medical Center, Research Drive, Durham, North Carolina, USA
| | - Derek LeRoith
- Division of EndocrinologyDiabetes and Bone Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Emily Jane Gallagher
- Division of EndocrinologyDiabetes and Bone Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
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182
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Iwata H, Tsuzuki S, Iwata M, Terasawa T. Ketoacidosis due to a Low-carbohydrate Diet in an Elderly Woman with Dementia and Abnormal Eating Behavior. Intern Med 2017; 56:2671-2675. [PMID: 28883241 PMCID: PMC5658538 DOI: 10.2169/internalmedicine.8689-16] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Strict restriction of carbohydrates can induce symptomatic ketoacidosis. We herein report a 76-year-old demented woman who developed ketoacidosis after 1 month of abnormal eating behavior involving selectively eating hamburger steak (estimated carbohydrate =12.7 g/day). Laboratory tests showed high-anion-gap metabolic acidosis with elevated blood ketone levels. She was successfully treated with intravenous fluids followed by oral intake of a regular diet. She remained relapse-free after correcting her eating habits. Healthcare providers should know that abnormal eating behavior in demented people can lead to an extremely-low-carbohydrate diet and cause atypical ketoacidosis unexplained by diabetes, heavy alcohol intake, or starvation conditions.
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Affiliation(s)
- Hitoshi Iwata
- Department of Emergency and General Internal Medicine, Fujita Health University School of Medicine, Japan
| | - Seiichiro Tsuzuki
- Department of Emergency and General Internal Medicine, Fujita Health University School of Medicine, Japan
| | - Mitsunaga Iwata
- Department of Emergency and General Internal Medicine, Fujita Health University School of Medicine, Japan
| | - Teruhiko Terasawa
- Department of Emergency and General Internal Medicine, Fujita Health University School of Medicine, Japan
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183
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Takeuchi M, Kawamura T, Sato I, Kawakami K. Population-based incidence of diabetic ketoacidosis in type 2 diabetes: medical claims data analysis in Japan. Pharmacoepidemiol Drug Saf 2017; 27:123-126. [PMID: 28752620 DOI: 10.1002/pds.4271] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 06/20/2017] [Accepted: 06/27/2017] [Indexed: 01/22/2023]
Abstract
PURPOSE Determination of the incidence rate of diabetic ketoacidosis (DKA) in type 2 diabetes mellitus (T2DM) is urgent, in response to the safety issue with use of the glucose lowering drugs, sodium-glucose cotransporter-2 inhibitors, and DKA. METHODS We extracted data of adult patients with T2DM from a medical claims database in Japan, which included 1 million individuals. The study period was 2005-2013, before the era of sodium-glucose cotransporter-2 inhibitors. The inclusion criteria were patients with a diagnosis of T2DM who had at least 1 prescription for a glucose-lowering drug. We further examined the number of DKA-related admissions and medication use prior to admission. Calculation of DKA incidence was on a patient-years basis, with 95% confidence interval using a Poisson distribution. RESULTS Of 36,674 adult patients with T2DM, we identified 74 cases admitted for DKA, with an estimated DKA incidence of 0.48/1000 (95% confidence interval, 0.38-0.60/1000) patient-years. Of these 74 cases, approximately two-thirds of patients had no past or recent history of glucose-lowering drug use before admission for DKA. CONCLUSIONS This study estimated that the incidence of DKA was 0.48/1000 patient-years in Japan, similar to previous studies. We also found that underuse of glucose-lowering medication was common among patients hospitalized for DKA. KEY POINTS The population-based incidence of DKA in T2DM is largely unknown. In Japan, the estimated DKA incidence was 0.48/1000 (95% CI, 0.38-0.60/1000) patient-years. Drug-induced DKA is an emerging research area, and our results can be applied to evaluating the risk of DKA.
