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Nan J, Wang D, Zhong R, Liu F, Luo J, Tang P, Song X, Zhang L. Sodium glucose cotransporter2 inhibitors for type 1 diabetes mellitus: A meta-analysis of randomized controlled trials. Prim Care Diabetes 2024; 18:17-24. [PMID: 37980217 DOI: 10.1016/j.pcd.2023.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 10/08/2023] [Accepted: 10/22/2023] [Indexed: 11/20/2023]
Abstract
AIMS Sodium glucose cotransporter2 (SGLT2) inhibitors are controversial in the treatment of type 1 diabetes mellitus (T1DM). This study is a systematic evaluation of the safety of SGLT2 inhibitors usage in T1DM. METHODS Comprehensive literature search in six databases from inception to September 2022. Randomized controlled trials (RCTs) of T1DM treated with SGLT2 inhibitor vs. placebo were included. Data were extracted from the literature that met the inclusion criteria. After quality evaluation by the Cochrane risk bias assessment tool, meta-analysis was performed using Revman 5.4 and Stata 17.1. RESULTS The study consisted of 16 RCTs with 7192 patients. The results indicated that SGLT2inhibitors reduce glycated hemoglobin (HbA1c, Mean difference (MD)- 0.29%, P < 0.05), fasting plasma glucose (FPG, MD-0.85 mmol/L, P < 0.05), mean amplitude of glucose excursions (MAGE, 15.75 mg/dL, P < 0.05), body weight (MD-3.49 kg, P < 0.05), and total insulin dosage (MD-7.14 IU/day, P < 0.05). Furthermore, cautious SGLT2 inhibitors did not induce the risk of hypoglycemia (RR1.00, P = 0.86), urinary tract infections (RR1.02, P = 0.085), and diarrhea (RR1.34, P = 0.523). CONCLUSION Based on this meta-analysis, SGLT22 inhibitors reduce insulin dosage without increasing the risk of hypoglycemia and diabetic ketoacidosis for type 1 diabetes mellitus in 1month.
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Affiliation(s)
- Juanli Nan
- Department of General Practice, The First Affiliated Hospital of Kunming Medical University, Kunming 650031, China
| | - Dekai Wang
- Department of General Practice, The First Affiliated Hospital of Kunming Medical University, Kunming 650031, China
| | - Ruxian Zhong
- Department of General Practice, The First Affiliated Hospital of Kunming Medical University, Kunming 650031, China
| | - Fen Liu
- Department of General Practice, The First Affiliated Hospital of Kunming Medical University, Kunming 650031, China
| | - Jingmei Luo
- Department of General Practice, The First Affiliated Hospital of Kunming Medical University, Kunming 650031, China
| | - Ping Tang
- Department of General Practice, The First Affiliated Hospital of Kunming Medical University, Kunming 650031, China
| | - Xiaoxiao Song
- School of Public Health, Kunming Medical University, Kunming 650500, China
| | - Lihua Zhang
- Department of General Practice, The First Affiliated Hospital of Kunming Medical University, Kunming 650031, China.
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Lupsa BC, Kibbey RG, Inzucchi SE. Ketones: the double-edged sword of SGLT2 inhibitors? Diabetologia 2023; 66:23-32. [PMID: 36255460 DOI: 10.1007/s00125-022-05815-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/21/2022] [Indexed: 12/13/2022]
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a class of medications used by individuals with type 2 diabetes that reduce hyperglycaemia by targeting glucose transport in the kidney, preventing its reabsorption, thereby inducing glucosuria. Besides improving HbA1c and reducing body weight and blood pressure, the SGLT2 inhibitors have also been demonstrated to improve cardiovascular and kidney outcomes, an effect largely independent of their effect on blood glucose levels. Indeed, the mechanisms underlying these benefits remain elusive. Treatment with SGLT2 inhibitors has been found to modestly increase systemic ketone levels. Ketone bodies are an ancillary fuel source substituting for glucose in some tissues and may also possess intrinsic anti-oxidative and anti-inflammatory effects. Some have proposed that ketones may in fact mediate the cardio-renal benefits of this drug category. However, a rare complication of SGLT2 inhibition is ketoacidosis, sometimes with normal or near-normal blood glucose concentrations, albeit occurring more frequently in patients with type 1 diabetes who are treated (predominately off-label) with one of these agents. We herein explore the notion that an underpinning of one of the more serious adverse effects of SGLT2 inhibitors may, in fact, explain, at least in part, some of their benefits-a potential 'double-edged sword' of this novel drug category.
