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Li H, Su B, Li GZ. Development and validation of a nomogram for screening patients with type 2 diabetic ketoacidosis. BMC Endocr Disord 2024; 24:148. [PMID: 39135031 PMCID: PMC11318303 DOI: 10.1186/s12902-024-01677-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 08/02/2024] [Indexed: 08/16/2024] Open
Abstract
OBJECTIVE AND BACKGROUND The early detection of diabetic ketoacidosis (DKA) in patients with type 2 diabetes (T2D) plays a crucial role in enhancing outcomes. We developed a nomogram prediction model for screening DKA in T2D patients. At the same time, the input variables were adjusted to reduce misdiagnosis. METHODS We obtained data on T2D patients from Mimic-IV V0.4 and Mimic-III V1.4 databases. A nomogram model was developed using the training data set, internally validated, subjected to sensitivity analysis, and further externally validated with data from T2D patients in Aviation General Hospital. RESULTS Based on the established model, we analyzed 1885 type 2 diabetes patients, among whom 614 with DKA. We further additionally identified risk factors for DKA based on literature reports and multivariate analysis. We identified age, glucose, chloride, calcium, and urea nitrogen as predictors in our model. The logistic regression model demonstrated an area under the curve (AUC) of 0.86 (95%CI: 0.85-0.90]. To validate the model, we collected data from 91 T2D patients, including 15 with DKA, at our hospital. The external validation of the model yielded an AUC of 0.68 (95%CI: 0.67-0.70). The calibration plot confirmed that our model was adequate for predicting patients with DKA. The decision-curve analysis revealed that our model offered net benefits for clinical use. CONCLUSIONS Our model offers a convenient and accurate tool for predicting whether DKA is present. Excluding input variables that may potentially hinder patient compliance increases the practical application significance of our model.
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Affiliation(s)
- Hui Li
- Department of The Infirmary, The Automation Engineering School of Beijing, Beijing, China
| | - Bo Su
- Department of Endocrinology, Aviation General Hospital, China Medical University, Beijing, 100012, People's Republic of China
| | - Gui Zhong Li
- Department of Pathophysiology, School of Basic Medical Sciences, Ningxia Medical University, Yinchuan, 750004, China.
- NHC Key Laboratory of Metabolic Cardiovascular Diseases Research, Ningxia Medical University, Ningxia, Yinchuan, 750004, China.
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Umpierrez GE, Davis GM, ElSayed NA, Fadini GP, Galindo RJ, Hirsch IB, Klonoff DC, McCoy RG, Misra S, Gabbay RA, Bannuru RR, Dhatariya KK. Hyperglycemic Crises in Adults With Diabetes: A Consensus Report. Diabetes Care 2024; 47:1257-1275. [PMID: 39052901 PMCID: PMC11272983 DOI: 10.2337/dci24-0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 03/29/2024] [Indexed: 07/27/2024]
Abstract
The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), Joint British Diabetes Societies for Inpatient Care (JBDS), American Association of Clinical Endocrinology (AACE), and Diabetes Technology Society (DTS) convened a panel of internists and diabetologists to update the ADA consensus statement on hyperglycemic crises in adults with diabetes, published in 2001 and last updated in 2009. The objective of this consensus report is to provide up-to-date knowledge about the epidemiology, pathophysiology, clinical presentation, and recommendations for the diagnosis, treatment, and prevention of diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) in adults. A systematic examination of publications since 2009 informed new recommendations. The target audience is the full spectrum of diabetes health care professionals and individuals with diabetes.
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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
| | - Georgia M. Davis
- Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Nuha A. ElSayed
- American Diabetes Association, Arlington, VA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Gian Paolo Fadini
- Department of Medicine, University of Padua, Padua, Italy
- Veneto Institute of Molecular Medicine, Padua, Italy
| | - Rodolfo J. Galindo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Irl B. Hirsch
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington, Seattle, WA
| | - David C. Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA
| | - Rozalina G. McCoy
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
- University of Maryland Institute for Health Computing, Bethesda, MD
| | - Shivani Misra
- Division of Metabolism, Digestion & Reproduction, Imperial College London, U.K
- Department of Diabetes & Endocrinology, Imperial College Healthcare NHS Trust, London, U.K
| | - Robert A. Gabbay
- American Diabetes Association, Arlington, VA
- Department of Medicine, Harvard Medical School, Boston, MA
| | | | - Ketan K. Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, U.K
- Department of Medicine, Norwich Medical School, University of East Anglia, Norwich, U.K
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Umpierrez GE, Davis GM, ElSayed NA, Fadini GP, Galindo RJ, Hirsch IB, Klonoff DC, McCoy RG, Misra S, Gabbay RA, Bannuru RR, Dhatariya KK. Hyperglycaemic crises in adults with diabetes: a consensus report. Diabetologia 2024; 67:1455-1479. [PMID: 38907161 DOI: 10.1007/s00125-024-06183-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 03/29/2024] [Indexed: 06/23/2024]
Abstract
The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), Joint British Diabetes Societies for Inpatient Care (JBDS), American Association of Clinical Endocrinology (AACE) and Diabetes Technology Society (DTS) convened a panel of internists and diabetologists to update the ADA consensus statement on hyperglycaemic crises in adults with diabetes, published in 2001 and last updated in 2009. The objective of this consensus report is to provide up-to-date knowledge about the epidemiology, pathophysiology, clinical presentation, and recommendations for the diagnosis, treatment and prevention of diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar state (HHS) in adults. A systematic examination of publications since 2009 informed new recommendations. The target audience is the full spectrum of diabetes healthcare professionals and individuals with diabetes.
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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, USA.
| | - Georgia M Davis
- Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Nuha A ElSayed
- American Diabetes Association, Arlington, VA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Gian Paolo Fadini
- Department of Medicine, University of Padua, Padua, Italy
- Veneto Institute of Molecular Medicine, Padua, Italy
| | - Rodolfo J Galindo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Irl B Hirsch
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington, Seattle, WA, USA
| | - David C Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, USA
| | - Rozalina G McCoy
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- University of Maryland Institute for Health Computing, Bethesda, MD, USA
| | - Shivani Misra
- Division of Metabolism, Digestion & Reproduction, Imperial College London, London, UK
- Department of Diabetes & Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Robert A Gabbay
- American Diabetes Association, Arlington, VA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | | | - Ketan K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Department of Medicine, Norwich Medical School, University of East Anglia, Norwich, UK
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Sakane N. Innovations and applications of ketone body monitoring in diabetes care. Diabetol Int 2024; 15:370-378. [PMID: 39101172 PMCID: PMC11291811 DOI: 10.1007/s13340-024-00735-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 05/18/2024] [Indexed: 08/06/2024]
Abstract
Ketone bodies, comprising β-hydroxybutyric acid (BHB), acetoacetate (AcAc), and acetone, play a vital role as essential energy substrates. In individuals with diabetes, ketone bodies can be elevated under various conditions, including diabetic ketoacidosis, use of sodium-glucose transporter type 2 (SGLT2) inhibitors, and extreme carbohydrate restriction. There are three methods for measuring ketone bodies. Urine ketone analysis (AcAc) is a standard clinical test, whereas blood ketone testing (BHB+AcAc) is valuable in identifying or resolving diabetic ketoacidosis. Recently, technology for measuring breath acetone has been introduced, which provides an easy means of monitoring ketogenic diets in obese individuals. The basic breath alcohol detector also reacts with breath acetone. Therefore, it is important for professional drivers taking SGLT2 inhibitors to be cautious as workplace breath alcohol detectors may show false-positive results. Conversely, if a positive result is obtained, a detailed examination of ketosis is necessary. This review provides an overview of ketone body measurements in individuals with diabetes.
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Affiliation(s)
- Naoki Sakane
- Division of Preventive Medicine, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, 1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555 Japan
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Foglino R, Barbetti F, Morotti E, Castorani V, Rigamonti A, Frontino G, Barera G, Bonfanti R. Case report: A case of Rabson-Mendenhall syndrome: long-term follow-up and therapeutic management with empagliflozin. Front Genet 2024; 15:1414451. [PMID: 38978877 PMCID: PMC11228259 DOI: 10.3389/fgene.2024.1414451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 05/31/2024] [Indexed: 07/10/2024] Open
Abstract
Background: Rabson-Mendenhall syndrome (RMS), a rare disorder characterized by severe insulin resistance due to biallelic loss-of-function variants of the insulin receptor gene (INSR), presents therapeutic challenges (OMIM: 262190). This case study explores the efficacy of adjunctive therapy with sodium-glucose cotransporter 2 inhibitors (SGLT2is) in the management of RMS in an 11-year-old male patient with compound heterozygous pathogenic variants of INSR. Methods: Despite initial efforts to regulate glycemia with insulin therapy followed by metformin treatment, achieving stable glycemic control presented a critical challenge, characterized by persistent hyperinsulinism and variable fluctuations in glucose levels. Upon the addition of empagliflozin to metformin, notable improvements in glycated hemoglobin (HbA1c) and time in range (TIR) were observed over a 10-month period. Results: After 10 months of treatment, empagliflozin therapy led to a clinically meaningful reduction in HbA1c levels, decreasing from 8.5% to 7.1%, along with an improvement in TIR from 47% to 74%. Furthermore, regular monitoring effectively averted normoglycemic ketoacidosis, a rare complication associated with SGLT2 inhibitor therapy. Conclusion: This case highlights the potential of SGLT2i as adjunctive therapy in RMS management, particularly in stabilizing glycemic variability. However, further research is warranted to elucidate the long-term efficacy and safety of this therapeutic approach in RMS and similar insulin resistance syndromes.
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Affiliation(s)
- R Foglino
- Pediatric Diabetes Unit IRCCS Ospedale San Raffaele, Vita Salute San Raffaele University, Milan, Italy
| | - F Barbetti
- Monogenic Diabetes Clinic, Unit of Endocrinology and Diabetes, Bambino Gesù Children Hospital IRCCS, Rome, Italy
| | - E Morotti
- Pediatric Diabetes Unit IRCCS Ospedale San Raffaele, Vita Salute San Raffaele University, Milan, Italy
| | - V Castorani
- Pediatric Diabetes Unit IRCCS Ospedale San Raffaele, Vita Salute San Raffaele University, Milan, Italy
| | - A Rigamonti
- Pediatric Diabetes Unit IRCCS Ospedale San Raffaele, Vita Salute San Raffaele University, Milan, Italy
| | - G Frontino
- Pediatric Diabetes Unit IRCCS Ospedale San Raffaele, Vita Salute San Raffaele University, Milan, Italy
| | - G Barera
- Pediatric Diabetes Unit IRCCS Ospedale San Raffaele, Vita Salute San Raffaele University, Milan, Italy
| | - R Bonfanti
- Pediatric Diabetes Unit IRCCS Ospedale San Raffaele, Vita Salute San Raffaele University, Milan, Italy
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Nyström T. Key results from observational studies and real-world evidence of sodium-glucose cotransporter-2 inhibitor effectiveness and safety in reducing cardio-renal risk. Diabetes Obes Metab 2024. [PMID: 38859661 DOI: 10.1111/dom.15696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/09/2024] [Accepted: 05/20/2024] [Indexed: 06/12/2024]
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors, originally designed to manage blood sugar levels in individuals with type 2 diabetes (T2D), have emerged as a crucial class of drugs for managing cardio-renal diseases. These drugs work by targeting the SGLT2 protein in the kidneys, promoting the excretion of glucose and influencing metabolic pathways beyond glucose control. The relationship between cardio-renal diseases and SGLT2 inhibitors has been explored through landmark trials and real-world evidence (RWE) studies, demonstrating significant reductions in cardio-renal complications. This review discusses the importance of RWE studies alongside randomized controlled trials in understanding the real-world effectiveness and safety of SGLT2 inhibitors. It outlines the advantages and disadvantages of RWE compared to RCTs, highlighting their complementary roles in providing comprehensive insights into treatment outcomes. By examining a range of RWE studies, the review underscores the cardio-renal benefits of SGLT2 inhibitors across various patient populations. Safety assessments indicate that SGLT2 inhibitors are generally well tolerated, with severe adverse events being rare. Common issues, such as genital mycotic infections and urinary tract infections, are acknowledged, alongside less frequent but significant adverse events including diabetic ketoacidosis, lower-limb amputations, and bone fractures. In summary, SGLT2 inhibitors show promising cardio-renal protective effects in real-world scenarios across diverse populations in T2D, indicating their potential as early intervention measures. Continued research is essential for gaining a thorough understanding of their long-term effects and safety profiles.