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Affiliation(s)
- Masato Takeuchi
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Taichi Kawamura
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan.,Senju Pharmaceutical Co., Ltd., Osaka, Japan
| | - Izumi Sato
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan.,K-CONNEX, Keihanshin Consortium for Fostering the Next Generation of Global Leaders in Research, Kyoto, Japan
| | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
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184
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Ahmed M, McKenna MJ, Crowley RK. DIABETIC KETOACIDOSIS IN PATIENTS WITH TYPE 2 DIABETES RECENTLY COMMENCED ON SGLT-2 INHIBITORS: AN ONGOING CONCERN. Endocr Pract 2017; 23:506-508. [PMID: 28437153 DOI: 10.4158/ep161447.lt] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Sodium-glucose cotransporter 2 (SGLT-2) inhibitors are increasingly used as an adjunctive treatment for type 2 diabetes. We report the occurrence of diabetic ketoacidosis (DKA) in 3 patients with type 2 diabetes recently commenced on SGLT-2 inhibitors. METHODS Clinical presentation, laboratory data, and treatment outcomes of all 3 cases are described. RESULTS All 3 patients had documented history of longstanding type 2 diabetes. The presentation in all patients was that of hyperglycaemia, acidosis, and ketosis occurring within 4 weeks of commencing SGLT-2 inhibitors. The risk factors for developing DKA were infection, myocardial infarction, and alcohol excess. DKA resolved within 24 hours of initiating intravenous fluids and insulin in all cases. CONCLUSION This case series illustrates the importance of careful patient selection, education, and monitoring when starting this group of antidiabetic medications. ABBREVIATIONS DKA = diabetic ketoacidosis SGLT-2 = sodium-glucose cotransporter 2 T2D = type 2 diabetes.
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185
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Abstract
Choices for the treatment of type 2 diabetes mellitus (T2DM) have multiplied as our understanding of the underlying pathophysiologic defects has evolved. Treatment should target multiple defects in T2DM and follow a patient-centered approach that considers factors beyond glycemic control, including cardiovascular risk reduction. The American Association of Clinical Endocrinologists/American College of Endocrinology and the American Diabetes Association recommend an initial approach consisting of lifestyle changes and monotherapy, preferably with metformin. Therapy choices are guided by glycemic efficacy, safety profiles, particularly effects on weight and hypoglycemia risk, tolerability, patient comorbidities, route of administration, patient preference, and cost. Balancing management of hyperglycemia with the risk of hypoglycemia and consideration of the effects of pharmacotherapy on weight figure prominently in US-based T2DM recommendations, whereas less emphasis has been placed on the ability of specific medications to affect cardiovascular outcomes. This is likely because, until recently, specific glucose-lowering agents have not been shown to affect cardiorenal outcomes. The Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients-Removing Excess Glucose (EMPA-REG OUTCOME), the Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results (LEADER) trial, and the Trial to Evaluate Cardiovascular and Other Long-term Outcomes with Semaglutide in Subjects with Type 2 Diabetes 6 (SUSTAIN-6) recently showed a reduction in overall cardiovascular risk with empagliflozin, liraglutide, and semaglutide treatment, respectively. Moreover, empagliflozin has become the first glucose-lowering agent indicated to reduce the risk of cardiovascular death in adults with T2DM and established cardiovascular disease. Results from cardiovascular outcomes trials have prompted an update to the 2017 American Diabetes Association standards of care, which now recommend consideration of empagliflozin or liraglutide for patients with suboptimally controlled long-standing T2DM and established atherosclerotic cardiovascular disease because these agents have been shown to reduce cardiovascular and all-cause mortality when added to standard care.