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Affiliation(s)
- Beatrice C Lupsa
- Department of Medicine (Endocrinology), Yale School of Medicine, New Haven, CT, USA.
| | - Richard G Kibbey
- Department of Medicine (Endocrinology), Yale School of Medicine, New Haven, CT, USA
- Department of Cellular & Molecular Physiology, Yale School of Medicine, New Haven, CT, USA
| | - Silvio E Inzucchi
- Department of Medicine (Endocrinology), Yale School of Medicine, New Haven, CT, USA
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3
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Yaribeygi H, Maleki M, Butler AE, Jamialahmadi T, Sahebkar A. New insights into cellular links between sodium-glucose cotransporter-2 inhibitors and ketogenesis. J Cell Biochem 2022; 123:1879-1890. [PMID: 36153819 DOI: 10.1002/jcb.30327] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/30/2022] [Accepted: 09/02/2022] [Indexed: 12/24/2022]
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT2is) are a newly developed class of highly effective antidiabetic therapies that normalize hyperglycemia via urinary glucose excretion. However, they may be accompanied by certain side effects that negatively impact their therapeutic benefits. SGLT2is induce a metabolic shift from glucose to fatty acids and thus increase lipolysis which, in turn, induces ketogenesis. The complete pathways linking SGLT2is to ketoacidosis have not yet been fully elucidated, though much is now known. Therefore, in this mechanistic study, we present the current knowledge and shed light upon the possible cellular pathways involved. A deeper understanding of the possible links between SGLT2is and ketogenesis could help to prevent adverse side effects in diabetic patients treated with these drugs.
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Affiliation(s)
- Habib Yaribeygi
- Research Center of Physiology, Semnan University of Medical Sciences, Semnan, Iran
| | - Mina Maleki
- Urology and Nephrology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alexandra E Butler
- Research Department, Royal College of Surgeons in Ireland Bahrain, Adliya, Bahrain
| | - Tannaz Jamialahmadi
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,Surgical Oncology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amirhossein Sahebkar
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran.,School of Medicine, The University of Western Australia, Perth, Australia.,Department of Biotechnology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
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4
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Perkins BA, Sherr JL, Mathieu C. Type 1 diabetes glycemic management: Insulin therapy, glucose monitoring, and automation. Science 2021; 373:522-527. [PMID: 34326234 DOI: 10.1126/science.abg4502] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Despite innovations in insulin therapy since its discovery, most patients living with type 1 diabetes do not achieve sufficient glycemic control to prevent complications, and they experience hypoglycemia, weight gain, and major self-care burden. Promising pharmacological advances in insulin therapy include the refinement of extremely rapid insulin analogs, alternate insulin-delivery routes, liver-selective insulins, add-on drugs that enhance insulin effect, and glucose-responsive insulin molecules. The greatest future impact will come from combining these pharmacological solutions with existing automated insulin delivery methods that integrate insulin pumps and glucose sensors. These systems will use algorithms enhanced by machine learning, supplemented by technologies that include activity monitors and sensors for other key metabolites such as ketones. The future challenges facing clinicians and researchers will be those of access and broad clinical implementation.