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Affiliation(s)
- Thomas Nyström
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
- Department of Internal Medicine, Section of Endocrinology and Diabetology, Södersjukhuset, Stockholm, Sweden
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Hirota Y, Kakei Y, Imai J, Katagiri H, Ebihara K, Wada J, Suzuki J, Urakami T, Omori T, Ogawa W. A multicenter, open-label, single-arm trial of the long-term safety of empagliflozin treatment for refractory diabetes mellitus with insulin resistance (EMPIRE-02). J Diabetes Investig 2024. [PMID: 38702973 DOI: 10.1111/jdi.14226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 03/26/2024] [Accepted: 04/17/2024] [Indexed: 05/06/2024] Open
Abstract
AIMS/INTRODUCTION Insulin resistance syndrome and lipoatrophic diabetes are rare conditions characterized by the development of treatment-refractory diabetes with severe insulin resistance. We recently conducted a 24 week, multicenter, single-arm trial (EMPIRE-01) that demonstrated a certain level of effectiveness and safety of empagliflozin for these conditions. To evaluate treatment safety over a longer period, we have now performed an additional 28 week trial (EMPIRE-02) that followed on from EMPIRE-01. MATERIALS AND METHODS The primary and secondary outcomes were safety and efficacy evaluations, respectively. All eight subjects of the EMPIRE-01 trial participated in EMPIRE-02. RESULTS Twenty adverse events (AEs) were recorded among five individuals during the combined 52 week treatment period of both trials. Whereas one case of chronic hepatitis B was moderate in severity, all other AEs were mild. There were thus no serious AEs or events necessitating discontinuation or suspension of treatment or a reduction in drug dose. Whereas ketoacidosis or marked increases in serum ketone body levels were not observed, the mean body mass of the subjects was decreased slightly after completion of EMPIRE-02. The improvement in mean values of glycemic parameters observed in EMPIRE-01 was not sustained in EMPIRE-02, mostly because of one individual whose parameters deteriorated markedly, likely as a result of nonadherence to diet therapy. The improvement in glycemic parameters was sustained during EMPIRE-02 after exclusion of this subject from analysis. CONCLUSIONS Empagliflozin demonstrated a certain level of safety and efficacy for the treatment of insulin resistance syndrome and lipoatrophic diabetes over 52 weeks, confirming its potential as a therapeutic option.
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Affiliation(s)
- Yushi Hirota
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yasumasa Kakei
- Clinical and Translational Research Center, Kobe University Hospital, Kobe, Japan
| | - Junta Imai
- Department of Metabolism and Diabetes, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Hideki Katagiri
- Department of Metabolism and Diabetes, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Ken Ebihara
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Jun Wada
- Department of Nephrology, Rheumatology, Endocrinology, and Metabolism, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Junichi Suzuki
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Tatsuhiko Urakami
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Takashi Omori
- Division of Clinical Biostatistics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Wataru Ogawa
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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Wachter H, von Loeffelholz C, Thomas-Rüddel DO, Bargenda S, Birkenfeld AL, Bauer M, Ehler J. [Life-threatening euglycemic ketoacidosis under treatment with empagliflozin in cardiac surgery patients: rare isolated case or a frequent problem in the future?]. DIE ANAESTHESIOLOGIE 2024; 73:336-339. [PMID: 38635034 PMCID: PMC11076387 DOI: 10.1007/s00101-024-01406-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 02/19/2024] [Accepted: 03/12/2024] [Indexed: 04/19/2024]
Affiliation(s)
- H Wachter
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Jena, Am Klinikum 1, 07749, Jena, Deutschland
| | - C von Loeffelholz
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Jena, Am Klinikum 1, 07749, Jena, Deutschland
| | - D O Thomas-Rüddel
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Jena, Am Klinikum 1, 07749, Jena, Deutschland
| | - S Bargenda
- Klinik für Herz- und Thoraxchirurgie, Universitätsklinikum Jena, Jena, Deutschland
| | - A L Birkenfeld
- Klinik für Diabetologie, Endokrinologie, Nephrologie, Innere Medizin IV, Universitätsklinikum Tübingen, Tübingen, Deutschland
- Deutsches Zentrum für Diabetesforschung (DZD e. V.), Neuherberg, Deutschland
| | - M Bauer
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Jena, Am Klinikum 1, 07749, Jena, Deutschland
| | - J Ehler
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Jena, Am Klinikum 1, 07749, Jena, Deutschland.
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Hirota Y, Kakei Y, Imai J, Katagiri H, Ebihara K, Wada J, Suzuki J, Urakami T, Omori T, Ogawa W. A Multicenter, Open-Label, Single-Arm Trial of the Efficacy and Safety of Empagliflozin Treatment for Refractory Diabetes Mellitus with Insulin Resistance (EMPIRE-01). Diabetes Ther 2024; 15:533-545. [PMID: 38216831 PMCID: PMC10838887 DOI: 10.1007/s13300-023-01526-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 12/15/2023] [Indexed: 01/14/2024] Open
Abstract
INTRODUCTION Insulin resistance syndrome and lipoatrophic diabetes are characterized by severe insulin resistance and are often refractory to treatment. Trials assessing the efficacy of antidiabetes drugs for these rare conditions have been limited, however. Sodium-glucose cotransporter 2 (SGLT2) inhibitors, which lower glycemia independently of insulin action, have shown efficacy for type 2 diabetes with insulin resistance. We here investigated the efficacy and safety of the SGLT2 inhibitor empagliflozin for treatment of insulin resistance syndrome and lipoatrophic diabetes. METHODS The trial was conducted at five academic centers in Japan and included seven patients with insulin resistance syndrome and one patient with lipoatrophic diabetes. Participants received 10 mg of empagliflozin daily. If the hemoglobin A1c (HbA1c) level was ≥ 7.0% (52 mmol/mol) after 12 weeks, the dose was adjusted to 25 mg. The study duration was 24 weeks, and the primary outcome was the change in HbA1c level by the end of the treatment period. Safety evaluations were performed for all participants. RESULTS By the end of the 24-week treatment period, the mean HbA1c level for all eight patients had decreased by 0.99 percentage points (10.8 mmol/mol) (95% confidence interval [CI], 0.59 to 1.38 percentage points, 6.6 to 14.9 mmol/mol) and the mean fasting plasma glucose concentration had declined by 63.9 mg/dL (3.55 mmol/L) (95% CI 25.5 to 102.3 mg/dL, 1.42 to 5.68 mmol/L). Continuous glucose monitoring revealed a reduction in mean glucose levels from 164.3 ± 76.1 to 137.6 ± 46.6 mg/dL (9.13 ± 4.23 to 7.65 ± 2.59 mmol/L) as well as an increase in the time in range (70-180 mg/dL) from 58.9 ± 36.1% to 70.8 ± 18.3%. Seventeen mild adverse events were recorded in five individuals throughout the study period. No severe events were reported. The mean body mass showed a slight decrease and the mean serum ketone body concentration showed a slight increase during treatment. CONCLUSION Our results demonstrate that empagliflozin shows a certain level of efficacy and safety for treatment of insulin resistance syndrome and lipoatrophic diabetes. TRIAL REGISTRATION jRCTs2051190029 and NCT04018365.
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Affiliation(s)
- Yushi Hirota
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Yasumasa Kakei
- Clinical and Translational Research Center, Kobe University Hospital, Kobe, Japan
| | - Junta Imai
- Department of Metabolism and Diabetes, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Hideki Katagiri
- Department of Metabolism and Diabetes, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Ken Ebihara
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Jun Wada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Junichi Suzuki
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Tatsuhiko Urakami
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Takashi Omori
- Division of Clinical Biostatistics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Wataru Ogawa
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan.
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Zhao Q, Tan Y, Wu Q, Xiao X, Wei X, Nian M, Yao J, Fan N, Wang R, Fan G. The risk factors of diabetic ketosis and diabetic ketoacidosis among patients with type 2 diabetes mellitus treated with SGLT2 inhibitors: a retrospective study. Expert Opin Drug Saf 2024; 23:57-65. [PMID: 37947121 DOI: 10.1080/14740338.2023.2275704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/19/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND There is limited evidence on the safety of sodium-glucose co-transporter-2 inhibitor (SGLT2i) use in the real world of China. We conducted this two-center, retrospective study to assess the incidence rate and risk factors of Dapagliflozin-associated DK/DKA among patients with type 2 diabetes mellitus (T2DM) in China. RESEARCH DESIGN AND METHODS Patients with T2DM treated with Dapagliflozin in Shanghai General Hospital were included in this retrospective analysis. Univariate and multivariate logistic regression was performed, and odds ratio (OR) and 95% confidence interval (CI) were calculated to identify the influencing factors associated with the occurrence of DK/DKA. RESULTS A total of 1985 T2DM patients received Dapagliflozin for the first time were included. The prevalence of DK and DKA was 2.47% and 0.35%, respectively. Multivariate logistic regression identified age <45 years [OR = 2.99, 95% CI (1.45-6.17)], concomitant use of Acarbose [OR = 2.18, 95% CI (1.06-3.38)], Metformin [OR = 1.84, 95% CI (1.01-3.38)], and Insulin [OR = 1.93, 95% CI (1.02-3.66)] as participating factors for DK/DKA. The 1:4 matched subset sensitivity analysis further confirmed the risk factors of Dapagliflozin-associated DK/DKA. CONCLUSIONS Age less than 45 years, concomitant use of Acarbose and insulin were risk factors for Dapagliflozin-associated DK/DKA. Clinicians should watch out for high-risk features among patients with SGLT2i prescription.
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Affiliation(s)
- Qingnan Zhao
- Department of Clinical Pharmacy, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Pancreatic Disease, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yijiong Tan
- Department of Clinical Pharmacy, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qinqin Wu
- Department of Pharmacy, Community Health Service Center of Guangfulin Street, Shanghai, China
| | - Xiangqin Xiao
- Department of Clinical Pharmacy, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xinyi Wei
- School of Public Health, Nanjing Medical University, Nanjing, China
| | - Mengqing Nian
- School of pharmacy, Nanjing Medical University, Nanjing, China
| | - Jie Yao
- School of pharmacy, Nanjing Medical University, Nanjing, China
| | - Nengguang Fan
- Department of Endocrinology and Metabolism, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ruiping Wang
- Clinical Research Center, Shanghai Skin Diseases Hospital, Tongji Medical University, Shanghai, China
| | - Guorong Fan
- Department of Clinical Pharmacy, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Al-Hindi B, Mohammed MA, Mangantig E, Martini ND. Prevalence of sodium-glucose transporter 2 inhibitor-associated diabetic ketoacidosis in real-world data: A systematic review and meta-analysis. J Am Pharm Assoc (2003) 2024; 64:9-26.e6. [PMID: 37844733 DOI: 10.1016/j.japh.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/30/2023] [Accepted: 10/09/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND The U.S. Food and Drug Administration (FDA) revised the labels of sodium-glucose transporter 2 (SGLT2) inhibitors in December 2015 to inform users regarding the risk of diabetic ketoacidosis (DKA). As more drugs of this class are approved and their indications are expanded, this serious adverse effect has been increasingly reported. OBJECTIVE This review evaluated observational studies to inform the prevalence of SGLT2-inhibitor-associated DKA compared with other antihyperglycemic agents. METHODS A systematic review was conducted in PubMed and EMBASE until 19 July 2022 (PROSPERO: CRD42022385425). We included published retrospective cohort active comparator/new user (ACNU) and prevalent new user studies assessing SGLT2-inhibitor-associated DKA prevalence in adult patients with type 2 diabetes mellitus (T2DM) against active comparators. We excluded studies which lacked 1:1 propensity score matching. The JBI Checklist for Cohort Studies guided the risk-of-bias assessments. Meta-analysis was conducted based on the inverse variance method in R software. RESULTS Sixteen studies with a sample of 2,956,100 nonunique patients met the inclusion criteria. Most studies were conducted in North America (n = 9) and adopted the ACNU design (n = 15). Meta-analysis of 14 studies identified 33% higher DKA risk associated with SGLT2 inhibitors (HR = 1.33, 95% CI: 1.14-1.55, P < 0.01). Meta-regression analysis identified the study location (P = 0.02), analysis principle (P < 0.001), exclusion of chronic comorbidities (P = 0.007), and canagliflozin (P = 0.04) as significant moderator variables. CONCLUSIONS Despite limitations related to heterogeneity, generalizability, and misclassification, the results of this study show that SGLT2 inhibitors increase the prevalence of DKA among adult T2DM patients in the real world. The findings supplement evidence from randomized controlled trials (RCTs) and call for continued vigilance.
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12
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Milder TY, Milder DA, Greenfield JR, Day RO. Sodium-Glucose Cotransporter 2 Inhibitor-Associated "Ketoacidosis" Versus "Diabetic Ketoacidosis": The Importance of Accurate Terminology. Drug Saf 2023; 46:1303-1305. [PMID: 37847339 DOI: 10.1007/s40264-023-01358-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2023] [Indexed: 10/18/2023]
Affiliation(s)
- Tamara Y Milder
- Department of Diabetes and Endocrinology, St. Vincent's Hospital, 384 Victoria St, Darlinghurst, Sydney, NSW, 2010, Australia.
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia.
- Clinical Science Pillar, Garvan Institute of Medical Research, Sydney, NSW, Australia.