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186
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Busch RS, Kane MP. Combination SGLT2 inhibitor and GLP-1 receptor agonist therapy: a complementary approach to the treatment of type 2 diabetes. Postgrad Med 2017; 129:686-697. [PMID: 28657399 DOI: 10.1080/00325481.2017.1342509] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Among persons with type 2 diabetes (t2d), the development of glucose intolerance involves dysfunction in several organs and tissues, including the muscle, liver, pancreas, kidney, gastrointestinal tract, adipose tissue, and brain. individuals with t2d typically have a number of comorbidities, including hypertension, hyperlipidemia, and being overweight or obese, and are, consequently, at high cardiovascular risk. guidelines recommend a comprehensive care strategy that includes treatment of diabetes-related complications and comorbidities beyond those related to hyperglycemia. use of glucose-lowering therapies with complementary activities that address multiple facets of the disease may improve long-term outcomes for patients with t2d. two recent drug classes developed for use in t2d, glucagon-like peptide-1 receptor agonists (glp-1ras) and sodium glucose cotransporter 2 (sglt2) inhibitors, have been shown in clinical trials to have beneficial effects on glycemic control, body weight, cardiovascular risk factors, and (for liraglutide, semaglutide, and empagliflozin) cardiovascular outcomes, while having an acceptable safety profile. between them, these drug classes directly or indirectly affect many of the organs and tissues involved in the pathogenesis of t2d, and their beneficial effects on glycemic- and cardiovascular-related parameters are likely to be complementary and potentially additive. in the largest clinical trial of a glp-1ra and an sglt2 inhibitor in combination (duration-8), patients with t2d (n = 685) who received exenatide plus dapagliflozin added to their treatment regimen for 28 weeks had significantly greater reductions from baseline in glycated hemoglobin, body weight, and systolic blood pressure compared with patients who received either drug as monotherapy. this review summarizes the complementary aspects of these drug classes and presents the available data among patients receiving dual therapy with a glp-1ra and an sglt2 inhibitor.
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Affiliation(s)
- Robert S Busch
- a Albany Medical Center Division of Community Endocrinology , Albany , NY , USA
| | - Michael P Kane
- b Department of Pharmacy Practice , Albany College of Pharmacy and Health Sciences , Albany , NY , USA
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187
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Abstract
Choices for the treatment of type 2 diabetes mellitus (T2DM) have multiplied as our understanding of the underlying pathophysiologic defects has evolved. Treatment should target multiple defects in T2DM and follow a patient-centered approach that considers factors beyond glycemic control, including cardiovascular risk reduction. The American Association of Clinical Endocrinologists/American College of Endocrinology and the American Diabetes Association recommend an initial approach consisting of lifestyle changes and monotherapy, preferably with metformin. Therapy choices are guided by glycemic efficacy, safety profiles, particularly effects on weight and hypoglycemia risk, tolerability, patient comorbidities, route of administration, patient preference, and cost. Balancing management of hyperglycemia with the risk of hypoglycemia and consideration of the effects of pharmacotherapy on weight figure prominently in US-based T2DM recommendations, whereas less emphasis has been placed on the ability of specific medications to affect cardiovascular outcomes. This is likely because, until recently, specific glucose-lowering agents have not been shown to affect cardiorenal outcomes. The Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients-Removing Excess Glucose (EMPA-REG OUTCOME), the Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results (LEADER) trial, and the Trial to Evaluate Cardiovascular and Other Long-term Outcomes with Semaglutide in Subjects with Type 2 Diabetes 6 (SUSTAIN-6) recently showed a reduction in overall cardiovascular risk with empagliflozin, liraglutide, and semaglutide treatment, respectively. Moreover, empagliflozin has become the first glucose-lowering agent indicated to reduce the risk of cardiovascular death in adults with T2DM and established cardiovascular disease. Results from cardiovascular outcomes trials have prompted an update to the 2017 American Diabetes Association standards of care, which now recommend consideration of empagliflozin or liraglutide for patients with suboptimally controlled long-standing T2DM and established atherosclerotic cardiovascular disease because these agents have been shown to reduce cardiovascular and all-cause mortality when added to standard care.
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188
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Abstract
C-peptide is a widely used measure of pancreatic beta cell function. It is produced in equimolar amounts to endogenous insulin but is excreted at a more constant rate over a longer time. Methods of estimation include urinary and unstimulated and stimulated serum sampling. Modern assays detect levels of c-peptide which can be used to guide diabetes diagnosis and management. We explore the evidence behind the various tests available. We recommend the glucagon stimulation c-peptide testing owing to its balance of sensitivity and practicality. C-peptide levels are associated with diabetes type and duration of disease. Specifically a c-peptide level of less than 0.2 nmol/l is associated with a diagnosis of type 1 diabetes mellitus (T1DM). C-peptide level may correlate with microvascular and macrovascular complications and future use of insulin therapy, as well as likely response to other individual therapies. We explore the potential uses of c-peptide measurement in clinical practice.