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Affiliation(s)
- Bruce A Perkins
- Division of Endocrinology, Department of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Jennifer L Sherr
- Department of Pediatrics (Endocrinology), Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Chantal Mathieu
- Department of Endocrinology, UZ Gasthuisberg, Katholieke Universiteit Leuven (KULeuven), Leuven, Belgium
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5
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Zou H, Liu L, Guo J, Wang H, Liu S, Xing Y, Deng C, Xiao Y, Zhou Z. Sodium-glucose cotransporter inhibitors as add-on therapy in addition to insulin for type 1 diabetes mellitus: A meta-analysis of randomized controlled trials. J Diabetes Investig 2021; 12:546-556. [PMID: 33245620 PMCID: PMC8015835 DOI: 10.1111/jdi.13387] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 06/06/2020] [Accepted: 08/09/2020] [Indexed: 12/16/2022] Open
Abstract
AIMS/INTRODUCTION Several clinical trials reported the effects of sodium-glucose cotransporter (SGLT) inhibitors in type 1 diabetes patients. This meta-analysis aimed to assess the efficacy and safety of SGLT inhibitors in type 1 diabetes patients. MATERIALS AND METHODS Relevant studies were identified in the PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure and Wan Fang databases through 1 April 2020. Differences were expressed as the 95% confidence interval (CI) or weighted mean difference (WMD) for continuous outcomes, and risk ratio (RR) for discontinuous outcomes. RESULTS A total of 13 RCTs with 7,962 cases were included. SGLT inhibitors reduced the fasting plasma glucose level (WMD -1.320 mmol/L, 95% CI -1.609 to -1.031, P < 0.001), glycated hemoglobin level (WMD -0.386%, 95% CI -0.431 to -0.342, P < 0.001) and daily total insulin dose (WMD -5.403, 95% CI -7.218 to -3.859, P < 0.001). However, higher risks of diabetic ketoacidosis (RR 5.042, 95% CI 3.160-8.046, P < 0.001), urinary tract infections (RR 1.259, 95% CI 1.034-1.533,P = 0.022) and genital infections (RR 2.995, 95% CI 1.953-4.594, P < 0.001) were associated with SGLT inhibitors, but SGLT inhibitors did not increase the hypoglycemia risk (RR 0.980, 95% CI 0.840-1.144,P = 0.799). In subgroup analysis, with a significant reduction of fasting plasma glucose, glycated hemoglobin and daily insulin doses, SGLT1/2 inhibitor did not increase genitourinary tract infections compared with a placebo. CONCLUSIONS SGLT2 and SGLT1/2 inhibitors can improve glycemic control in patients with type 1 diabetes.
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Affiliation(s)
- Hailan Zou
- Department of Metabolism and EndocrinologyThe Second Xiangya HospitalCentral South UniversityChangshaHunanChina
- National Clinical Research Center for Metabolic DiseasesChangshaHunanChina
| | - Lili Liu
- Department of Metabolism and EndocrinologyThe Second Xiangya HospitalCentral South UniversityChangshaHunanChina
- National Clinical Research Center for Metabolic DiseasesChangshaHunanChina
| | - Jia Guo
- Xiangya School of NursingCentral South UniversityChangshaChina
| | - Hongjuan Wang
- Xiangya School of NursingCentral South UniversityChangshaChina
| | - Siyun Liu
- Chongqing General HospitalUniversity of Chinese Academy of SciencesBeijingChina
| | - Yixuan Xing
- Department of Metabolism and EndocrinologyThe Second Xiangya HospitalCentral South UniversityChangshaHunanChina
- National Clinical Research Center for Metabolic DiseasesChangshaHunanChina
| | - Chao Deng
- Department of Metabolism and EndocrinologyThe Second Xiangya HospitalCentral South UniversityChangshaHunanChina
- National Clinical Research Center for Metabolic DiseasesChangshaHunanChina
| | - Yang Xiao
- Department of Metabolism and EndocrinologyThe Second Xiangya HospitalCentral South UniversityChangshaHunanChina
- National Clinical Research Center for Metabolic DiseasesChangshaHunanChina
| | - Zhiguang Zhou
- Department of Metabolism and EndocrinologyThe Second Xiangya HospitalCentral South UniversityChangshaHunanChina
- National Clinical Research Center for Metabolic DiseasesChangshaHunanChina
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Rysz J, Franczyk B, Radek M, Ciałkowska-Rysz A, Gluba-Brzózka A. Diabetes and Cardiovascular Risk in Renal Transplant Patients. Int J Mol Sci 2021; 22:3422. [PMID: 33810367 PMCID: PMC8036743 DOI: 10.3390/ijms22073422] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/05/2021] [Accepted: 03/08/2021] [Indexed: 02/06/2023] Open
Abstract
End-stage kidney disease (ESKD) is a main public health problem, the prevalence of which is continuously increasing worldwide. Due to adverse effects of renal replacement therapies, kidney transplantation seems to be the optimal form of therapy with significantly improved survival, quality of life and diminished overall costs compared with dialysis. However, post-transplant patients frequently suffer from post-transplant diabetes mellitus (PTDM) which an important risk factor for cardiovascular and cardiovascular-related deaths after transplantation. The management of post-transplant diabetes resembles that of diabetes in the general population as it is based on strict glycemic control as well as screening and treatment of common complications. Lifestyle interventions accompanied by the tailoring of immunosuppressive regimen may be of key importance to mitigate PTDM-associated complications in kidney transplant patients. More transplant-specific approach can include the exchange of tacrolimus with an alternative immunosuppressant (cyclosporine or mammalian target of rapamycin (mTOR) inhibitor), the decrease or cessation of corticosteroid therapy and caution in the prescribing of diuretics since they are independently connected with post-transplant diabetes. Early identification of high-risk patients for cardiovascular diseases enables timely introduction of appropriate therapeutic strategy and results in higher survival rates for patients with a transplanted kidney.