- School of Clinical Medicine, UNSW Medicine & Health, St. Vincent's Healthcare Clinical Campus, UNSW Sydney, Sydney, NSW, Australia.
| | - David A Milder
- School of Clinical Medicine, UNSW Medicine & Health, St. Vincent's Healthcare Clinical Campus, UNSW Sydney, Sydney, NSW, Australia
- Department of Anaesthesia, Westmead Hospital, Sydney, NSW, Australia
- Department of Anaesthesia, St. Vincent's Hospital, Sydney, NSW, Australia
- Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Jerry R Greenfield
- Department of Diabetes and Endocrinology, St. Vincent's Hospital, 384 Victoria St, Darlinghurst, Sydney, NSW, 2010, Australia
- Clinical Science Pillar, Garvan Institute of Medical Research, Sydney, NSW, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St. Vincent's Healthcare Clinical Campus, UNSW Sydney, Sydney, NSW, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St. Vincent's Healthcare Clinical Campus, UNSW Sydney, Sydney, NSW, Australia
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13
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Fujiwara M, Shimizu M, Okano T, Maejima Y, Shimomura K. Successful treatment of nivolumab and ipilimumab triggered type 1 diabetes by using sodium-glucose transporter 2 inhibitor: a case report and systematic review. Front Public Health 2023; 11:1264056. [PMID: 38106883 PMCID: PMC10725247 DOI: 10.3389/fpubh.2023.1264056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/31/2023] [Indexed: 12/19/2023] Open
Abstract
Objective Checkpoint inhibitors (CPIs) can trigger complications related to the autoimmune process such as CPI-triggered diabetes mellitus. The typical treatment for CPI-triggered diabetes is insulin, but a detailed therapeutic method has not yet been established. To prevent severe symptoms and mortality of diabetic ketoacidosis in advanced-stage cancer patients, the establishment of effective treatment of CPI-triggered diabetes, other than insulin therapy, is required. Methods We present a case of a 76-year-old man with CPI-triggered diabetes who was treated with nivolumab and ipilimumab for lung cancer. We also conducted a systematic review of 48 case reports of type 1 diabetes associated with nivolumab and ipilimumab therapy before June 2023. Results The patient's hyperglycemia was not sufficiently controlled by insulin therapy, and after the remission of ketoacidosis, the addition of a sodium-glucose transporter (SGLT) 2 inhibitor, dapagliflozin, improved glycemic control. Most of the reported nivolumab/ipilimumab-induced type 1 diabetes was treatable with insulin, but very few cases required additional oral anti-diabetic agents to obtain good glucose control. Conclusion Although SGLT2 inhibitors have been reported to have adverse effects on ketoacidosis, recent studies indicate that the occurrence of ketoacidosis is relatively rare. Considering the pathological mechanism of CPI-triggered diabetes, SGLT2 inhibitors could be an effective choice if they are administered while carefully monitoring the patient's ketoacidosis.
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Affiliation(s)
- Makoto Fujiwara
- Department of Bioregulation and Pharmacological Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan
- Department of Diabetes, Endocrinology and Metabolism, Tsukuba Medical Center, Ibaraki, Japan
| | - Masaru Shimizu
- Department of Bioregulation and Pharmacological Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan
- Department of Neurology, Matsumura General Hospital, Fukushima, Japan
| | - Tatsuya Okano
- Department of Bioregulation and Pharmacological Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yuko Maejima
- Department of Bioregulation and Pharmacological Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Kenju Shimomura
- Department of Bioregulation and Pharmacological Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan
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14
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Koutentakis M, Kuciński J, Świeczkowski D, Surma S, Filipiak KJ, Gąsecka A. The Ketogenic Effect of SGLT-2 Inhibitors-Beneficial or Harmful? J Cardiovasc Dev Dis 2023; 10:465. [PMID: 37998523 PMCID: PMC10672595 DOI: 10.3390/jcdd10110465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/09/2023] [Accepted: 11/14/2023] [Indexed: 11/25/2023] Open
Abstract
Sodium-glucose cotransporter-2 (SGLT-2) inhibitors, also called gliflozins or flozins, are a class of drugs that have been increasingly used in the management of type 2 diabetes mellitus (T2DM) due to their glucose-lowering, cardiovascular (CV), and renal positive effects. However, recent studies suggest that SGLT-2 inhibitors might also have a ketogenic effect, increasing ketone body production. While this can be beneficial for some patients, it may also result in several potential unfavorable effects, such as decreased bone mineral density, infections, and ketoacidosis, among others. Due to the intricate and multifaceted impact caused by SGLT-2 inhibitors, this initially anti-diabetic class of medications has been effectively used to treat both patients with chronic kidney disease (CKD) and those with heart failure (HF). Additionally, their therapeutic potential appears to extend beyond the currently investigated conditions. The objective of this review article is to present a thorough summary of the latest research on the mechanism of action of SGLT-2 inhibitors, their ketogenesis, and their potential synergy with the ketogenic diet for managing diabetes. The article particularly discusses the benefits and risks of combining SGLT-2 inhibitors with the ketogenic diet and their clinical applications and compares them with other anti-diabetic agents in terms of ketogenic effects. It also explores future directions regarding the ketogenic effects of SGLT-2 inhibitors.
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Affiliation(s)
- Michail Koutentakis
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Banacha 1A, 02-097 Warsaw, Poland;
| | - Jakub Kuciński
- Central Clinical Hospital, Medical University of Warsaw, Banacha 1A, 02-097 Warsaw, Poland;
| | - Damian Świeczkowski
- Department of Toxicology, Faculty of Pharmacy, Medical University of Gdansk, 80-416 Gdańsk, Poland;
| | - Stanisław Surma
- Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland;
| | - Krzysztof J. Filipiak
- Department of Clinical Sciences, Maria Sklodowska-Curie Medical Academy, 00-001 Warsaw, Poland;
- Department of Hypertensiology, Angiology and Internal Medicine, Poznań University of Medical Sciences, 61-848 Poznań, Poland
| | - Aleksandra Gąsecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Banacha 1A, 02-097 Warsaw, Poland;
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15
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Chow E, Clement S, Garg R. Euglycemic diabetic ketoacidosis in the era of SGLT-2 inhibitors. BMJ Open Diabetes Res Care 2023; 11:e003666. [PMID: 37797963 PMCID: PMC10551972 DOI: 10.1136/bmjdrc-2023-003666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/19/2023] [Indexed: 10/07/2023] Open
Abstract
Euglycemic diabetic ketoacidosis (EDKA) is an emerging complication of diabetes associated with an increasing use of sodium-glucose transporter type 2 (SGLT-2) inhibitor drugs. This review highlights the growing incidence of EDKA and its diagnostic challenges due to the absence of hallmark hyperglycemia seen in diabetic ketoacidosis (DKA). The paper presents a classification system for the severity of EDKA, categorizing it into mild, moderate, and severe based on serum pH and bicarbonate levels. Another classification system is proposed to define stages of EDKA based on anion gap and ketones at the time of diagnosis and during the treatment period. A treatment algorithm is proposed to guide clinicians in managing EDKA. This treatment algorithm includes monitoring anion gap and ketones to guide insulin and fluid management, and slower transition to subcutaneous insulin to prevent a relapse. Increased awareness of EDKA is essential for a timely diagnosis because an early diagnosis and treatment can improve clinical outcomes.
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Affiliation(s)
- Erica Chow
- Division of Endocrinology, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Stephen Clement
- Division of Endocrinology, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Rajesh Garg
- Division of Endocrinology, Harbor-UCLA Medical Center, Torrance, California, USA
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16
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Abdel-Qadir H, Carrasco R, Austin PC, Chen Y, Zhou L, Fang J, Su HM, Lega IC, Kaul P, Neilan TG, Thavendiranathan P. The Association of Sodium-Glucose Cotransporter 2 Inhibitors With Cardiovascular Outcomes in Anthracycline-Treated Patients With Cancer. JACC CardioOncol 2023; 5:318-328. [PMID: 37397088 PMCID: PMC10308059 DOI: 10.1016/j.jaccao.2023.03.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/28/2023] [Accepted: 03/01/2023] [Indexed: 07/04/2023] Open
Abstract
Background Sodium glucose cotransporter-2 inhibitors (SGLT2is) are hypothesized to reduce the risk of anthracycline-associated cardiotoxicity. Objectives This study sought to determine the association between SGLT2is and cardiovascular disease (CVD) after anthracycline-containing chemotherapy. Methods Using administrative data sets, we conducted a population-based cohort study of people >65 years of age with treated diabetes and no prior heart failure (HF) who received anthracyclines between January 1, 2016, and December 31, 2019. After estimating propensity scores for SGLT2i use, the average treatment effects for the treated weights were used to reduce baseline differences between SGLT2i-exposed and -unexposed controls. The outcomes were hospitalization for HF, incident HF diagnoses (in- or out-of-hospital), and documentation of any CVD in future hospitalizations. Death was treated as a competing risk. Cause-specific HRs for each outcome were determined for SGLT2i-treated people relative to unexposed controls. Results We studied 933 patients (median age 71.0 years, 62.2% female), 99 of whom were SGLT2i treated. During a median follow-up of 1.6 years, there were 31 hospitalizations for HF (0 in the SGLT2i group), 93 new HF diagnoses, and 74 hospitalizations with documented CVD. Relative to controls, SGLT2i exposure was associated with HR of 0 for HF hospitalization (P < 0.001) but no significant difference in incident HF diagnosis (HR: 0.55; 95% CI: 0.23-1.31; P = 0.18) or CVD diagnosis (HR: 0.39; 95% CI: 0.12-1.28; P = 0.12). There was no significant difference in mortality (HR: 0.63; 95% CI: 0.36-1.11; P = 0.11). Conclusions SGLT2is may reduce the rate of HF hospitalization after anthracycline-containing chemotherapy. This hypothesis warrants further testing in randomized controlled trials.
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Affiliation(s)
- Husam Abdel-Qadir
- Women’s College Hospital, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Ted Rogers Program in Cardiotoxicity Prevention, University Health Network, Toronto, Ontario, Canada
| | - Rodrigo Carrasco
- Ted Rogers Program in Cardiotoxicity Prevention, University Health Network, Toronto, Ontario, Canada
| | - Peter C. Austin
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Yue Chen
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Limei Zhou
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
| | - Jiming Fang
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
| | - Henry M.H. Su
- Ted Rogers Program in Cardiotoxicity Prevention, University Health Network, Toronto, Ontario, Canada
| | - Iliana C. Lega
- Women’s College Hospital, Toronto, Ontario, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Padma Kaul
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Canadian Virtual Coordinating Centre for Global Collaborative Cardiovascular Research Centre, University of Alberta, Edmonton, Alberta, Canada
| | | | - Paaladinesh Thavendiranathan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Ted Rogers Program in Cardiotoxicity Prevention, University Health Network, Toronto, Ontario, Canada
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17
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He Z, Lam K, Zhao W, Yang S, Li Y, Mo J, Gao S, Liang D, Qiu K, Huang M, Wu J. SGLT-2 inhibitors and euglycemic diabetic ketoacidosis/diabetic ketoacidosis in FAERS: a pharmacovigilance assessment. Acta Diabetol 2023; 60:401-411. [PMID: 36576563 DOI: 10.1007/s00592-022-02015-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 12/05/2022] [Indexed: 12/29/2022]
Abstract
AIMS To investigate the main feature and the association between euglycemic diabetic ketoacidosis (euDKA) /diabetic ketoacidosis (DKA) and sodium-dependent glucose transporters 2 inhibitors (SGLT-2i) from the FDA adverse event reporting system (FAERS). METHODS Cases of SGLT-2i-associated with euDKA/DKA were extracted from the FAERS database and compared with the reports for other hypoglycemia agents (ATC10 class). Disproportionality analyses used the reporting odds ratio (ROR) and information components (IC). The lower limit of the IC 95% credibility interval for IC > 0 is considered a reported signal, with at least 3 cases. RESULTS A total of 10,195 cases of euDKA (n = 1680) and DKA (n = 8515) associated with SGLT-2i were identified from the FAERS. The SGLT-2i was associated with higher reporting of euDKA and DKA compared to other hypoglycemia agents (ROR = 16.69 [95% CI 14.89-18.70], IC = 3.27 [95% CI 2.91-3.66] for euDKA; ROR = 16.44 [95% CI 15.72-17.20], IC = 3.19 [95% CI 3.05-3.34] for DKA). In available data, the median onset time of euDKA/DKA was 31 days, and canagliflozin had the longest onset time (96.5 days for euDKA and 75 days for DKA) compared with dapagliflozin and empagliflozin (p < 0.05). Male patients predominate in euDKA (51.9%), and female patients predominate in DKA (53.7%). Most patients discontinue the treatment (95.5% for euDKA, 93.9% for DKA), and approximately 49.0% (n = 3658) of patients had symptomatic remission after discontinuation of SGLT-2i, and 2.3% (n = 173) of patients had no remission. About 75.6% (n = 6126) of patients need hospitalization after euDKA/DKA. CONCLUSIONS Post-marketing data showed that SGLT-2i was significantly associated with higher reporting of euDKA/DKA. Although euDKA/DKA is rare, clinicians should be aware of SGLT-2i-associated euDKA/DKA events.
