Sodium-glucose cotransporter 2 inhibitor and sarcopenia in a lean elderly adult with type 2 diabetes: A case report

Long-term safety and efficacy of SGLT2 inhibitor use in older east Asians with type 2 diabetes

Sodium-glucose cotransporter 2 inhibitors (SGLT2is) have been shown in cardiovascular outcome trials to reduce the risk of heart failure and major adverse cardiovascular as well as renal events in individuals with type 2 diabetes. Moreover, clinical evidence indicates that SGLT2i use reduces heart failure and chronic kidney disease (CKD) in east Asian patients with type 2 diabetes. Thus, SGLT2is might seem to be the preferred treatment for older patients with type 2 diabetes even in the presence of multiple comorbidities. However, older patients with type 2 diabetes may well have impaired physiological function, making the risk of certain adverse events higher than that in the general population. While a randomized clinical trial has been conducted to evaluate changes in skeletal muscle mass and function as well as those in cognitive function with SGLT2i use in older Japanese individuals with type 2 diabetes who are otherwise healthy, the safety of SGLT2is remains to be established among older individuals with type 2 diabetes also having impaired activity of daily living and/or cognitive impairment. Even so, international and domestic consensus reports recommend SGLT2is for patients with type 2 diabetes and heart failure, CKD, and/or cardiovascular diseases, and SGLT2is are being widely prescribed by general practitioners to older individuals with type 2 diabetes with little regard to the patient's comorbidities. We maintain that SGLT2i use in older patients with type 2 diabetes should be prescribed cautiously in consideration of the pathophysiology of the disease and the presence of complications and comorbidities as well as the individual's lifestyle.

Efficacy and safety of the sodium-glucose co-transporter-2 inhibitor empagliflozin in elderly Japanese adults (≥65 years) with type 2 diabetes: A randomized, double-blind, placebo-controlled, 52-week clinical trial (EMPA-ELDERLY)

AIM

Use of sodium-glucose co-transporter-2 inhibitors (SGLT2is) for glycaemic control is increasing in individuals with type 2 diabetes (T2D) for their additional benefits on heart failure and chronic kidney disease. However, SGLT2is generally reduce body weight, which might promote sarcopenia in older individuals. We evaluated the effects of the SGLT2i empagliflozin on muscle mass and strength in addition to glucose control in elderly adults with T2D.

MATERIALS AND METHODS

Individuals with T2D aged ≥65 years with body mass index ≥22 kg/m2 and glycated haemoglobin (HbA1c) 7.0%-10.0% were randomized 1:1 to once-daily empagliflozin 10 mg or placebo for 52 weeks. The primary endpoint was change from baseline in HbA1c at week 52. Secondary endpoints included changes from baseline in muscle mass and strength.

RESULTS

Of the 129 individuals randomized, 72.4% were men, mean age 74.1 years, body mass index 25.6 kg/m2 and HbA1c 7.6%. The placebo-adjusted mean change from baseline in HbA1c at week 52 with empagliflozin was -0.57% [95% confidence interval (CI) -0.78, -0.36]. Change in body weight was -3.26 kg and -0.90 kg with empagliflozin and placebo, respectively (placebo-adjusted difference: -2.37 kg; 95% CI -3.07, -1.68). Placebo-adjusted change in muscle mass was -0.61 kg (95% CI -1.61, 0.39), fat mass -1.84 kg (95% CI -2.65, -1.04) and grip strength -0.3 kg (95% CI -1.1, 0.5).

CONCLUSIONS

Empagliflozin improved glucose control and reduced body weight without compromising muscle mass or strength in elderly adults with T2D in this trial.

The Effects of Sodium-Glucose Cotransporter 2 Inhibitors on Body Composition in Type 2 Diabetes Mellitus: A Narrative Review

Body composition is related to cardiometabolic disorders and is a major driver of the growing incidence of type 2 diabetes mellitus (T2DM). Altered fat distribution and decreased muscle mass are related to dysglycemia and impose adverse health-related outcomes in people with T2DM. Hence, improving body composition and maintaining muscle mass is crucial in T2DM. Sodium-glucose cotransporter 2 (SGLT2) inhibitors are novel glucose-lowering medications gaining popularity because of their cardiorenal-protective effects and weight-lowering characteristics. However, reports on myopathy secondary to SGLT2 inhibitor treatment raised a safety concern. The importance of maintaining muscle mass in people with T2DM necessitates further investigation to explore the impact of novel medications on body composition. In this review, we discussed current evidence on the impact of SGLT2 inhibitors on body composition in people with T2DM.