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Affiliation(s)
- Jacek Rysz
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, 90-549 Lodz, Poland; (J.R.); (B.F.)
| | - Beata Franczyk
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, 90-549 Lodz, Poland; (J.R.); (B.F.)
| | - Maciej Radek
- Department of Neurosurgery, Surgery of Spine and Peripheral Nerves, Medical University of Lodz, 90-549 Lodz, Poland;
| | | | - Anna Gluba-Brzózka
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, 90-549 Lodz, Poland; (J.R.); (B.F.)
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SGLT2 inhibition versus sulfonylurea treatment effects on electrolyte and acid-base balance: secondary analysis of a clinical trial reaching glycemic equipoise: Tubular effects of SGLT2 inhibition in Type 2 diabetes. Clin Sci (Lond) 2021; 134:3107-3118. [PMID: 33205810 DOI: 10.1042/cs20201274] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/12/2020] [Accepted: 11/18/2020] [Indexed: 12/19/2022]
Abstract
Sodium-glucose transporter (SGLT)2 inhibitors increase plasma magnesium and plasma phosphate and may cause ketoacidosis, but the contribution of improved glycemic control to these observations as well as effects on other electrolytes and acid-base parameters remain unknown. Therefore, our objective was to compare the effects of SGLT2 inhibitors dapagliflozin and sulfonylurea gliclazide on plasma electrolytes, urinary electrolyte excretion, and acid-base balance in people with Type 2 diabetes (T2D). We assessed the effects of dapagliflozin and gliclazide treatment on plasma electrolytes and bicarbonate, 24-hour urinary pH and excretions of electrolytes, ammonium, citrate, and sulfate in 44 metformin-treated people with T2D and preserved kidney function. Compared with gliclazide, dapagliflozin increased plasma chloride by 1.4 mmol/l (95% CI 0.4-2.4), plasma magnesium by 0.03 mmol/l (95% CI 0.01-0.06), and plasma sulfate by 0.02 mmol/l (95% CI 0.01-0.04). Compared with baseline, dapagliflozin also significantly increased plasma phosphate, but the same trend was observed with gliclazide. From baseline to week 12, dapagliflozin increased the urinary excretion of citrate by 0.93 ± 1.72 mmol/day, acetoacetate by 48 μmol/day (IQR 17-138), and β-hydroxybutyrate by 59 μmol/day (IQR 0-336), without disturbing acid-base balance. In conclusion, dapagliflozin increases plasma magnesium, chloride, and sulfate compared with gliclazide, while reaching similar glucose-lowering in people with T2D. Dapagliflozin also increases urinary ketone excretion without changing acid-base balance. Therefore, the increase in urinary citrate excretion by dapagliflozin may reflect an effect on cellular metabolism including the tricarboxylic acid cycle. This potentially contributes to kidney protection.
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Sampani E, Sarafidis P, Dimitriadis C, Kasimatis E, Daikidou D, Bantis K, Papanikolaou A, Papagianni A. Severe euglycemic diabetic ketoacidosis of multifactorial etiology in a type 2 diabetic patient treated with empagliflozin: case report and literature review. BMC Nephrol 2020; 21:276. [PMID: 32669085 PMCID: PMC7364613 DOI: 10.1186/s12882-020-01930-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 07/06/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Sodium-glucose co-transporter-2 (SGLT-2) inhibitors are a relatively novel class of oral medications for the treatment of Type 2 DM with a generally acceptable safety profile. However, these agents have been associated with rare events of a serious and potentially life-threatening complication named euglycemic diabetic ketoacidosis (euDKA). euDKA is not identical with the typical diabetic ketoacidosis, as it often presents with serious metabolic acidosis but only mild to moderate glucose and anion gap elevation. CASE PRESENTATION We report a case of a 51-year old female with Type 2 DM treated with an SGLT-2 inhibitor, developing severe metabolic acidosis with only mild blood glucose elevation after a routine surgery. A careful evaluation of involved factors led to the diagnosis of euDKA, followed by cautious application of simple therapeutic measures that resulted in complete restoration of acidosis and glycemic control in less than 48-h. CONCLUSIONS Euglycemic ketoacidosis is a rare but rather serious complication of SGLT-2 inhibitors use, often with a multifactorial etiology. Its atypical presentation requires a high level of awareness by physicians as early recognition of this complication can quickly and safely restore acid-base balance.