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Affiliation(s)
- Zhichao He
- Department of Pharmacy, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang West Road, Guangzhou, 510120, People's Republic of China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Guangzhou, People's Republic of China
| | - Kakei Lam
- School of Pharmaceutical Sciences, Sun Yat-Sen University, 132 Waihuan East Road, Guangzhou, 511400, People's Republic of China
| | - Wenxia Zhao
- Department of Pharmacy, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang West Road, Guangzhou, 510120, People's Republic of China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Guangzhou, People's Republic of China
| | - Shan Yang
- Department of Pharmacy, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang West Road, Guangzhou, 510120, People's Republic of China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Guangzhou, People's Republic of China
| | - Yu Li
- School of Pharmaceutical Sciences, Sun Yat-Sen University, 132 Waihuan East Road, Guangzhou, 511400, People's Republic of China
| | - Jiayao Mo
- School of Pharmaceutical Sciences, Sun Yat-Sen University, 132 Waihuan East Road, Guangzhou, 511400, People's Republic of China
| | - Siyuan Gao
- Department of Pharmacy, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang West Road, Guangzhou, 510120, People's Republic of China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Guangzhou, People's Republic of China
| | - Dan Liang
- Department of Pharmacy, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang West Road, Guangzhou, 510120, People's Republic of China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Guangzhou, People's Republic of China
| | - Kaifeng Qiu
- Department of Pharmacy, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang West Road, Guangzhou, 510120, People's Republic of China.
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Guangzhou, People's Republic of China.
| | - Min Huang
- School of Pharmaceutical Sciences, Sun Yat-Sen University, 132 Waihuan East Road, Guangzhou, 511400, People's Republic of China.
| | - Junyan Wu
- Department of Pharmacy, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang West Road, Guangzhou, 510120, People's Republic of China.
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Guangzhou, People's Republic of China.
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Zhao Z, Zhao F, Zhang Y, Hu X, Li J, Tian C, Jin P, Liu D. Risk factors of dapagliflozin-associated diabetic ketosis/ketoacidosis in patients with type 2 diabetes mellitus: A matched case-control study. Diabetes Res Clin Pract 2023; 196:110236. [PMID: 36610546 DOI: 10.1016/j.diabres.2023.110236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/20/2022] [Accepted: 12/23/2022] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To investigate the risk factors of dapagliflozin-associated diabetic ketosis/ketoacidosis (DK/DKA) in patients with type 2 diabetes mellitus (T2DM). RESEARCH DESIGN AND METHODS A case-control study was conducted in a general hospital in China from 2018 to 2021. T2DM patients who developed DK/DKA after dapagliflozin treatment were identified. Each patient in the DA/DKA group was matched with a patient in the non-DK/DKA group in terms of the baseline characteristics. Receiver operating characteristic (ROC) curve analysis and logistic regressions were performed. RESULTS Out of 1,684 hospitalized patients taking dapagliflozin, 170 were diagnosed with dapagliflozin-associated DK/DKA. A total of 137 cases were matched with 137 controls. The mean time-to-onset (TTO) of DK/DKA was 28.59 days. Logistic regression showed that current drinking (OR = 7.656, p < 0.001), T2DM duration ≥ 7.625 years (OR = 2.399, p = 0.017), acute ST-elevations myocardial infarction (STEMI) (OR = 12.770, p = 0.028), acute infection (OR = 2.862, p = 0.043), insulin dose reduction/cessation before dapagliflozin exposure (OR = 6.751, p < 0.001), and a major plus or major operation (OR = 2.652, p = 0.022) were risk factors for dapagliflozin-associated DK/DKA. Furthermore, T2DM duration ≥ 7.625 years (p = 0.046) and acute STEMI (p < 0.001) were independently associated with more severe DK/DKA. CONCLUSION Current drinking, long T2DM duration, STEMI, acute infection, insulin deficiency, and major operation are the risk factors associated with DK/DKA in T2DM patients. Furthermore, long T2DM duration and STEMI were associated with more severe DK/DKA situations.
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Affiliation(s)
- Zinan Zhao
- Department of Pharmacy, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences; Beijing Key Laboratory of Assessment of Clinical Drugs Risk and Individual Application (Beijing Hospital), Beijing, PR China
| | - Fei Zhao
- Department of Pharmacy, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences; Beijing Key Laboratory of Assessment of Clinical Drugs Risk and Individual Application (Beijing Hospital), Beijing, PR China
| | - Yatong Zhang
- Department of Pharmacy, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences; Beijing Key Laboratory of Assessment of Clinical Drugs Risk and Individual Application (Beijing Hospital), Beijing, PR China
| | - Xin Hu
- Department of Pharmacy, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences; Beijing Key Laboratory of Assessment of Clinical Drugs Risk and Individual Application (Beijing Hospital), Beijing, PR China
| | - Jianchun Li
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, PR China
| | - Chao Tian
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, PR China
| | - Pengfei Jin
- Department of Pharmacy, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences; Beijing Key Laboratory of Assessment of Clinical Drugs Risk and Individual Application (Beijing Hospital), Beijing, PR China.
| | - Deping Liu
- Department of Cardiology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, PR China.
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Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT2 inhibitors) were originally developed as antidiabetic agents, with cardiovascular (CV) outcome trials demonstrating improved CV outcomes in patients with type 2 diabetes mellitus (T2D). Secondary analyses of CV outcome trials and later dedicated kidney outcome trials consistently reported improved kidney-related outcomes independent of T2D status and across a range of kidney function and albuminuria. Importantly, SGLT2 inhibitors are generally safe and well tolerated, with clinical trials and real-world analyses demonstrating a decrease in the risk of acute kidney injury. The kidney protective effects of SGLT2 inhibitors generally extend across different members of the class, possibly on the basis of hemodynamic, metabolic, anti-inflammatory, and antifibrotic mechanisms. In this review, we summarize the effects of SGLT2 inhibitors on kidney outcomes in diverse patient populations.
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Affiliation(s)
- Atit Dharia
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Ontario, Canada; , , , .,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Abid Khan
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Ontario, Canada; , , , .,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Vikas S Sridhar
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Ontario, Canada; , , , .,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - David Z I Cherney
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Ontario, Canada; , , , .,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Kietaibl AT, Huber J, Clodi M, Abrahamian H, Ludvik B, Fasching P. [Position statement: surgery and diabetes mellitus (Update 2023)]. Wien Klin Wochenschr 2023; 135:256-271. [PMID: 37101047 PMCID: PMC10133078 DOI: 10.1007/s00508-022-02121-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2022] [Indexed: 04/28/2023]
Abstract
This position statement reflects the perspective of the Austrian Diabetes Association concerning the perioperative management of people with diabetes mellitus based on the available scientific evidence. The paper covers necessary preoperative examinations from an internal/diabetological point of view as well as the perioperative metabolic control by means of oral antihyperglycemic and/or insulin therapy.
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Affiliation(s)
- Antonia-Therese Kietaibl
- 5. Medizinische Abteilung für Endokrinologie, Rheumatologie und Akutgeriatrie, Klinik Ottakring, Wien, Österreich
| | - Joakim Huber
- Interne Abteilung mit Akutgeriatrie und Palliativmedizin, Franziskus Spital, Standort Landstraße, Wien, Österreich
| | - Martin Clodi
- ICMR - Institute for Cardiovascular and Metabolic Research, Johannes Kepler Universität Linz, Linz, Österreich.
- Abteilung für Innere Medizin, Konventhospital der Barmherzigen Brüder Linz, Linz, Österreich.
| | | | - Bernhard Ludvik
- 1. Medizinische Abteilung für Diabetologie, Endokrinologie und Nephrologie, Klinik Landstraße, Wien, Österreich
| | - Peter Fasching
- 5. Medizinische Abteilung für Endokrinologie, Rheumatologie und Akutgeriatrie, Klinik Ottakring, Wien, Österreich
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Nardella E, D'Addio S, Cipolla C, Manna R. Diabetic ketoacidosis during treatment with sodium-glucose cotransporter 2 inhibitors reveals a latent autoimmune diabetes in adult. Minerva Endocrinol (Torino) 2022; 47:475-476. [PMID: 33855387 DOI: 10.23736/s2724-6507.21.03432-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Elisabetta Nardella
- Department of Internal Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Stefano D'Addio
- Department of Internal Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Clelia Cipolla
- Department of Life Sciences and Global Health, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy -
| | - Raffaele Manna
- Department of Internal Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy.,Rare Diseases and Periodic Fevers Research Center, Sacred Heart Catholic University, Rome, Italy
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22
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Khunti K, Aroda VR, Bhatt DL, Bozkurt B, Buse JB, Heerspink HL, Inzucchi SE, Lam CSP, Marx N, McMurray JJV, Solomon SD, Kosiborod MN. Re-examining the widespread policy of stopping sodium-glucose cotransporter-2 inhibitors during acute illness: A perspective based on the updated evidence. Diabetes Obes Metab 2022; 24:2071-2080. [PMID: 35801339 DOI: 10.1111/dom.14805] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 06/23/2022] [Accepted: 07/01/2022] [Indexed: 11/28/2022]
Abstract
Sodium-glucose cotransporter-2 (SGLT2) inhibitors are now seen as an integral part of therapy in type 2 diabetes to control not only blood glucose but to improve cardiovascular and kidney outcomes. Diabetic ketoacidosis (DKA) is an uncommon but serious complication of type 2 diabetes, which has a high case fatality rate. The absolute risk of DKA in large, prospective randomized clinical trials in people with type 2 diabetes using SGLT2 inhibitors has been low, although the relative risk is higher in those assigned to SGLT2 inhibitors compared with placebo. In those without diabetes but prescribed SGLT2 inhibitors for heart failure or chronic kidney disease, the risk of DKA is similar to placebo. Over the course of the COVID-19 pandemic, cases of DKA have also been reported in cases of COVID-19 hospitalizations. Consensus guidelines have recommended that SGLT2 inhibitors should be avoided in cases of serious illness and suggest they are not recommended for routine in-hospital use. However, recent data suggest potential beneficial effects of SGLT2 inhibitors in the setting of acute illness with COVID-19 with no increase in adverse events and low rates of DKA, which were non-severe. Given the low rates of DKA in cardiovascular outcome trials and in hospitalized patients with type 2 diabetes, the potential for SGLT2 inhibitors not being re-initiated following discharge and their cardiovascular and kidney benefits, we believe the practice of routine 'sick day' guidance should be re-examined based on current evidence with a call for further research in this area. Furthermore, high-quality trials of initiation of SGLT2 inhibitors in people admitted to hospital with cardiovascular disease or kidney disease, and trials of continuation of SGLT2 inhibitors in people, with careful monitoring of DKA should be conducted. These should be further supplemented with large observational studies.
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Affiliation(s)
- Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Vanita R Aroda
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Deepak L Bhatt
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Biykem Bozkurt
- Section of Cardiology, Baylor College of Medicine, Houston Baylor, Houston, Texas, USA
| | - John B Buse
- Division of Endocrinology and Metabolism, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | | | - Silvio E Inzucchi
- Section of Endocrinology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore, Singapore
| | - Nikolaus Marx
- Department of Internal Medicine I-Cardiology, RWTH Aachen University, Aachen, Germany
| | - John J V McMurray
- Department of Medicine, British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
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23
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Pathak BD, Dhakal B, Bhattarai AM, Regmi BU, Mandal SK, Panta PR, Khadka S, Simkhada N. Euglycemic diabetic ketoacidosis in a patient with acute stroke taking sodium glucose co-transporter 2 inhibitor. Ann Med Surg (Lond) 2022; 79:104118. [PMID: 35860094 PMCID: PMC9289500 DOI: 10.1016/j.amsu.2022.104118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 12/05/2022] Open
Abstract
Introduction Diabetic Ketoacidosis is characterized by a triad of metabolic acidosis, hyperglycemia, and ketonemia. It is a medical emergency that needs urgent and aggressive management. In some cases, the blood glucose level may be relatively normal. Such a condition is known as Euglycemic Diabetic Ketoacidosis. Case presentation We present a case of Euglycemic Diabetic Ketoacidosis, who was initially brought to the emergency room with the features of acute stroke. There was a diagnostic dilemma among the treating physicians due to his relatively normal blood glucose levels while he developed ketoacidosis. Discussion Presentation of the patients includes similar to DKA such as nausea, vomiting, malaise, fatigue, and Kussmaul's respiration. The diabetic patients under sodium glucose co-transporter-2 inhibitor therapy may develop it under the setting of different precipitating factors like infection, trauma/surgery, strenuous physical exercise, fasting, alcohol intake and acute vascular events. Conclusion Euglycemic DKA is a rare condition and its diagnosis is a challenging task. So, we should always consider it as a differential whenever any diabetic patient shows with increased anion gap metabolic acidosis with or without typical symptoms and signs. Also, we need to be aware to discontinue of SGLT-2 medication during the time of infection, surgery, severe trauma, acute illness and dehydration in the diabetic patients. Diabetic Ketoacidosis is a medical emergency with a triad of metabolic acidosis, hyperglycemia and ketonemia. The precipitating factors includes infection, surgery, fasting, alcohol intake, acute vascular events, trauma and prolonged physical exercise. Patient presents with complaints similar to DKA such as nausea, vomiting, malaise, fatigue, and Kussmaul's respiration. Management includes fluid resuscitation, insulin infusion, dextrose and potassium supplementation.