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Affiliation(s)
- Emma Leighton
- Diabetes Department, Gartnavel General Hospital, Glasgow, UK
| | | | - Gregory C Jones
- Diabetes Department, Gartnavel General Hospital, Glasgow, UK.
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189
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Jain RK. Empagliflozin/linagliptin single-pill combination therapy for patients with type 2 diabetes mellitus. Expert Opin Pharmacother 2017; 18:545-549. [DOI: 10.1080/14656566.2017.1299712] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Rajeev Kumar Jain
- Aurora Health Center, Aurora Advanced Healthcare, Inc., Milwaukee, WI, USA
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190
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Dey J. SGLT2 inhibitor/DPP-4 inhibitor combination therapy - complementary mechanisms of action for management of type 2 diabetes mellitus. Postgrad Med 2017; 129:409-420. [PMID: 28322073 DOI: 10.1080/00325481.2017.1307081] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Type 2 diabetes mellitus is a progressive disease with multiple underlying pathophysiologic defects. Monotherapy alone cannot maintain glycemic control and leads to treatment failure. Ideally, a combination of glucose-lowering agents should have complementary mechanisms of action that address multiple pathophysiologic pathways, can be used at all stages of the disease, and be generally well tolerated with no increased risk of hypoglycemia, cardiovascular events, or weight gain. The combination should also provide conveniences for patients, such as oral dosing, single-pill formulations, and once-daily administration, potentially translating to improved adherence. Two classes of glucose-lowering agents that meet these criteria are the sodium glucose cotransporter-2 (SGLT2) inhibitors and dipeptidyl peptidase-4 (DPP-4) inhibitors. This article reviews the rationale for combination therapy with these agents, and evidence from clinical trials with empagliflozin and linagliptin or dapagliflozin and saxagliptin in the management of type 2 diabetes mellitus. Both combinations have been approved as single-pill formulations.
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Affiliation(s)
- Jayant Dey
- a Endocrine & Metabolic Disorders Institute , Tupelo , MS , USA
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191
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Pfützner A, Klonoff D, Heinemann L, Ejskjaer N, Pickup J. Euglycemic ketosis in patients with type 2 diabetes on SGLT2-inhibitor therapy-an emerging problem and solutions offered by diabetes technology. Endocrine 2017; 56:212-216. [PMID: 28303514 DOI: 10.1007/s12020-017-1264-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 02/06/2017] [Indexed: 01/24/2023]
Abstract
Diabetic ketoacidosis is an infrequent but life-threatening acute complication of diabetes, affecting predominantly patients with type 1 diabetes, children, and pregnant women, where ketosis is usually associated with marked hyperglycemia. Recently, an increasing number of cases have been reported of euglycemic diabetic ketoacidosis in patients with type 2 diabetes receiving sodium-glucose cotransporter 2 inhibitor treatment in routine practice. There is a minor, but not negligible diabetic ketoacidosis risk associated with this drug class, which was not seen in randomized clinical trials. However, sodium-glucose cotransporter2 inhibitors increase the risk of ketosis by increasing glucagon secretion in the pancreas and decreasing the renal excretion of 3-hydroxybutyrate and acetoacetate. When used in addition to insulin, any insulin dose reduction required to avoid hypoglycemia may lead to insufficient suppression of lipolysis and ketogenesis. sodium-glucose cotransporter2 inhibitor-induced loss of urinary glucose encourages euglycemia. Normo-glycemic or near-normoglycemic diabetic ketoacidosis represents a major threat to the health and well-being of a patient, because it may occur undetected and without any indicative hyperglycemia. In consequence, patients on sodium-glucose cotransporter2 inhibitors are recommended to perform regular blood ketone tests since they are not alerted to incipient diabetic ketoacidosis by glucose testing alone. This option is offered by several blood glucose meters that can also measure ketones with a separate ketone strip or in one case by an automatic parallel ketone assessment from the same strip. The need for extra testing and the associated costs may be a barrier to patient acceptance of this risk mitigation procedure. However, patients who are at risk for euglycemic diabetic ketoacidosis when being treated with sodium-glucose cotransporter2 inhibitors should be specially advised to monitor blood ketone levels on a regular basis.