Sodium-glucose co-transporter 2 inhibitors and Sarcopenia: A controversy that must be solved

Diabetes mellitus is a risk factor for muscle loss and sarcopenia. Sodium-glucose co-transporter 2 inhibitors (SGLT2i) or "gliflozins" are one of the newest anti-hyperglycemic drugs. They reduce blood glucose levels by inhibiting renal glucose reabsorption in the early proximal convoluted tubule. Various randomized trials showed that SGLT2i have cardio-protective and reno-protective action. SGLT2i also affect body composition. They usually decrease body fat percentage, visceral and subcutaneous adipose tissue. However, regarding the muscle mass, there are conflicting findings some studies showing detrimental effects and others showed neutral or beneficial effects. This issue is extremely important not only because of the wide use of SGLT2i around globe; but also skeletal muscle mass consumes large amounts of calories during exercise and is an important determinant of resting metabolic rate and skeletal muscle loss hinders energy consumption leading to obesity. In this systematic review, we extensively reviewed the experimental and clinical studies regarding the impact of SGLT2i on muscle mass and related metabolic alterations. Importantly, studies are heterogeneous and there is unmet need to highlight the alterations in muscle during SGLT2i use.

Relationship between sodium-glucose cotransporter-2 inhibitors and muscle atrophy in patients with type 2 diabetes mellitus: a systematic review and meta-analysis

Aim

This study aims to assess the association between sodium-glucose cotransporter type-2 inhibitor (SGLT-2i) treatment and muscle atrophy in patients with type 2 diabetes mellitus (T2DM).

Methods

We searched six databases from 1 January 2012 to 1 May 2023, without language restrictions. The primary outcome was muscle. Secondary outcomes were weight loss, weakness, malaise, or fatigue. Subgroup analyses were performed according to different definitions of muscle, treatment duration, and measurement methods. The quality of the studies was assessed using the Cochrane tool. The quality of the evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool.

Results

Nineteen randomized controlled trials (RCTs) involving 1,482 participants were included. Compared with the control group, a meta-analysis showed that T2DM participants in the group treated with SGLT-2i demonstrated statistically significant reductions in lean body mass of 0.66 (95% confidence interval (CI), -1.05 to -0.27; p = 0.0009) and skeletal muscle mass of 0.35 (95% CI, -0.66 to -0.04; p = 0.03). No deaths or serious adverse events were reported. The quality of evidence in the included trials was low.

Conclusions

SGLT-2i may lead to a reduction in muscle strength in the treatment of T2DM compared to the control group. However, there is still a lack of high-quality evidence to evaluate muscle atrophy caused by SGLT-2i.

Systematic review registration

https://inplasy.com/inplasy-2022-12-0061/, identifier 2022120061.

Exercise mitigates Dapagliflozin-induced skeletal muscle atrophy in STZ-induced diabetic rats

BACKGROUND

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are commonly used in the management of type 2 diabetes mellitus (T2DM) and have been found to worsen the reduction of skeletal muscle mass in individuals with T2DM. This study aims to examine the potential of exercise in mitigating the skeletal muscle atrophy induced by SGLT2i treatment.

METHODS

A rat model of T2DM (40 male Sprague-Dawley rats; T2DM induced by a combination of high-fat diet and streptozotocin) was used to examine the effects of six-week treatment with Dapagliflozin (DAPA, SGLT2i) in combination with either aerobic exercise (AE) or resistance training (RT) on skeletal muscle. T2DM-eligible rats were randomized into the T2DM control group (CON, n = 6), DAPA treatment group (DAPA, n = 6), DAPA combined with aerobic exercise intervention group (DAPA + AE, n = 6), and DAPA combined with resistance training intervention group (DAPA + RT, n = 6). To assess the morphological changes in skeletal muscle, myosin ATPase and HE staining were performed. mRNA expression levels of Atrogin-1, MuRF1, and Myostatin were determined using quantitative PCR. Furthermore, protein expression levels of AKT, p70S6K, mTOR, FoXO1/3A, NF-κB, and MuRF1 were examined through western blotting.

RESULTS

Both the administration of DAPA alone and the combined exercise intervention with DAPA resulted in significant reductions in blood glucose levels and body weight in rats. However, DAPA alone administration led to a decrease in skeletal muscle mass, whereas RT significantly increased skeletal muscle mass and muscle fiber cross-sectional area. The DAPA + RT group exhibited notable increases in both total protein levels and phosphorylation levels of AKT and p70S6K in skeletal muscle. Moreover, the DAPA, DAPA + AE, and DAPA + RT groups demonstrated downregulation of protein expression (FoXO1/3A) and mRNA levels (Atrogin-1, MuRF1, and Myostatin) associated with muscle atrophy.