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Luo X, Ji R, Lu W, Zhu H, Li L, Hu J. Dapagliflozin-Associated Euglycemic Diabetic Ketoacidosis in a Patient Who Underwent Surgery for Pancreatic Carcinoma: A Case Report. Front Surg 2022; 9:769041. [PMID: 35284482 PMCID: PMC8906517 DOI: 10.3389/fsurg.2022.769041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 01/21/2022] [Indexed: 11/13/2022] Open
Abstract
Diabetic ketoacidosis (DKA), an acute and life-threatening complication of diabetes, is a metabolic disorder caused by insulin deficiency and an increase in counter-regulatory hormones. Several cases of DKA without marked hyperglycemia have been reported and are defined as euglycemic DKA (eu-DKA). The use of sodium-glucose cotransporter 2 inhibitors (SGLT2is) is associated with the occurrence of eu-DKA, of which, dapagliflozin is one of the agents. In this study, we report a case of dapagliflozin-associated eu-DKA following surgery for pancreatic carcinoma. A 57-year-old woman presented with acute abdominal pain after surgery for pancreatic carcinoma. Emergency exploratory laparotomy was performed because of suspicion of gastrointestinal perforation based on a CT scan. The surgeons observed that the stomach was significantly dilated but not perforated. Meanwhile, the patient developed shock and severe acidosis. A further examination confirmed the diagnosis of dapagliflozin-associated eu-DKA. We reviewed the precipitating factors and mechanisms of SGLT2i-associated eu-DKA and discussed the treatment and prevention of this condition. Clinicians need to be alert of the occurrence of SGLT2i-associated eu-DKA in patients treated with this drug in the perioperative period.
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25
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Kang DY, Kim H, Ko S, Kim H, Shinn J, Kang MG, Byeon SJ, Choi JH, Shin SY, Kim HS. Sodium-Glucose Cotransporter-2 Inhibitor-Related Diabetic Ketoacidosis: Accuracy Verification of Operational Definition. J Korean Med Sci 2022; 37:e53. [PMID: 35191230 PMCID: PMC8860766 DOI: 10.3346/jkms.2022.37.e53] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 01/05/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The most important aspect of a retrospective cohort study is the operational definition (OP) of the disease. We developed a detailed OP for the detection of sodium-glucose cotransporter-2 inhibitors (SGLT2i) related to diabetic ketoacidosis (DKA). The OP was systemically verified and analyzed. METHODS All patients prescribed SGLT2i at four university hospitals were enrolled in this experiment. A DKA diagnostic algorithm was created and distributed to each hospital; subsequently, the number of SGLT2i-related DKAs was confirmed. Then, the algorithm functionality was verified through manual chart reviews by an endocrinologist using the same OP. RESULTS A total of 8,958 patients were initially prescribed SGLT2i. According to the algorithm, 0.18% (16/8,958) were confirmed to have SGLT2i-related DKA. However, based on manual chart reviews of these 16 cases, there was only one case of SGLT2i-related DKA (positive predictive value = 6.3%). Even after repeatedly narrowing the diagnosis range of the algorithm, the effect of a positive predictive value was insignificant (6.3-10.0%, P > 0.999). CONCLUSION Owing to the nature of electronic medical record data, we could not create an algorithm that clearly differentiates SGLT2i-related DKA despite repeated attempts. In all retrospective studies, a portion of the samples should be randomly selected to confirm the accuracy of the OP through chart review. In retrospective cohort studies in which chart review is not possible, it will be difficult to guarantee the reliability of the results.
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Affiliation(s)
- Dong Yoon Kang
- Drug Safety Monitoring Center, Seoul National University Hospital, Seoul, Korea
| | - Hyunah Kim
- College of Pharmacy, Sookmyung Women's University, Seoul, Korea
| | - SooJeong Ko
- Department of Medical Informatics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - HyungMin Kim
- Department of Medical Informatics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jiwon Shinn
- Department of Medical Informatics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Min-Gyu Kang
- Division of Allergy and Clinical Immunology, Departmemt of Internal Medicine, Chungbuk National University Hospital, Chungbuk National College of Medicine, Cheongju, Korea
| | - Sun-Ju Byeon
- Department of Pathology, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Jeong-Hee Choi
- Department of Pulmonology and Allergy, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Soo-Yong Shin
- Department of Digital Health, SAIHST, Sungkyunkwan University, Seoul, Korea
| | - Hun-Sung Kim
- Department of Medical Informatics, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
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26
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Hashi R, Fujiki N, Yagi T. Tubular Injury Causing Protracted Glycosuria Following Withdrawal of a Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitor: A Possible Role in the Development of Protracted Hypoglycemia and Ketoacidosis. TOHOKU J EXP MED 2021; 255:291-296. [PMID: 34911880 DOI: 10.1620/tjem.255.291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We herein present the case of a 45-year-old diabetic woman who developed diabetic ketoacidosis following the administration of dapagliflozin, a sodium-glucose cotransporter 2 (SGLT2) inhibitor. The patient had been diagnosed with diabetes three years previously and was being treated with multiple daily injections of insulin. Metformin hydrochloride and dapagliflozin were added seven months and 11 months later, respectively. Her clinical course was uneventful until the onset of influenza. She then discontinued insulin and oral medications voluntarily. On arrival at the hospital, she was found to be in a state of ketoacidosis, and promptly received insulin and saline infusion. In retrospect, the initial amount of glucose infused was insufficient, and the hypoglycemia was thought to have been prolonged. This phenomenon may also have affected her long-term urinary glucose excretion. Her urinary L-type fatty acid-binding protein (L-FABP) level was found to be markedly elevated (48.8 μg/g·Cr, reference value < 8.4 μg/g·Cr) as was her urinary β2-microglobulin level (9,230 μg/L, reference value < 230 μg/L). Patients with SGLT-2 inhibitor-associated diabetic ketoacidosis often exhibit protracted hyperglycosuria, in which acute proximal renal tubular dysfunction is considered to be etiologically implicated.
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Affiliation(s)
- Rika Hashi
- Department of Metabolic and Endocrinology, BellLand General Hospital
| | - Noritaka Fujiki
- Department of Metabolic and Endocrinology, BellLand General Hospital
| | - Toshihito Yagi
- Department of Metabolic and Endocrinology, BellLand General Hospital
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27
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Menghoum N, Oriot P, Hermans MP. Clinical and biochemical characteristics and analysis of risk factors for euglycaemic diabetic ketoacidosis in type 2 diabetic individuals treated with SGLT2 inhibitors: A review of 72 cases over a 4.5-year period. Diabetes Metab Syndr 2021; 15:102275. [PMID: 34562870 DOI: 10.1016/j.dsx.2021.102275] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 08/30/2021] [Accepted: 09/01/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIMS To study euglycemic diabetic ketoacidosis (euDKA) outcomes associated with sodium-glucose co-transporter 2 inhibitors (SGLT2is) METHODS: Review of 72 euDKA cases in T2DM between September 2015 and January 2020 (PUBMED). RESULTS euDKA could occur at any time during SGLT2is treatment, with nausea, abdominal pain and vomiting as main symptoms. Hyperglycemia did not correlate with pH and β-hydroxybutyrates. Low pH and high β-hydroxybutyrates were significantly associated with euDKA. In biguanides users, acidosis was unrelated to lactic acidosis. euDKA occurred during fasting, surgery, acute infection, insulin deprivation (endogenous or exogenous). CONCLUSIONS These data support avoidance of euDKA risk states in SGLT2i users.
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Affiliation(s)
- N Menghoum
- Department of Internal Medicine, Mouscron Hospital Center, Avenue de Fécamp 49, 7700, Mouscron, Belgium; Pole of Cardiovascular Research, Institute of Experimental and Clinical Research, Catholic University of Louvain, 1200, Brussels, Belgium
| | - P Oriot
- Department of Internal Medicine, Mouscron Hospital Center, Avenue de Fécamp 49, 7700, Mouscron, Belgium; Department of Diabetology, Mouscron Hospital Centre, Avenue de Fécamp 49, 7700, Mouscron, Belgium.
| | - M P Hermans
- Endocrinology & Nutrition Unit, Cliniques Universitaires St-Luc, and Pole of Cardiovascular Research, Institute of Experimental and Clinical Research, Catholic University of Louvain, Avenue Hippocrate 55, 1200, Brussels, Belgium
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28
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Morton A. Review article: Diagnosing acute pancreatitis in diabetes mellitus. Emerg Med Australas 2021; 34:6-8. [PMID: 34655153 DOI: 10.1111/1742-6723.13882] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/06/2021] [Indexed: 11/29/2022]
Abstract
Acute pancreatitis is a common reason for presentation to EDs. The criteria for diagnosis of acute pancreatitis are defined by the revised Atlanta classification. Patients with diabetes mellitus are at increased risk of acute pancreatitis. Uncomplicated diabetes mellitus, complications such as ketoacidosis and newer medications used in the treatment of hyperglycaemia may all be associated with elevated serum lipase and amylase in the absence of acute pancreatitis. Checkpoint inhibitors may also precipitate acute type 1 diabetes mellitus and be associated with elevated lipase and amylase. Finally, individuals with diabetes mellitus are at increased risk of hypertriglyceridaemic pancreatitis, which may be associated with falsely normal lipase and amylase because of laboratory interference. Awareness of these factors in individuals with diabetes mellitus presenting to EDs with symptoms suggestive of acute pancreatitis is important for accurate diagnosis.
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Affiliation(s)
- Adam Morton
- Endocrinology and Obstetric Medicine, Mater Health, Brisbane, Queensland, Australia
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29
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Longato E, Bonora BM, Di Camillo B, Sparacino G, Tramontan L, Avogaro A, Fadini GP. Outcomes of patients with type 2 diabetes treated with SGLT-2 inhibitors versus DPP-4 inhibitors. An Italian real-world study in the context of other observational studies. Diabetes Res Clin Pract 2021; 179:109024. [PMID: 34454002 DOI: 10.1016/j.diabres.2021.109024] [Citation(s) in RCA: 3] [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: 04/07/2021] [Revised: 07/15/2021] [Accepted: 08/23/2021] [Indexed: 12/26/2022]
Abstract
AIMS We compared cardiovascular outcomes of patients with type 2 diabetes (T2D) receiving sodium glucose cotransporter-2 inhibitors (SGLT2i) or dipeptidyl peptidase-4 inhibitors (DPP4i) under routine care. METHODS From an administrative claims database of >5.2M citizen, we identified patients with T2D who initiated SGLT2i or DPP4i from 2014 to 2018. Patients were matched by propensity scores. The primary outcome was the 3-point major adverse cardiovascular events (3P-MACE). RESULTS After matching, we included 3216 patients/group, with mean age of 63 years, diabetes duration of 8.7 years, and 20% had cardiovascular disease. During a median follow-up of 18 months, the rate of 3P-MACE was lower among patients who initiated SGLT2i versus DPP4i (HR 0.74; 95 %C.I. 0.58-0.94). Initiators of SGLT2i also showed significantly lower rates of myocardial infarction (HR 0.75; 95 %C.I. 0.56-1.00), hospitalization for heart failure (HR 0.44; 95 %C.I. 0.25-0.95) or cardiovascular causes (HR 0.72; 95 %C.I. 0.60-0.87), and all-cause death (HR 0.49; 95 %C.I. 0.25-0.95). Renal failure was less common with SGLT2i than with DPP4i. Results were consistent to those obtained in a meta-analysis of 10 observational studies on ~1.5M patients. CONCLUSIONS Patients with T2D who initiated SGLT2i under routine care had better cardio-renal outcomes and lower all-cause mortality than similar patients who initiated DPP4i.
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Affiliation(s)
- Enrico Longato
- Department of Information Engineering, University of Padova, Via Gradenico, 35100 Padova, Italy
| | | | - Barbara Di Camillo
- Department of Information Engineering, University of Padova, Via Gradenico, 35100 Padova, Italy
| | - Giovanni Sparacino
- Department of Information Engineering, University of Padova, Via Gradenico, 35100 Padova, Italy
| | - Lara Tramontan
- Arsenàl.IT, Veneto's Research Centre for eHealth Innovation, Viale Guglielmo Oberdan, 5, 31100 Treviso, Italy
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Via Giustiniani 2, 35100 Padova, Italy
| | - Gian Paolo Fadini
- Department of Medicine, University of Padova, Via Giustiniani 2, 35100 Padova, Italy; Veneto Institute of Molecular Medicine, 35129 Padua, Italy.