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Affiliation(s)
- A Pfützner
- Pfützner Science & Health Institute, Mainz, UK.
| | - D Klonoff
- Mills Peninsula Healthcare Services, San Mateo, USA
| | | | - N Ejskjaer
- Department of Endocrinology, Clinical Institute, Aalborg University, Aalborg University Hospital, Aalborg, UK
| | - J Pickup
- Division of Diabetes and Nutritional Sciences, King's College London, Guy's Hospital, London, UK
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192
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Abstract
PURPOSE OF REVIEW There are currently over 40 different drugs in 12 distinct classes approved in the USA to treat patients with type 2 diabetes mellitus. This review summarizes our current knowledge about potential side effects of antidiabetic therapy and attempts to apply it to a clinical practice setting. RECENT FINDINGS Given the heterogeneity of both the patients and the disease, it is mathematically impossible to test every available drug combination in long-term outcome, prospective, randomized blinded fashion before a clinician decides which agent(s) to prescribe to a specific patient in a given situation. To complicate the clinician's dilemma, there is lack of available tests to predict an individual's response or propensity to side effects. Further, the data available are derived from small, short-term registration trials and typically focus on relative rather than absolute risks of any given drug and do not address the potential adverse outcomes if a patient's diabetes remains untreated. Clinicians have to personalize their choice of antidiabetic therapy based both on the specific characteristics of the patient in front of them (stage of diabetes and its complications, overall health status, socioeconomic situation, other medications present, desire to improve control of diabetes, etc.) and the current knowledge about the relative and absolute balance of benefits and risks of any individual medication in that specific patient. It has to be recognized that this requires constant re-evaluation as database of our experience with antidiabetic therapy expands.
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Affiliation(s)
- George Grunberger
- Grunberger Diabetes Institute, 43494 Woodward Avenue, suite 208, Bloomfield Hills, MI, 48302, USA.
- Internal Medicine and Molecular Medicine and Genetics, Wayne State University School of Medicine, Detroit, MI, USA.
- Internal Medicine, Oakland University William Beaumont School of Medicine, Rochester, MI, USA.
- Internal Medicine, First Faculty of Medicine, Charles University, Prague, Czech Republic.
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193
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Umpierrez GE, Pasquel FJ. Management of Inpatient Hyperglycemia and Diabetes in Older Adults. Diabetes Care 2017; 40:509-517. [PMID: 28325798 PMCID: PMC5864102 DOI: 10.2337/dc16-0989] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 11/02/2016] [Indexed: 02/03/2023]
Abstract
Adults aged 65 years and older are the fastest growing segment of the U.S. population, and their number is expected to double to 89 million between 2010 and 2050. The prevalence of diabetes in hospitalized adults aged 65-75 years and over 80 years of age has been estimated to be 20% and 40%, respectively. Similar to general populations, the presence of hyperglycemia and diabetes in elderly patients is associated with increased risk of hospital complications, longer length of stay, and increased mortality compared with subjects with normoglycemia. Clinical guidelines recommend target blood glucose between 140 and 180 mg/dL (7.8 and 10 mmol/L) for most patients in the intensive care unit (ICU). A similar blood glucose target is recommended for patients in non-ICU settings; however, glycemic targets should be individualized in older adults on the basis of a patient's clinical status, risk of hypoglycemia, and presence of diabetes complications. Insulin is the preferred agent to manage hyperglycemia and diabetes in the hospital. Continuous insulin infusion in the ICU and rational use of basal-bolus or basal plus supplement regimens in non-ICU settings are effective in achieving glycemic goals. Noninsulin regimens with the use of dipeptidyl peptidase 4 inhibitors alone or in combination with basal insulin have been shown to be safe and effective and may represent an alternative to basal-bolus regimens in elderly patients. Smooth transition of care to the outpatient setting is facilitated by providing oral and written instructions regarding timing and dosing of insulin as well as education in basic skills for home management.