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Affiliation(s)
- Erasmia Sampani
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Konstantinoupoleos 49, GR54642, Thessaloniki, Greece
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Konstantinoupoleos 49, GR54642, Thessaloniki, Greece.
| | - Chrysostomos Dimitriadis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Konstantinoupoleos 49, GR54642, Thessaloniki, Greece
| | - Efstratios Kasimatis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Konstantinoupoleos 49, GR54642, Thessaloniki, Greece
| | - Dimitra Daikidou
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Konstantinoupoleos 49, GR54642, Thessaloniki, Greece
| | - Konstantinos Bantis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Konstantinoupoleos 49, GR54642, Thessaloniki, Greece
| | - Alexios Papanikolaou
- 2nd Department of Obstetrics and Gynecology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aikaterini Papagianni
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Konstantinoupoleos 49, GR54642, Thessaloniki, Greece
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Magnesium, Calcium, Potassium, Sodium, Phosphorus, Selenium, Zinc, and Chromium Levels in Alcohol Use Disorder: A Review. J Clin Med 2020; 9:jcm9061901. [PMID: 32570709 PMCID: PMC7357092 DOI: 10.3390/jcm9061901] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 06/15/2020] [Indexed: 02/07/2023] Open
Abstract
Macronutrients and trace elements are important components of living tissues that have different metabolic properties and functions. Trace elements participate in the regulation of immunity through humoral and cellular mechanisms, nerve conduction, muscle spasms, membrane potential regulation as well as mitochondrial activity and enzymatic reactions. Excessive alcohol consumption disrupts the concentrations of crucial trace elements, also increasing the risk of enhanced oxidative stress and alcohol-related liver diseases. In this review, we present the status of selected macroelements and trace elements in the serum and plasma of people chronically consuming alcohol. Such knowledge helps to understand the mechanisms of chronic alcohol-use disorder and to progress and prevent withdrawal effects, also improving treatment strategies.
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Sampani E, Sarafidis P, Papagianni A. Euglycaemic diabetic ketoacidosis as a complication of SGLT-2 inhibitors: epidemiology, pathophysiology, and treatment. Expert Opin Drug Saf 2020; 19:673-682. [PMID: 32521174 DOI: 10.1080/14740338.2020.1764532] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Sodium-glucose co-transporters 2 (SGLT-2) inhibitors are a relatively novel class of oral medications for the treatment of Type 2 Diabetes Mellitus, which lower plasma glucose by inhibiting glucose reabsorption in the proximal renal tubule. Apart from their hypoglycemic action, recent data suggest these agents have additional major cardioprotective and nephroprotective properties. AREAS COVERED This review summarizes the existing data on epidemiology, pathophysiology, and treatment of euglycaemic ketoacidosis (euDKA) as a complication of SGLT-2 inhibitor use. EXPERT OPINION Although SGLT-2 inhibitors have a relatively good adverse event profile, they have been associated with the serious and potentially life-threatening metabolic complication of euDKA. Data from major outcome trials suggest that the rate of DKA is quite low. However, the rate of DKA could be generally underestimated in clinical trials due to the atypical presentation of ketoacidosis, and even more so in real-life conditions. Management of this serious metabolic complication requires a proper understanding of its pathophysiology as well as increased awareness and early recognition of the potential risk factors involved. Following this, the institution of an array of simple supportive measures, could safely restore normal acid-base balance in most patients.
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Affiliation(s)
- Erasmia Sampani
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki , Thessaloniki, Greece
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki , Thessaloniki, Greece
| | - Aikaterini Papagianni
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki , Thessaloniki, Greece
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Abstract
PURPOSE OF REVIEW Our goal is to discuss how to personalize the management of patients with type 2 diabetes by adjusting glycemic targets and tailoring medical therapy to account for unique patient characteristics. RECENT FINDINGS We review the pharmacotherapeutic options for the management of type 2 diabetes, focusing on potential advantages and disadvantages of each class of agents. We also discuss how to approach specific patient subpopulations and propose a conceptual framework for incorporating these factors into clinical practice. As the diabetes treatment landscape rapidly expands, physicians have the exciting opportunity to offer patients increasingly individualized care.