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30
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Palmer BF, Clegg DJ. Euglycemic Ketoacidosis as a Complication of SGLT2 Inhibitor Therapy. Clin J Am Soc Nephrol 2021; 16:1284-1291. [PMID: 33563658 PMCID: PMC8455044 DOI: 10.2215/cjn.17621120] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Sodium-glucose cotransporter-2 (SGLT2) inhibitors are drugs designed to lower plasma glucose concentration by inhibiting Na+-glucose-coupled transport in the proximal tubule. Clinical trials demonstrate these drugs have favorable effects on cardiovascular outcomes to include slowing the progression of CKD. Although most patients tolerate these drugs, a potential complication is development of ketoacidosis, often with a normal or only a minimally elevated plasma glucose concentration. Inhibition of sodium-glucose cotransporter-2 in the proximal tubule alters kidney ATP turnover so that filtered ketoacids are preferentially excreted as Na+ or K+ salts, leading to indirect loss of bicarbonate from the body and systemic acidosis under conditions of increased ketogenesis. Risk factors include reductions in insulin dose, increased insulin demand, metabolic stress, low carbohydrate intake, women, and latent autoimmune diabetes of adulthood. The lack of hyperglycemia and nonspecific symptoms of ketoacidosis can lead to delays in diagnosis. Treatment strategies and various precautions are discussed that can decrease the likelihood of this complication.
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Affiliation(s)
- Biff F. Palmer
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Deborah J. Clegg
- Associate Dean for Research, College of Nursing and Health Professionals, Drexel University, Philadelphia, Pennsylvania
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Provenzano M, Pelle MC, Zaffina I, Tassone B, Pujia R, Ricchio M, Serra R, Sciacqua A, Michael A, Andreucci M, Arturi F. Sodium-Glucose Co-transporter-2 Inhibitors and Nephroprotection in Diabetic Patients: More Than a Challenge. Front Med (Lausanne) 2021; 8:654557. [PMID: 34150796 PMCID: PMC8212983 DOI: 10.3389/fmed.2021.654557] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 05/11/2021] [Indexed: 12/16/2022] Open
Abstract
Diabetic nephropathy is the most common cause of end-stage renal disease worldwide. Control of blood glucose and blood pressure (BP) reduces the risk of developing this complication, but once diabetic nephropathy is established, it is then only possible to slow its progression. Sodium-glucose cotransporter-2 inhibitors (SGLT2is) are a novel class of oral hypoglycemic agents that increase urinary glucose excretion by suppressing glucose reabsorption at the renal proximal tubule. SGLT2is lower glycated hemoglobin (HbA1c) without increasing the risk of hypoglycemia, induce weight loss and improve various metabolic parameters including BP, lipid profile, albuminuria and uric acid. Several clinical trials have shown that SGLT2is (empagliflozin, dapagliflozin canagliflozin, and ertugliflozin) improve cardiovascular and renal outcomes and mortality in patients with type 2 diabetes. Effects of SGLT2is on the kidney can be explained by multiple pathways. SGLT2is may improve renal oxygenation and intra-renal inflammation thereby slowing the progression of kidney function decline. Additionally, SGLT2is are associated with a reduction in glomerular hyperfiltration, an effect which is mediated by the increase in natriuresis, the re-activation of tubule-glomerular feedback and independent of glycemic control. In this review, we will focus on renal results of major cardiovascular and renal outcome trials and we will describe direct and indirect mechanisms through which SGLT2is confer renal protection.
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Affiliation(s)
- Michele Provenzano
- Chair of Nephrology, Department of Health Sciences, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Maria Chiara Pelle
- Department of Medical and Surgical Sciences, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Isabella Zaffina
- Unit of Internal Medicine, Department of Medical and Surgical Sciences, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Bruno Tassone
- Unit of Internal Medicine, Department of Medical and Surgical Sciences, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Roberta Pujia
- Unit of Internal Medicine, Department of Medical and Surgical Sciences, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Marco Ricchio
- Unit of Internal Medicine, Department of Medical and Surgical Sciences, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Raffaele Serra
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology at the Department of Surgical and Medical Sciences University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Angela Sciacqua
- Unit of Geriatric, Department of Medical and Surgical Sciences, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Ashour Michael
- Chair of Nephrology, Department of Health Sciences, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Michele Andreucci
- Chair of Nephrology, Department of Health Sciences, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Franco Arturi
- Unit of Internal Medicine, Department of Medical and Surgical Sciences, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
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Nasa P, Chaudhary S, Shrivastava PK, Singh A. Euglycemic diabetic ketoacidosis: A missed diagnosis. World J Diabetes 2021; 12:514-523. [PMID: 33995841 PMCID: PMC8107974 DOI: 10.4239/wjd.v12.i5.514] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/01/2021] [Accepted: 03/26/2021] [Indexed: 02/06/2023] Open
Abstract
Euglycemic diabetic ketoacidosis (DKA) is an acute life-threatening metabolic emergency characterized by ketoacidosis and relatively lower blood glucose (less than 11 mmol/L). The absence of hyperglycemia is a conundrum for physicians in the emergency department and intensive care units; it may delay diagnosis and treatment causing worse outcomes. Euglycemic DKA is an uncommon diagnosis but can occur in patients with type 1 or type 2 diabetes mellitus. With the addition of sodium/ glucose cotransporter-2 inhibitors in diabetes mellitus management, euglycemic DKA incidence has increased. The other causes of euglycemic DKA include pregnancy, fasting, bariatric surgery, gastroparesis, insulin pump failure, cocaine intoxication, chronic liver disease and glycogen storage disease. The pathophysiology of euglycemic DKA involves a relative or absolute carbohydrate deficit, milder degree of insulin deficiency or resistance and increased glucagon/insulin ratio. Euglycemic DKA is a diagnosis of exclusion and should be considered in the differential diagnosis of a sick patient with a history of diabetes mellitus despite lower blood glucose or absent urine ketones. The diagnostic workup includes arterial blood gas for metabolic acidosis, serum ketones and exclusion of other causes of high anion gap metabolic acidosis. Euglycemic DKA treatment is on the same principles as for DKA with correction of dehydration, electrolytes deficit and insulin replacement. The dextrose-containing fluids should accompany intravenous insulin to correct metabolic acidosis, ketonemia and to avoid hypoglycemia.
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Affiliation(s)
- Prashant Nasa
- Department of Critical Care Medicine, NMC Specialty Hospital, Dubai 7832, United Arab Emirates
| | - Sandeep Chaudhary
- Department of Endocrinology, NMC Specialty Hospital, Dubai 7832, United Arab Emirates
| | | | - Aanchal Singh
- Department of Critical Care Medicine, NMC Specialty Hospital, Dubai 7832, United Arab Emirates
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33
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Euglycemic Diabetic Ketoacidosis Caused by SGLT2 Inhibitors and a Ketogenic Diet: A Case Series and Review of Literature. AACE Clin Case Rep 2021; 7:17-19. [PMID: 33851013 PMCID: PMC7924151 DOI: 10.1016/j.aace.2020.11.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Objective Sodium-glucose cotransporter-2 (SGLT2) inhibitors are a relatively novel class of oral medications for the treatment of type 2 diabetes mellitus (T2DM). Their use has increased recently due to their beneficial renal and cardiovascular outcomes, but they come with the rare risk of diabetic ketoacidosis (DKA) at normal or slightly elevated glucose values, termed euglycemic DKA (euDKA). Recently, carbohydrate-deprived, ketogenic diets have gained popularity due to benefits of weight loss and improved control of T2DM. We describe 2 patients with T2DM who developed euDKA caused by SGLT2 inhibitor use while on a ketogenic diet and provide a review of the literature. Methods We describe the hospital course, laboratory data, and treatment of 2 patients and provide a literature review. Results Both of our patients were found to have normal or mildly elevated serum glucose levels, with an elevated anion gap and ketosis, representative of euDKA. The first patient developed euDKA after only 1 dose of empagliflozin, while the second patient developed euDKA after only 1 week of being on a ketogenic diet while on an SGLT2 inhibitor. Conclusion While there have been a few reports of euDKA with SGLT2 inhibitors and ketogenic diets, many physicians prescribing these medications may not be aware of this association. Therefore, they must inform their patients to avoid a ketogenic diet if on an SGLT2 inhibitor. If a patient presents with symptoms of DKA and is eating a carbohydrate-free diet while taking an SGLT2 inhibitor, there should be a low threshold to screen for DKA.
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34
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Goto S, Ishikawa JY, Idei M, Iwabuchi M, Namekawa M, Nomura T. Life-Threatening Complications Related to Delayed Diagnosis of Euglycemic Diabetic Ketoacidosis Associated with Sodium-Glucose Cotransporter-2 Inhibitors: A Report of 2 Cases. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e929773. [PMID: 33723205 PMCID: PMC7980085 DOI: 10.12659/ajcr.929773] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Case series Patients: Female, 52-year-old • Female, 76-year-old Final Diagnosis: Euglycemic diabetic ketoacidosis • myocardial infarction • sinus node dysfunction Symptoms: Unconsciousness • vomiting Medication: — Clinical Procedure: Hemodialysis • pacemaker insertion Specialty: Critical Care Medicine • Endocrinology and Metabolic
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Affiliation(s)
- Shunsaku Goto
- Department of Anesthesiology, Tokyo Women's Medical University, Tokyo, Japan.,Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Jun-Ya Ishikawa
- Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Masafumi Idei
- Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Masahiro Iwabuchi
- Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Motoki Namekawa
- Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Takeshi Nomura
- Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
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35
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Großmann S, Hoffmann U, Girlich C. [Confusion, tachypnea, and tachycardia in a 71-year-old man with type 2 diabetes mellitus]. Internist (Berl) 2021; 62:672-678. [PMID: 33411015 PMCID: PMC7788531 DOI: 10.1007/s00108-020-00930-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2020] [Indexed: 11/14/2022]
Abstract
Bei Patienten mit Diabetes mellitus Typ 2 muss im Falle einer unklaren Bewusstseinsstörung und/oder Bauchschmerzen eine Natrium/Glukose-Kotransporter-2(SGLT-2)-Inhibitor-induzierte diabetische Ketoazidose in die Differenzialdiagnose einbezogen werden. Dabei können die Blutzuckerspiegel trotz ausgeprägter Azidose nur moderat erhöht sein. Bei Nachweis ist eine umgehende intensivmedizinische Therapie unerlässlich.
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Affiliation(s)
- S Großmann
- Klinik für Pneumologie und konservative Intensivmedizin, Krankenhaus Barmherzige Brüder Regensburg, Prüfeninger Straße 86, 93049, Regensburg, Deutschland.
| | - U Hoffmann
- Klinik für Allgemeine Innere Medizin und Geriatrie, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Deutschland
| | - C Girlich
- Klinik für Allgemeine Innere Medizin und Geriatrie, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Deutschland
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36
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Milder TY, Stocker SL, Day RO, Greenfield JR. Potential Safety Issues with Use of Sodium-Glucose Cotransporter 2 Inhibitors, Particularly in People with Type 2 Diabetes and Chronic Kidney Disease. Drug Saf 2020; 43:1211-1221. [PMID: 33095409 PMCID: PMC7582030 DOI: 10.1007/s40264-020-01010-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2020] [Indexed: 12/31/2022]
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a major advance in the fields of diabetology, nephrology, and cardiology. The cardiovascular and renal benefits of SGLT2 inhibitors are likely largely independent of their glycaemic effects, and this understanding is central to the use of these agents in the high-risk population of people with type 2 diabetes and chronic kidney disease. There are a number of potential safety issues associated with the use of SGLT2 inhibitors. These include the rare but serious risks of diabetic ketoacidosis and necrotising fasciitis of the perineum. The data regarding a possibly increased risk of lower limb amputation and fracture with SGLT2 inhibitor therapy are conflicting. This article aims to explore the potential safety issues associated with the use of SGLT2 inhibitors, with a particular focus on the safety of these drugs in people with type 2 diabetes and chronic kidney disease. We discuss strategies that clinicians can implement to minimise the risk of adverse effects including diabetic ketoacidosis and volume depletion. Risk mitigation strategies with respect to SGLT2 inhibitor-associated diabetic ketoacidosis are of particular importance during the current coronavirus disease 2019 (COVID-19) pandemic.
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Affiliation(s)
- Tamara Y Milder
- Department of Diabetes and Endocrinology, St. Vincent's Hospital, Sydney, Australia.,Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, Australia.,Diabetes and Metabolism, Garvan Institute of Medical Research, Sydney, Australia.,St. Vincent's Clinical School, University of NSW, Sydney, Australia
| | - Sophie L Stocker
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, Australia.,St. Vincent's Clinical School, University of NSW, Sydney, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, Australia.,St. Vincent's Clinical School, University of NSW, Sydney, Australia
| | - Jerry R Greenfield
- Department of Diabetes and Endocrinology, St. Vincent's Hospital, Sydney, Australia. .,Diabetes and Metabolism, Garvan Institute of Medical Research, Sydney, Australia. .,St. Vincent's Clinical School, University of NSW, Sydney, Australia.