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Affiliation(s)
- Guillermo E Umpierrez
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Francisco J Pasquel
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
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194
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Araki E, Onishi Y, Asano M, Kim H, Yajima T. Efficacy and safety of dapagliflozin over 1 year as add-on to insulin therapy in Japanese patients with type 2 diabetes: the DAISY (Dapagliflozin Added to patients under InSulin therapY) trial. Diabetes Obes Metab 2017; 19:562-570. [PMID: 27987240 DOI: 10.1111/dom.12853] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 12/02/2016] [Accepted: 12/12/2016] [Indexed: 01/10/2023]
Abstract
AIMS To evaluate the efficacy and safety of dapagliflozin as add-on to insulin in Japanese patients with type 2 diabetes. MATERIALS AND METHODS Insulin-treated Japanese patients were randomized to 5 mg dapagliflozin or placebo during a 16-week double-blind treatment period. Both groups then received dapagliflozin 5 or 10 mg (the dose was increased at or after week 24 if glycated haemoglobin [HbA1c] at the previous visit was >7.5%) during a 36-week open-label extension period. The exploratory efficacy endpoint was to assess the maintenance efficacy of 5/10 mg dapagliflozin + insulin over 52 weeks of treatment. Safety was assessed in terms of adverse events, laboratory variables and vital signs. RESULTS The changes in HbA1c from baseline to weeks 16 and 52 were -0.62% and -0.74%, respectively, in the dapagliflozin group, vs -0.08% and -0.83%, respectively, in the placebo-dapagliflozin group. Body weight decreased at both time points in the dapagliflozin group and after switching to open-label dapagliflozin in the placebo-dapagliflozin group. The total insulin dose decreased slightly after starting dapagliflozin. Adverse events occurred in 82.9% and 71.7% of patients in the dapagliflozin and placebo-dapagliflozin groups, respectively. Hypoglycaemia occurred in 35.0% and 41.7% of patients in the dapagliflozin and placebo-dapagliflozin groups, respectively, but the incidence was not increased by use of dapagliflozin in either trial period. Genital/urinary tract infections, renal impairment/failure, volume depletion, fracture and hepatic disorders occurred in ≤5% of patients. CONCLUSION This trial showed that administration of dapagliflozin as an add-on to insulin therapy was effective, was well tolerated and had insulin-sparing effects in Japanese patients with type 2 diabetes.
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Affiliation(s)
- Eiichi Araki
- Department of Metabolic Medicine, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Yukiko Onishi
- Division of Diabetes and Metabolism, The Institute for Adult Diseases, Asahi Life Foundation, Tokyo, Japan
| | - Michiko Asano
- Research and Development, AstraZeneca K.K., Osaka, Japan
| | - Hyosung Kim
- Research and Development, AstraZeneca K.K., Osaka, Japan
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195
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Fioretto P, Avogaro A. Dapagliflozin: potential beneficial effects in the prevention and treatment of renal and cardiovascular complications in patients with type 2 diabetes. Expert Opin Pharmacother 2017; 18:517-527. [PMID: 28277831 DOI: 10.1080/14656566.2017.1300253] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Diabetic kidney disease is the leading cause of end-stage renal disease, a significant contributor to cardiovascular (CV) disease, responsible for much of the morbidity and mortality in patients with type 2 diabetes (T2DM). Strategies to slow or prevent the onset and progression of diabetic kidney disease are critical for effectively managing T2DM and reducing CV risk. Sodium-glucose cotransporter 2 (SGLT2) inhibitors are effective antidiabetic agents, which may provide nephroprotective and CV protective effects. Areas covered: This review examines the role of the kidney in glucose homeostasis, discusses renal hemodynamic changes in diabetes, and outlines the major hypotheses regarding the mechanisms underlying renal injury in diabetes. The potential benefits of SGLT2 inhibitors in the prevention and treatment of CV complications in patients with T2DM are reviewed, with particular focus on dapagliflozin. Expert opinion: Dapagliflozin and other SGLT2 inhibitors have the capacity to decrease hyperglycemia and visceral fat, components of the metabolic syndrome particularly associated with the progression of CV disease. However, the mechanisms of action of SGLT2 inhibitors resulting in their positive CV effects remain unclear. Furthermore, the mechanism of action of SGLT2 inhibitors on heart function in non-diabetic patients with decompensated heart failure remains to be explored.