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Affiliation(s)
- Patricia R Peter
- Section of Endocrinology, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, FMP 106, P.O. Box 208020, New Haven, CT, 06520, USA.
| | - Beatrice C Lupsa
- Section of Endocrinology, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, FMP 106, P.O. Box 208020, New Haven, CT, 06520, USA
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12
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Jhaveri U, Vardesh D. Sodium-glucose Cotransporter-2 Inhibitors and Euglycaemic Diabetic Ketoacidosis in the Perioperative Period: Case Report. Cureus 2019; 11:e5455. [PMID: 31511817 PMCID: PMC6716770 DOI: 10.7759/cureus.5455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The use of sodium-glucose cotransporter-2 inhibitors (SGLT2i) has been steadily increasing over the past few years due to their efficacy in glycaemic control as well as added benefits of weight loss and reduction in cardiovascular mortality. SGLT2i are a class of oral hypoglycaemics that work by increasing urinary glucose excretion via the inhibition of the sodium-glucose cotransporter-2 in the proximal tubule of the kidney. Euglycaemic diabetic ketoacidosis (euDKA) is a potentially life-threatening adverse effect of SGLT2i. The literature shows an increasing awareness of this issue amongst physicians. However, in addition to prescriber education, emphasis needs to be placed on patient education to highlight this potentially serious adverse effect. We present two cases of patients with euDKA following SGLT2i use in the perioperative period. The cases discussed reiterate the importance of awareness of SGLT2i-induced euDKA during the perioperative period. Both cases raise the question of whether patients are being adequately educated about the drug, its adverse effects and under what conditions to cease the medication.
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Nephrology Consultation for Severe SGLT2 Inhibitor-Induced Ketoacidosis in Type 2 Diabetes: Case Report. ACTA ACUST UNITED AC 2019; 55:medicina55080462. [PMID: 31405158 PMCID: PMC6723212 DOI: 10.3390/medicina55080462] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 08/06/2019] [Accepted: 08/08/2019] [Indexed: 12/15/2022]
Abstract
Euglycemic diabetic ketoacidosis (euDKA) related to sodium-glucose cotransporter 2 inhibitor (SGLT2-I), despite being reported as consistent, though infrequent, adverse effect in all trials on SGLT2-I in type 2 diabetes mellitus (T2D), still remains poorly known in the real world. On the other hand, the use of this new class of antihyperglycemic agents is expected to increase based on the recent solid evidence of remarkable cardiorenal protection. Therefore, improving awareness on risk factors, diagnosis, and treatment of euDKA is essential to allow correct implementation of SGLT2-I in clinical practice. We here report a T2D patient admitted to the emergency department and then transferred to the nephrology-dialysis unit because of severe euglycemic diabetic ketoacidosis (euDKA) related to sodium-glucose cotransporter 2 inhibitor (SGLT2-I). In our patient, a concurrent acute kidney injury at presentation, initially attributed to excessive use of nonsteroid anti-inflammatory agents, and the absence of severe hyperglycemia led to delayed diagnosis and proper therapy. The detailed description of decision-making process for diagnosis and therapy, and the analysis of precipitating factors as well, discloses the helpful contribution of nephrologist to optimize prevention and management of euDKA.
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Abstract
INTRODUCTION Sodium-glucose cotransporter type 2 inhibitors (SGLT2is) are recommended after metformin for a large spectrum of patients with type 2 diabetes, because of a favorable benefit/risk profile despite a variety of adverse events. AREAS COVERED This narrative review discusses the safety profile of SGLT2is: initial concerns (cardiovascular safety, acute renal failure, hypoglycemia, urinary and genital infections, volume depletion, bladder cancer), further concerns (euglycemic ketoacidosis, bone fractures) and more recent concerns (lower limb amputation, Fournier's gangrene). EXPERT OPINION Overall, the safety profile of SGLT2is is good. The only increased adverse event that was consistently reported in clinical trials and observational studies is genital mycotic infections, with only a borderline increase in urinary tract infections. Among clinical trials, only the CANVAS program reported an unexpected increase in bone fractures and peripheral amputations. A variety of rare adverse events have been described as case reports, including ketoacidosis, amputations and Fournier gangrene, which led to specific warnings by regulatory agencies. Identifying predisposing patient's characteristics and/or precipitating clinical conditions would help prevent the most severe complications. These adverse events should not mask the overall cardiovascular and renal benefit of SGLT2is, especially in patients with type 2 diabetes at high cardiovascular risk.