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37
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Scheen AJ. Sodium-glucose cotransporter type 2 inhibitors for the treatment of type 2 diabetes mellitus. Nat Rev Endocrinol 2020; 16:556-577. [PMID: 32855502 DOI: 10.1038/s41574-020-0392-2] [Citation(s) in RCA: 143] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/03/2020] [Indexed: 02/07/2023]
Abstract
The management of type 2 diabetes mellitus (T2DM) is becoming increasingly complex. Sodium-glucose cotransporter type 2 inhibitors (SGLT2is) are the newest antidiabetic agents for T2DM. By targeting the kidney, they have a unique mechanism of action, which results in enhanced glucosuria, osmotic diuresis and natriuresis, thereby improving glucose control with a limited risk of hypoglycaemia and exerting additional positive effects such as weight loss and the lowering of blood pressure. Several outcome studies with canagliflozin, dapagliflozin or empagliflozin reported a statistically significant reduction in major cardiovascular events, hospitalization for heart failure and progression to advanced renal disease in patients with T2DM who have established atherosclerotic cardiovascular disease, several cardiovascular risk factors, albuminuric mild to moderate chronic kidney disease or heart failure. Current guidelines proposed a new paradigm in the management of T2DM, with a preferential place for SGLT2is, after metformin, in patients with atherosclerotic cardiovascular disease, heart failure and progressive kidney disease. Ongoing trials might extend the therapeutic potential of SGLT2is in patients with, but also without, T2DM. This Review provides an update of the current knowledge on SGLT2is, moving from their use as glucose-lowering medications to their new positioning as cardiovascular and renal protective agents.
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Affiliation(s)
- André J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège, Belgium.
- Division of Clinical Pharmacology, Center for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium.
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38
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Sriphrapradang C, Thewjitcharoen Y, Buranapin S, Sawanyawisuth K, Yenseung N, Ubonchareon W, Limpijankit L, Himathongkam T. Effectiveness and safety of sodium-glucose co-transporter-2 inhibitors in Thai adults with type 2 diabetes mellitus: a real-world study. Curr Med Res Opin 2020; 36:1601-1610. [PMID: 32776785 DOI: 10.1080/03007995.2020.1808454] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Sodium-glucose co-transporter-2 inhibitors (SGLT2is) are widely used to improve both glycemic control and cardio-renal outcomes. We aim to evaluate the real-life clinical effectiveness, safety and outcomes of SGLT2is in Thai adults with type 2 diabetes mellitus (T2DM). METHODS This was a retrospective study involving adults with T2DM who were treated with SGLT2is for ≥3 months. RESULTS Among 1159 participants (women 52.6%; age: 61.1 ± 10.9 years; body mass index: 28.7 ± 5.2 kg/m2), 65.1%, 34.3% and 0.6% received dapagliflozin, empagliflozin and canagliflozin, respectively. Median SGLT2i treatment duration was 15 (IQR, 8-23) months. Of the patients, 16.5%, 6.4%, 4.9% and 1.6% had pre-existing coronary artery disease, stroke, heart failure and peripheral arterial disease, respectively. Mean HbA1c decreased by 0.7% (95% CI, -1.0 to -0.4) from a baseline of 8.3 ± 1.5%. At 24 months, body weight, and systolic and diastolic blood pressure decreased significantly from the baseline average of 2.5 kg, 3.5 mmHg and 2.4 mmHg, respectively. The median decline in eGFR was -1.3 ml/min/1.73 m2/year. The incidences of pollakiuria, genital tract infection, urinary tract infection and hypoglycemia were 7.2%, 2.8%, 2.2% and 0.9%, respectively. No participants developed diabetic ketoacidosis during the observation period. CONCLUSIONS SGLT2is improved cardiometabolic parameters in Thai adults, clinically confirming findings in controlled trials.
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Affiliation(s)
- Chutintorn Sriphrapradang
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Supawan Buranapin
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | | | - Nalin Yenseung
- Diabetes and Thyroid Center, Theptarin Hospital, Bangkok, Thailand
| | - Wisawa Ubonchareon
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Laddawan Limpijankit
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Abstract
Diabetic ketoacidosis (DKA) is not a rare presentation to hospital, despite being an entirely preventable condition. A concerning number of people also develop DKA while already in hospital. Management of DKA has changed in the last decade, and national guidelines introduced, to help standardise care, spread best practice, and reduce mortality and morbidity.
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Affiliation(s)
- Kate Evans
- University Hospitals Plymouth NHS Trust, Plymouth, UK
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40
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Górriz JL, Navarro-González JF, Ortiz A, Vergara A, Nuñez J, Jacobs-Cachá C, Martínez-Castelao A, Soler MJ. Sodium-glucose cotransporter 2 inhibition: towards an indication to treat diabetic kidney disease. Nephrol Dial Transplant 2020; 35:i13-i23. [PMID: 32003834 PMCID: PMC6993197 DOI: 10.1093/ndt/gfz237] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Indexed: 12/19/2022] Open
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have clearly demonstrated their beneficial effect in diabetic kidney disease (DKD) on top of the standard of care [blood glucose control, renin–angiotensin system blockade, smoking cessation and blood pressure (BP) control], even in patients with overt DKD. However, the indication of this drug class is still blood glucose lowering in type 2 diabetic patients with estimated glomerular filtration rate >45 mL/min/1.73 m2. Based on the new evidence, several scientific societies have emphasized the preferential prescription of SGLT2i for patients at risk of heart failure or kidney disease, but still within the limits set by health authorities. A rapid positioning of both the European Medicines Agency and the US Food and Drug Administration will allow patients with overt DKD to benefit from SGLT2i. Clinical experience suggests that SGLT2i safety management may in part mirror renin–angiotensin blockade safety management in patients with overt DKD. This review focuses on the rationale for an indication of SGTL2i in DKD. We further propose clinical steps for maximizing the safety of SGLT2i in DKD patients on other antidiabetic, BP or diuretic medication.
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Affiliation(s)
- Jose Luis Górriz
- Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, GEENDIAB, Valencia, Spain.,REDINREN, Madrid, Spain
| | - Juan F Navarro-González
- REDINREN, Madrid, Spain.,Unidad de Investigación y Servicio de Nefrología, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain.,Instituto de Tecnologías Biomédicas, Universidad de La Laguna, GEENDIAB, Santa Cruz de Tenerife, Spain
| | - Alberto Ortiz
- REDINREN, Madrid, Spain.,IIS-Fundación Jimenez Diaz UAM and School of Medicine, UAM, GEENDIAB, Madrid, Spain
| | - Ander Vergara
- Department of Nephrology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.,Nephrology Research Group, Vall d'Hebron Research Institute (VHIR), GEENDIAB, Barcelona, Spain
| | - Julio Nuñez
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain.,CIBER Cardiovascular
| | - Conxita Jacobs-Cachá
- Department of Nephrology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.,Nephrology Research Group, Vall d'Hebron Research Institute (VHIR), GEENDIAB, Barcelona, Spain
| | | | - Maria Jose Soler
- REDINREN, Madrid, Spain.,Department of Nephrology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.,Nephrology Research Group, Vall d'Hebron Research Institute (VHIR), GEENDIAB, Barcelona, Spain
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41
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Schempf J, Chow LS, Harindhanavudhi T. Uncovering Autoimmune Diabetes in a Patient With Euglycemic Diabetic Ketoacidosis. Am J Med Sci 2020; 360:307-308. [PMID: 32536417 DOI: 10.1016/j.amjms.2020.05.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 04/07/2020] [Accepted: 05/15/2020] [Indexed: 11/30/2022]
Affiliation(s)
- John Schempf
- Division of Diabetes and Endocrinology, Department of Medicine, University of Minnesota, Minneapolis, Minnesota.
| | - Lisa S Chow
- Division of Diabetes and Endocrinology, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Tasma Harindhanavudhi
- Division of Diabetes and Endocrinology, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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42
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Fatima T, Sedrakyan S, Awan MR, Khatun MK, Rana D, Jahan N. Use of Sodium-Glucose Co-Transporter-2 Inhibitors in Type 1 Diabetics: Are the Benefits Worth the Risks? Cureus 2020; 12:e10076. [PMID: 33005503 PMCID: PMC7522056 DOI: 10.7759/cureus.10076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The mainstay of treatment for type 1 diabetes is insulin. The use of insulin for tight glycemic control is the key to preventing micro- and macrovascular complications, but it can also lead to hypoglycemic episodes. Therefore, there is a need for the introduction of a drug that can maintain glucose levels within a safe range without increasing the risk of hypoglycemia. For this reason, SGLT2 (sodium-glucose co-transporter-2) inhibitors has been a hot topic in the last couple of years. They have been proved very efficient in treating type 2 diabetes. Many trials on the safety and efficacy of SGLT2 inhibitors have been done on type 1 diabetics. Some other studies have also been done that prove their benefits in increasing arterial efficacy and reducing GFR (glomerular filtration rate). This review article discusses the benefits and risks. The literature search was performed using PubMed, and after applying the inclusion and exclusion criteria, 16 published papers were found. All relevant articles on the topic have been included. Our review has shown that the benefits of SGLT2 inhibitors outweigh their risks. Their benefits include good glycemic control, HBA1c (glycated haemoglobin) reduction, weight loss, and blood pressure improvement. Furthermore, improvement in GFR and arterial efficacy is also significant. Side effects such as UTI (urinary tract infection) and genital infection have been observed, but their incidence is low. However, DKA (diabetic ketoacidosis) and hypoglycemia are severe side effects that should be highlighted. Hypoglycemia can be prevented by strictly monitoring blood sugar levels. The patient must be educated and counseled about DKA and its symptoms. This will ensure the safety of the patient as euglycemic DKA can prove fatal if not diagnosed earlier. So, SGLT2 inhibitors can be used as an effective drug to control blood sugar levels in type 1 diabetes, especially in patients with a BMI higher than 30. It will not only achieve the treatment goals but can also decrease the morbidity and mortality of the patients. However, more studies need to be done to fully understand DKA caused by SGLT2 inhibitors.
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43
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Pitocco D, Di Leo M, Tartaglione L, Rizzo EG, Caputo S, Rizzi A, Pontecorvi A. An Approach to Diabetic Ketoacidosis in an Emergency Setting. Rev Recent Clin Trials 2020; 15:278-288. [PMID: 32646361 DOI: 10.2174/1574887115666200709172402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/27/2020] [Accepted: 04/30/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Diabetic Ketoacidosis (DKA) is one of the most commonly encountered diabetic complication emergencies. It typically affects people with type 1 diabetes at the onset of the disease. It can also affect people with type 2 diabetes, although this is uncommon. METHODS Research and online content related to diabetes online activity is reviewed. DKA is caused by a relative or absolute deficiency of insulin and elevated levels of counter-regulatory hormones. RESULTS Goals of therapy are to correct dehydration, acidosis, and to reverse ketosis, gradually restoring blood glucose concentration to near normal. CONCLUSION It is essential to monitor potential complications of DKA and, if necessary, to treat them and any precipitating events.
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Affiliation(s)
- Dario Pitocco
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli, Roma, Italy
| | - Mauro Di Leo
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli, Roma, Italy
| | - Linda Tartaglione
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli, Roma, Italy
| | - Emanuele Gaetano Rizzo
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli, Roma, Italy
| | - Salvatore Caputo
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli, Roma, Italy
| | - Alessandro Rizzi
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli, Roma, Italy
| | - Alfredo Pontecorvi
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli, Roma, Italy
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44
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Abstract
PURPOSE OF REVIEW Diabetic ketoacidosis is a life-threatening complication of diabetes characterized by hyperglycemia, acidosis, and ketosis. Ketoacidosis may occur with blood glucose level < 200 mg/dl (improperly defined as euglycemic ketoacidosis, euKA) and also in people without diabetes. The absence of marked hyperglycemia can delay diagnosis and treatment, resulting in potential serious adverse outcomes. RECENT FINDINGS Recently, with the wide clinical use of sodium glucose co-transporter 2 inhibitors (SGLT2i), euKA has come back into the spotlight. Use of SGLT2i use can predispose to the development of ketoacidosis with relatively low or normal levels of blood glucose. This condition, however, can occur, in the absence of diabetes, in settings such as pregnancy, restriction on caloric intake, glycogen storage diseases or defective gluconeogenesis (alcohol abuse or chronic liver disease), and cocaine abuse. euKA is a challenging diagnosis for most physicians who may be misled by the presence of normal glycemia or mild hyperglycemia. In this article, we review pathophysiology, etiologies, clinical presentation and the management of euKA.
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Affiliation(s)
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Gian Paolo Fadini
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padova, Italy.
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45
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Morton A. Review article: Ketoacidosis in the emergency department. Emerg Med Australas 2020; 32:371-376. [PMID: 32266781 DOI: 10.1111/1742-6723.13503] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 03/09/2020] [Indexed: 01/05/2023]
Abstract
Diabetic ketoacidosis, a life-threatening complication of type 1 diabetes mellitus, is a common cause of presentation to EDs. Two new drug classes have been found to cause ketoacidosis with distinctive presentations. The sodium-glucose transport protein 2 inhibitors used in the management of type 2 diabetes mellitus may present with ketoacidosis with normal glucose levels. Ketoacidosis with these medications may be prolonged and recur after initial resolution. Checkpoint inhibitors may present with fulminant diabetic ketoacidosis in individuals with previously normal glucose tolerance. Ketoacidosis may also occur as a result of starvation and alcohol excess, as well as a number of rare causes. Other causes of metabolic acidosis with both high and normal anion gap need to be considered in the differential diagnosis of ketoacidosis. Diabetic ketoacidosis may also present with biochemical changes suggestive of myocardial ischaemia and pancreatitis in the absence of these pathologies. The present paper reviews ketone body metabolism, ketone testing and the causes and differential diagnosis of ketoacidosis with particular relevance to emergency medicine.