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Affiliation(s)
- Paola Fioretto
- a Department of Medicine , University of Padua , Padua , Italy
| | - Angelo Avogaro
- b Unit of Metabolic Diseases, Department of Medicine , University of Padua , Padua , Italy
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196
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Chen J, Fan F, Wang JY, Long Y, Gao CL, Stanton RC, Xu Y. The efficacy and safety of SGLT2 inhibitors for adjunctive treatment of type 1 diabetes: a systematic review and meta-analysis. Sci Rep 2017; 7:44128. [PMID: 28276512 PMCID: PMC5343472 DOI: 10.1038/srep44128] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 02/03/2017] [Indexed: 12/13/2022] Open
Abstract
To assess the efficacy and safety of the SGLT-2 inhibitors as adjunct therapy to insulin in T1DM, clinical trials indexed in PubMed, Cochrane Library, EMbase from inception through April 5, 2016. A meta-analysis was conducted on trials of SGLT-2 inhibitors in patients with T1DM on insulin therapy using RevMan 5.3 software. Of the 371 articles identified, ten met eligibility criteria. Seven clinical trials including four randomized controlled trials and 581 patients were included. Compared with the control group, SGLT-2 inhibitors group had significantly reduced fasting plasma glucose by 0.69 mmol/L [1.32; 0.07], glycosylated hemoglobin A1C by 0.37% [0.54; 0.20], body weight by 2.54 kg [3.48; 1.60] and total daily insulin dose by 6.22 IU [8.04; 4.40]. The total incidence of adverse events (AEs), hypoglycemia, and genital and urinary infections were also similar to placebo, while an increased incidence of diabetic ketoacidosis (DKA) (n = 16) was seen in SGLT-2 inhibitors group. The present study demonstrates that SGLT-2 inhibitors are effective as adjunct therapy to insulin in T1DM, heralding improved glycemic control, reduced body weight and total daily insulin dose without an increase in total AEs, hypoglycemia, or genital and urinary infections. However, the risk of DKA should be carefully monitored in future clinical trials.
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Affiliation(s)
- Jiao Chen
- Department of Endocrinology, Affiliated Hospital of Southwest Medical College, Luzhou, Sichuan 646000, China
| | - Fang Fan
- Department of Endocrinology, Affiliated Hospital of Southwest Medical College, Luzhou, Sichuan 646000, China
| | - J Y Wang
- Department of Endocrinology, Affiliated Hospital of Southwest Medical College, Luzhou, Sichuan 646000, China
| | - Yang Long
- Department of Endocrinology, Affiliated Hospital of Southwest Medical College, Luzhou, Sichuan 646000, China
| | - C L Gao
- Department of Endocrinology, Affiliated Hospital of Southwest Medical College, Luzhou, Sichuan 646000, China
| | - R C Stanton
- Joslin Diabetes Center, Boston, MA, USA.,Beth Israel Deaconess Medical Center, Boston, MA, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Yong Xu
- Department of Endocrinology, Affiliated Hospital of Southwest Medical College, Luzhou, Sichuan 646000, China
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197
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Kum-Nji JS, Gosmanov AR, Steinberg H, Dagogo-Jack S. Hyperglycemic, high anion-gap metabolic acidosis in patients receiving SGLT-2 inhibitors for diabetes management. J Diabetes Complications 2017; 31:611-614. [PMID: 27913012 DOI: 10.1016/j.jdiacomp.2016.11.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 10/21/2016] [Accepted: 11/04/2016] [Indexed: 11/21/2022]
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT-2i) are a class of antidiabetic medications that improve glycemic control via inhibiting the reabsorption of filtered glucose and are approved for use in type 2 diabetes (T2DM). These drugs have recently been associated with euglycemic diabetic ketoacidosis (DKA). An increasing number of cases of SGLT-2i-associated DKA have occurred in patients with T2DM. Herein, we describe five episodes of hyperglycemic DKA in four type 2 diabetes patients receiving SGLT-2i therapy. Risk for ketoacidosis in our case series was mediated predominately by reduction of insulin dose and insulinopenia. None of the patients reported a history of low carbohydrate diet or alcohol use, and all but one patient had negative glutamic acid decarboxylase antibodies. Resolution of DKA in SGLT-2i treated patients took longer than for T1DM patients with DKA based on literature data. The mechanisms by which SGLT-2i are associated with ketoacidosis are not fully understood and likely involve hyperglucagonemia and other factors. Further studies are needed to elucidate the precise mechanism.