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Affiliation(s)
- André J Scheen
- a Division of Clinical Pharmacology , Center for Interdisciplinary Research on Medicines (CIRM), Liège University , Liège , Belgium.,b Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine , CHU Liège , Liège , Belgium
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15
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Fitchett D. A safety update on sodium glucose co-transporter 2 inhibitors. Diabetes Obes Metab 2019; 21 Suppl 2:34-42. [PMID: 31081590 DOI: 10.1111/dom.13611] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 12/02/2018] [Accepted: 12/06/2018] [Indexed: 12/15/2022]
Abstract
Sodium glucose co-transporter 2 inhibitors (SGLT2is) are the first class of glucose lowering agent to be shown to reduce cardiovascular events. They are generally well tolerated with infrequent serious adverse events. The most frequent side effect is genital mycotic infections with candida species that are usually mild to moderate in severity, easily treated and infrequently recur. Urinary tract infections, although common in patients with diabetes, have not been shown to be increased in controlled studies with SGLT2i. Hypoglycaemia can occur when an SGLT2i is added to agents that cause hypoglycaemia, such as insulin or sulphonylureas. Volume depletion and hypotension is infrequent and can be minimized by adjusting diuretic and antihypertensive treatment in patients at risk. Acute renal failure or kidney injury was observed in early observational studies. However, in randomized controlled trials (RCTs) and in more recent observational studies a decreased incidence of acute kidney injury was observed in SGLT2-treated patients compared to those receiving either placebo or another class of glucose lowering agents. An increased incidence of amputation (largely feet and toes) was observed in the RCT with canagliflozin but not with the other SGLT2i. Observational studies have shown either an increased risk of amputation with other agents whereas another study showed no increase. Although the increased risk of amputation is very low, avoidance of SGLT2i in patients at high risk seems prudent. Increased incidence of fractures was observed with canagliflozin but not with SGLT2i nor in a meta-analysis that included canagliflozin, empagliflozin and dapagliflozin. No increased incidence of cancer has been observed in either RCTs or observational studies.
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Affiliation(s)
- David Fitchett
- Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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16
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Lupsa BC, Inzucchi SE. Use of SGLT2 inhibitors in type 2 diabetes: weighing the risks and benefits. Diabetologia 2018; 61:2118-2125. [PMID: 30132031 DOI: 10.1007/s00125-018-4663-6] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 05/08/2018] [Indexed: 12/15/2022]
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors belong to a novel class of glucose-lowering medications that reduce plasma glucose concentrations by inhibiting glucose reabsorption by the kidney, inducing glucosuria. Their actions encompass reductions in HbA1c, fasting and postprandial blood glucose levels, body weight and BP. To date, empagliflozin and canagliflozin have additionally been shown to improve cardiovascular outcomes in high-risk individuals and to slow the progression of diabetic kidney disease. Adverse effects associated with this class include urinary frequency, dehydration, genitourinary tract infections and, rarely, euglycaemic diabetic ketoacidosis. Of the SGLT2 inhibitors, only canagliflozin has been linked to a higher risk of lower-extremity amputations and bone fractures compared with placebo. Optimal prescribing of agents within this relatively new drug category requires a full understanding of their risks in addition to their benefits.
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Affiliation(s)
- Beatrice C Lupsa
- Section of Endocrinology, Yale University School of Medicine, Yale-New Haven Hospital, 333 Cedar Street, FMP 106, P.O. Box 208020, New Haven, CT, 06520, USA
| | - Silvio E Inzucchi
- Section of Endocrinology, Yale University School of Medicine, Yale-New Haven Hospital, 333 Cedar Street, FMP 106, P.O. Box 208020, New Haven, CT, 06520, USA.
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Affiliation(s)
- Biff F Palmer
- From the Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (B.F.P.); and the Department of Biomedical Sciences, Diabetes and Obesity Research Institute, Cedars-Sinai Medical Center, Los Angeles (D.J.C.)
| | - Deborah J Clegg
- From the Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (B.F.P.); and the Department of Biomedical Sciences, Diabetes and Obesity Research Institute, Cedars-Sinai Medical Center, Los Angeles (D.J.C.)