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Affiliation(s)
- Adam Morton
- Department of Endocrinology, Mater Health Services Brisbane, Brisbane, Queensland, Australia.,Department of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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46
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Dardano A, Miccoli R, Bianchi C, Daniele G, Del Prato S. Invited review. Series: Implications of the recent CVOTs in type 2 diabetes: Which patients for GLP-1RA or SGLT-2 inhibitor? Diabetes Res Clin Pract 2020; 162:108112. [PMID: 32198123 DOI: 10.1016/j.diabres.2020.108112] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 03/03/2020] [Indexed: 12/23/2022]
Abstract
Large cardiovascular outcome trials (CVOTs) have lent support to a cardiovascular protection with the use of SGLT2-inhibitors (SGLT2is) and GLP1-Receptor Agonists (GLP1-RAs) in subjects with type 2 diabetes. These two classes of novel glucose lowering agents have been shown to have a similar effect on the risk reduction of Major Adverse Cardiovascular Events (MACE: nonfatal myocardial infarction, nonfatal stroke, cardiovascular mortality). Nonetheless, they may not be simply interchangeable. Rather, careful evaluation of all the results of CVOTs leads identification of different effects that may allow profiling of the ideal individuals with T2DM who may benefit most from the use of one or the other class of agents. These differences include effect on heart failure, stroke and diabetic kidney disease that have prompt recent guidelines and recommendation for the treatment of type 2 diabetes to suggest the preferential use of SGLT2is in those with evidence of heart failure and impaired kidney function, while both SGLT2i and GLP1-RAs with proven effect could be use in those with prevalent atherosclerotic cardiovascular disease. This review discusses all these elements of differentiation along with others that in the future may help establishing the best cardiorenal benefit for individuals with T2DM.
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Affiliation(s)
- Angela Dardano
- Department of Clinical and Experimental Medicine, Section of Diabetes, Nuovo Ospedale Santa Chiara, University of Pisa, Pisa 56124, Italy
| | - Roberto Miccoli
- Department of Clinical and Experimental Medicine, Section of Diabetes, Nuovo Ospedale Santa Chiara, University of Pisa, Pisa 56124, Italy
| | - Cristina Bianchi
- Department of Clinical and Experimental Medicine, Section of Diabetes, Nuovo Ospedale Santa Chiara, University of Pisa, Pisa 56124, Italy
| | - Giuseppe Daniele
- Department of Clinical and Experimental Medicine, Section of Diabetes, Nuovo Ospedale Santa Chiara, University of Pisa, Pisa 56124, Italy
| | - Stefano Del Prato
- Department of Clinical and Experimental Medicine, Section of Diabetes, Nuovo Ospedale Santa Chiara, University of Pisa, Pisa 56124, Italy.
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Schwarzfuchs D, Rabaev E, Sagy I, Zimhony-Nissim N, Lipnitzki I, Musa H, Jotkowitz A, Brandstaetter E, Barski L. Clinical and Epidemiological Characteristics of Diabetic Ketoacidosis in Older Adults. J Am Geriatr Soc 2020; 68:1256-1261. [PMID: 32134118 DOI: 10.1111/jgs.16376] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 01/19/2020] [Accepted: 01/22/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Much of the research previously done on diabetic ketoacidosis (DKA) was based on a young population with type 1 diabetes mellitus (type 1 DM). But substantial numbers of DKA episodes occur in patients with a prior history of type 2 diabetes mellitus (type 2 DM). There is a lack of Data are lacking about DKA in older adults. The aims of this study were to analyze the clinical characteristics and outcomes of older adult patients with DKA. DESIGN Retrospective matched cohort study of adult patients hospitalized with DKA between 2004 and 2017. SETTING Soroka University Medical Center, Be'er Sheva, Israel. PARTICIPANTS The clinical characteristics of DKA patients 65 years and older were compared with patients younger than 65 years. MEASUREMENTS The primary outcome was in-hospital mortality. RESULTS The study cohort included 385 consecutive patients for whom the admission diagnosis was DKA: 307 patients (79.7%) younger than 65 years (group 1), and 78 patients (20.3%) older than 65 years (group 2). Patients in group 2 compared with group 1 had a significantly higher Charlson index (6 [6-6] vs 6 [6-7]; P < .0001) and DM with target organ damage (24.4% vs 6.2%; P < .0001). Patients in group 2 compared with group 1 had more serious disease according to results of laboratory investigations. The total in-hospital mortality rate of patients in group 2 was 16.7% compared with 1.6% in patients in group 1 in a sex and co-morbidities matched analysis (P = .001). CONCLUSIONS DKA in older adults is a common problem. The serious co-morbidities and precipitating factors such as infection/sepsis, myocardial infarction, and cerebrovascular accidents, may explain the severity of the problem of DKA in older adults and the high rate of mortality of these patients. DKA appears to be a lifethreatening condition in older adults. The alertness of physicians to DKA in older adults, timely diagnosis, proper treatment, and prevention are cornerstones of care. J Am Geriatr Soc 68:1256-1261, 2020.
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Affiliation(s)
- Dan Schwarzfuchs
- Department of Emergency Medicine, Soroka University Medical Center, Be'er Sheva, Israel
| | - Elena Rabaev
- Department of Internal Medicine F, Soroka University Medical Center, Be'er Sheva, Israel.,Beit Yona Home for Senior Citizens, Be'er Sheva, Israel
| | - Iftach Sagy
- Department of Internal Medicine F, Soroka University Medical Center, Be'er Sheva, Israel.,Clinical Research Center, Soroka University Medical Center, Be'er Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Noa Zimhony-Nissim
- Clinical Research Center, Soroka University Medical Center, Be'er Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Inna Lipnitzki
- Department of Internal Medicine F, Soroka University Medical Center, Be'er Sheva, Israel
| | - Hadeel Musa
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Alan Jotkowitz
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Evgenia Brandstaetter
- Department of Internal Medicine F, Soroka University Medical Center, Be'er Sheva, Israel
| | - Leonid Barski
- Department of Internal Medicine F, Soroka University Medical Center, Be'er Sheva, Israel
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48
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Fadini GP, Li Volsi P, Devangelio E, Poli M, Cazzetta G, Felace G, Avogaro A. Predictors of early discontinuation of dapagliflozin versus other glucose-lowering medications: a retrospective multicenter real-world study. J Endocrinol Invest 2020; 43:329-336. [PMID: 31515744 DOI: 10.1007/s40618-019-01110-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 09/03/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS In routine clinical practice, early discontinuation of newly initiated glucose-lowering medications (GLM) is relatively common. We herein evaluated if the clinical characteristics associated with early discontinuation of dapagliflozin were different from those associated with early discontinuation of other GLM. METHODS The DARWIN-T2D was a multicenter retrospective study conducted at diabetes specialist outpatient clinics in Italy. We included 2484 patients who were initiated on dapagliflozin in 2015-2016 and 14,801 patients who were initiated on other GLM (DPP-4 inhibitors, GLP-1 receptor agonists, or gliclazide) in the same period. After excluding patients who had not (yet) returned to follow-up, we compared the characteristics of patients who persisted on drug versus those who were no longer on drug at the first available follow-up after at least 3 months. RESULTS As compared to those who persisted on drug, patients who discontinued dapagliflozin (51.7%) were more often female, had higher baseline fasting plasma glucose (FPG), HbA1c, and eGFR, and less common use of metformin. Upon multiple regression, higher HbA1c, higher eGFR, and lower metformin use remained independently associated with early discontinuation. Among patients who had been initiated on other GLM, 41.7% discontinued. Variables independently associated with discontinuation were older age, longer diabetes duration, higher HbA1c, eGFR, and albumin excretion, more common use of insulin and less metformin. CONCLUSION In routine clinical practice, all variables associated with dapagliflozin discontinuation were also associated with discontinuation of other GLM. Thus, despite a distinctive mechanism of action and a peculiar tolerability profile, no specific predictor of dapagliflozin discontinuation was detected.
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Affiliation(s)
- G P Fadini
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy.
| | - P Li Volsi
- Ospedale di Pordenone - Azienda per l'Assistenza Sanitaria n.5, Friuli Occidentale, 33170, Pordenone, Italy
| | - E Devangelio
- Presidio Territoriale di Assistenza-Distretto Socio Sanitario di Massafra - Azienda Sanitaria Locale di Taranto, 74016, Massafra, Italy
| | - M Poli
- Ospedale Girolamo Fracastoro di San Bonifacio - Azienda ULSS n.9 Scaligera, 37047, San Bonifacio, Italy
| | - G Cazzetta
- Distretto Socio Sanitario Gagliano del Capo, sede Tricase - Azienda Sanitaria Locale di Lecce, 73039, Tricase, Italy
| | - G Felace
- Ospedale di Spilimbergo - Azienda per l'Assistenza Sanitaria n.5, Friuli Occidentale, 33170, Pordenone, Italy
| | - A Avogaro
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy
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49
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Bonora BM, Avogaro A, Fadini GP. Extraglycemic Effects of SGLT2 Inhibitors: A Review of the Evidence. Diabetes Metab Syndr Obes 2020; 13:161-174. [PMID: 32021362 PMCID: PMC6982447 DOI: 10.2147/dmso.s233538] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 12/24/2019] [Indexed: 12/13/2022] Open
Abstract
Patients with type 2 diabetes (T2D) are often overweight/obese and affected by arterial hypertension, dyslipidaemia, and have high serum levels of uric acid. Moreover, T2D patient have a higher risk of developing cardiovascular or renal complications, which are leading causes of morbidity and mortality in this population. Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are a new class of glucose-lowering medications that block the reabsorption of glucose in the kidney, thereby increasing urinary glucose excretion, and lowering blood glucose levels. The beneficial effects of SGLT2 inhibition extend beyond glycaemic control, and include improvement in blood pressure, body weight, uric acid concentrations, liver steatosis, oxidative stress, and inflammation. In dedicated cardiovascular outcome trials, SGLT2i treatment was associated with a significant reduction in the rate of cardiovascular events and renal endpoints. In this review, we summarize the evidence for extra-glycemic effects of SGLT2i and the potential mechanisms driving cardiorenal protection exerted by this class of medications.
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Affiliation(s)
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Padova35128, Italy
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50
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Hampp C, Swain RS, Horgan C, Dee E, Qiang Y, Dutcher SK, Petrone A, Chen Tilney R, Maro JC, Panozzo CA. Use of Sodium-Glucose Cotransporter 2 Inhibitors in Patients With Type 1 Diabetes and Rates of Diabetic Ketoacidosis. Diabetes Care 2020; 43:90-97. [PMID: 31601640 DOI: 10.2337/dc19-1481] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 09/16/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To estimate real-world off-label use of sodium-glucose cotransporter 2 (SGLT2) inhibitors in patients with type 1 diabetes, estimate rates of diabetic ketoacidosis (DKA), and compare them with DKA rates observed in sotagliflozin clinical trials. RESEARCH DESIGN AND METHODS We identified initiators of SGLT2 inhibitors in the Sentinel System from March 2013 to June 2018, determined the prevalence of type 1 diabetes using a narrow and a broad definition, and measured rates of DKA using administrative claims data. Standardized incidence ratios (SIRs) were calculated using age- and sex-specific follow-up time in Sentinel and age- and sex-specific DKA rates from sotagliflozin trials 309, 310, and 312. RESULTS Among 475,527 initiators of SGLT2 inhibitors, 0.50% and 0.92% met narrow and broad criteria for type 1 diabetes, respectively. Rates of DKA in the narrow and broad groups were 7.3/100 person-years and 4.5/100 person-years, respectively. Among patients who met narrow criteria for type 1 diabetes, rates of DKA were highest for patients aged 25-44 years, especially females aged 25-44 years (19.7/100 person-years). More DKA events were observed during off-label use of SGLT2 inhibitors in Sentinel than would be expected based on sotagliflozin clinical trials (SIR = 1.83; 95% CI 1.45-2.28). CONCLUSIONS Real-world off-label use of SGLT2 inhibitors among patients with type 1 diabetes accounted for a small proportion of overall SGLT2 inhibitor use. However, the risk for DKA during off-label use was notable, especially among young, female patients. Although real-word rates of DKA exceeded the expectation based on clinical trials, results should be interpreted with caution due to differences in study methods, patient samples, and study drugs.
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Affiliation(s)
- Christian Hampp
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - Richard S Swain
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - Casie Horgan
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Elizabeth Dee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Yandong Qiang
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - Sarah K Dutcher
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - Andrew Petrone
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Rong Chen Tilney
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Judith C Maro
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Catherine A Panozzo
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
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