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Affiliation(s)
- Juliette Sandifer Kum-Nji
- Department of Medicine, Division of Endocrinology, Diabetes & Metabolism, University of Tennessee Health Science Center, Memphis, TN
| | | | - Helmut Steinberg
- Department of Medicine, Division of Endocrinology, Diabetes & Metabolism, University of Tennessee Health Science Center, Memphis, TN
| | - Samuel Dagogo-Jack
- Department of Medicine, Division of Endocrinology, Diabetes & Metabolism, University of Tennessee Health Science Center, Memphis, TN.
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198
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Abstract
An association between perioperative hyperglycemia and adverse outcomes has been established in surgical patients, 1 -3 with morbidity being reduced in those treated with insulin.5 -6 A practical treatment algorithm and literature summary is provided for surgical patients with diabetes and hyperglycemia.
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Affiliation(s)
- Elizabeth W Duggan
- From the Departments of Anesthesiology (E.W.D., K.C.) and Medicine (G.E.U.), Emory University School of Medicine, Atlanta, Georgia
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199
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Messana JA, Schwartz SS, Townsend RR. An evidence-based practice-oriented review focusing on canagliflozin in the management of type 2 diabetes. Vasc Health Risk Manag 2017; 13:43-54. [PMID: 28255241 PMCID: PMC5322811 DOI: 10.2147/vhrm.s105721] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Caring for patients with type 2 diabetes mellitus (T2DM) has entered an era with many recent additions to the regimens used to clinically control their hyperglycemia. The most recent class of agents approved by the Food and Drug Administration (FDA) for T2DM is the sodium–glucose-linked transporter type 2 (SGLT2) inhibitors, which work principally in the proximal tubule of the kidney to block filtered glucose reabsorption. In the few years attending this new class arrival in the market, there has been a great deal of interest generated by the novel mechanism of action of SGLT2 inhibitors and by recent large outcome trials suggesting benefit on important clinical outcomes such as death, cardiovascular disease and kidney disease progression. In this review, we focus on canagliflozin, the first-in-class marketed SGLT2 inhibitor in the USA. In some cases, we included data from other SGLT2 inhibitors, such as outcomes in clinical trials, important insights on clinical features and benefits, and adverse effects. These agents represent a fundamentally different way of controlling blood glucose and for the first time in T2DM care to offer the opportunity to reduce glucose, blood pressure, and weight with effects sustained for at least 2 years. Important side effects include genital mycotic infections and the potential for orthostatic hypotension and rare instances of normoglycemic ketoacidosis. Active ongoing clinical trials promise to deepen our experience with the potential benefits, as well as the clinical risks attending the use of this new group of antidiabetic agents.
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Affiliation(s)
- Joseph A Messana
- Nephrology Division, Perelman School of Medicine, University of Pennsylvania
| | - Stanley S Schwartz
- Main Line Health; Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Raymond R Townsend
- Nephrology Division, Perelman School of Medicine, University of Pennsylvania
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200
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Dhatariya K. Blood Ketones: Measurement, Interpretation, Limitations, and Utility in the Management of Diabetic Ketoacidosis. Rev Diabet Stud 2017; 13:217-225. [PMID: 28278308 DOI: 10.1900/rds.2016.13.217] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Diabetic ketoacidosis (DKA) remains a common medical emergency. Over the last few years, new national guidelines have changed the focus in managing the condition from being glucose-centered to ketone-centered. With the advent of advancing technology and the increasing use of hand-held, point-of-care ketone meters, greater emphasis is placed on making treatment decisions based on these readings. Furthermore, recent warnings about euglycemic DKA occurring in people with diabetes using sodium-glucose co-transporter 2 (SGLT-2) inhibitors urge clinicians to inform their patients of this condition and possible testing options. This review describes the reasons for a change in treating DKA, and outlines the benefits and limitations of using ketone readings, in particular highlighting the difference between urine and capillary readings.
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Affiliation(s)
- Ketan Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk NR4 7UY, UK
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