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18
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Filippatos T, Tzavella E, Rizos C, Elisaf M, Liamis G. Acid-base and electrolyte disorders associated with the use of antidiabetic drugs. Expert Opin Drug Saf 2017; 16:1121-1132. [DOI: 10.1080/14740338.2017.1361400] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Theodosios Filippatos
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Eleftheria Tzavella
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Christos Rizos
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Moses Elisaf
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - George Liamis
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
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19
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Ferrannini E, Baldi S, Frascerra S, Astiarraga B, Barsotti E, Clerico A, Muscelli E. Renal Handling of Ketones in Response to Sodium-Glucose Cotransporter 2 Inhibition in Patients With Type 2 Diabetes. Diabetes Care 2017; 40:771-776. [PMID: 28325783 DOI: 10.2337/dc16-2724] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 02/27/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Pharmacologically induced glycosuria elicits adaptive responses in glucose homeostasis and hormone release, including decrements in plasma glucose and insulin levels, increments in glucagon release, enhanced lipolysis, and stimulation of ketogenesis, resulting in an increase in ketonemia. We aimed at assessing the renal response to these changes. RESEARCH DESIGN AND METHODS We measured fasting and postmeal urinary excretion of glucose, β-hydroxybutyrate (β-HB), lactate, and sodium in 66 previously reported patients with type 2 diabetes and preserved renal function (estimated glomerular filtration rate ≥60 mL · min-1 · 1.73 m-2) and in control subjects without diabetes at baseline and following empagliflozin treatment. RESULTS With chronic (4 weeks) sodium-glucose cotransporter 2 inhibition, baseline fractional glucose excretion (<2%) rose to 38 ± 12% and 46 ± 11% (fasting vs. postmeal, respectively; P < 0.0001) over a range of BMIs (range 23-41 kg/m2) and creatinine clearance (65-168 mL · min-1 · m-2). Excretion of β-HB (median [interquartile range]: 0.08 [0.10] to 0.31 [0.43] µmol · min-1), lactate (0.06 [0.06] to 0.28 [0.25] µmol · min-1), and sodium (0.27 [0.22] to 0.36 [0.16] mEq · min-1) all increased (P ≤ 0.001 for all) and were each positively related to glycosuria (P ≤ 0.001). These parameters changed in the same direction in subjects without diabetes, but changes were smaller than in the patients with diabetes. Although plasma N-terminal pro-B-type natriuretic peptide levels were unaltered, plasma erythropoietin concentrations increased by 31 (64)% (P = 0.0078). CONCLUSIONS We conclude that the sodium-glucose cotransporter 2 inhibitor-induced increase in β-HB is not because of reduced renal clearance but because of overproduction. The increased lactate excretion contributes to lower plasma lactate levels, whereas the increased natriuresis may help in normalizing the exchangeable sodium pool. Taken together, glucose loss through joint inhibition of glucose and sodium reabsorption in the proximal tubule induces multiple changes in renal metabolism.
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Affiliation(s)
| | - Simona Baldi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Silvia Frascerra
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Brenno Astiarraga
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Elisabetta Barsotti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Aldo Clerico
- CNR Institute of Clinical Physiology, Pisa, Italy
| | - Elza Muscelli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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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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Tsimihodimos V, Filippatos TD, Elisaf MS. Effects of sodium-glucose co-transporter 2 inhibitors on metabolism: unanswered questions and controversies. Expert Opin Drug Metab Toxicol 2016; 13:399-408. [DOI: 10.1080/17425255.2017.1258055] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Vasilios Tsimihodimos
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | | | - Moses S. Elisaf
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
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Abstract
Inhibitors of sodium-glucose cotransporters type 2 (SGLT2) reduce hyperglycemia by increasing urinary glucose excretion. They have been evaluated in patients with type 2 diabetes treated with diet/exercise, metformin, dual oral therapy or insulin. Three agents are available in Europe and the USA (canagliflozin, dapagliflozin, empagliflozin) and others are commercialized in Japan or in clinical development. SGLT2 inhibitors reduce glycated hemoglobin, with a minimal risk of hypoglycemia. They exert favorable effects beyond glucose control with consistent body weight, blood pressure, and serum uric acid reductions. Empagliflozin showed remarkable reductions in cardiovascular/all-cause mortality and in hospitalization for heart failure in patients with previous cardiovascular disease. Positive renal outcomes were also shown with empagliflozin. Mostly reported adverse events are genital mycotic infections, while urinary tract infections and events linked to volume depletion are rather rare. Concern about a risk of ketoacidosis and bone fractures has been recently raised, which deserves caution and further evaluation.
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Affiliation(s)
- André J Scheen
- Division of Clinical Pharmacology, Center for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium.
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège, Belgium.
- Department of Medicine, CHU Sart Tilman (B35), B-4000, Liege 1, Belgium.
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