CONCLUSIONS

Our findings provide support for the notion that dapagliflozin may induce skeletal muscle atrophy through mechanisms unrelated to protein metabolism impairment in skeletal muscle, as it does not hinder protein metabolic pathways while reduces muscle atrophy-related genes. Additionally, our observations reveal that RT proves more effective than AE in enhancing skeletal muscle mass and muscle fiber cross-sectional area in rats with T2DM by stimulating protein anabolism within the skeletal muscle.

Adverse events and drug-drug interactions of sodium glucose co-transporter 2 inhibitors in patients treated for heart failure

INTRODUCTION

Sodium glucose co-transporter 2-inhibitors (SGLT2-I), antihyperglycemic agents, are increasingly prescribed in chronic heart failure (CHF). Their risk for drug-drug interactions (DDI) seems low. Safety-data derive mainly from diabetes-patients. This review aims to summarize adverse-events (AE) and DDI of the SGLT2-I dapagliflozin, empagliflozin and sotagliflozin in patients with CHF.

AREAS COVERED

Literature-search-terms in PubMed were 'adverse event/drug-drug interaction' and 'heart failure AND 'dapagliflozin' OR 'empagliflozin' OR 'sotagliflozin.'AEreported in randomized controlled trials (RCT) comprisegenitaland urinary-tract infections, hypotension, ketoacidosis, renal impairment, hypoglycemia, limb-amputations, Fournier's gangrene, bone-fractures, hepatopathy, pancreatitis, diarrhea, malignancy and venous thromboembolism. Their incidence is largely unknown, since they were not consistently evaluated in RCT of CHF. Further AE from meta-analyses, pharmacovigilance reports, case-series and case-reports include erythrocytosis, hypertriglyceridemia, myopathy, sarcopenia, skin problems, ventricular tachycardia, and urinary retention. The maximal observation period of RCT in CHF was 26 months.DDI were mainly studied in healthy volunteers for 3-8 days. In CHF or diabetes-patients, DDI were reported with interleukin-17-inhibitors, linezolid, lithium, tacrolimus, valproate, angiotensin-receptor-neprilysin-inhibitors and intravenous iron.

EXPERT OPINION

Guidelines recommend treatment with SGLT2-I for CHF but no data on AE during long-term therapy and only little information on DDI are available, which stresses the need for further research. Evidence-based recommendations for ketoacidosis-prevention are desirable.

Effect of SGLT-2 inhibitors on body composition in patients with type 2 diabetes mellitus: A meta-analysis of randomized controlled trials

OBJECTIVE

Type 2 diabetes mellitus(T2DM) is closely related to sarcopenic obesity(SO). Body composition measurement including body weight, body mass index, waist circumference, percentage body fat, fat mass, muscle mass, visceral adipose tissue and subcutaneus adipose tissue, plays a key role in evaluating T2DM and SO. The weight reduction effect of sodium-glucose cotransporter 2(SGLT-2) inhibitors has been demonstrated. However, there are warnings that SGLT-2 inhibitors should be used with caution because they may increase the risk of sarcopenia. The effect of SGLT-2 inhibitors on body composition in T2DM is inconclusive. In this work, a meta-analysis of randomized controlled trials was conducted to evaluate the effect of SGLT-2 inhibitors on body composition in T2DM.

METHODS

PubMed, the Cochrane Library, EMbase and Web of Science databases were searched by computer. All statistical analyses were carried out with Review Manager version 5. 3. Results were compared by weight mean difference(WMD), with 95% confidence intervals(CI) for continuous outcomes. A random effects model was applied regardless of heterogeneity. The I2 statistic was applied to evaluate the heterogeneity of studies. Publication bias was assessed using Funnel plots.

RESULTS

18 studies with 1430 participants were eligible for the meta-analysis. SGLT-2 inhibitors significantly reduced body weight(WMD:-2. 73kg, 95%CI: -3. 32 to -2. 13, p<0. 00001), body mass index(WMD:-1. 13kg/m2, 95%CI: -1. 77 to -0. 50, p = 0. 0005), waist circumference(WMD:-2. 20cm, 95%CI: -3. 81 to -0. 58, p = 0. 008), visceral fat area(MD:-14. 79cm2, 95%CI: -24. 65 to -4. 93, p = 0. 003), subcutaneous fat area(WMD:-23. 27cm2, 95% CI:-46. 44 to -0. 11, P = 0. 05), fat mass(WMD:-1. 16kg, 95%CI: -2. 01 to -0. 31, p = 0. 008), percentage body fat(WMD:-1. 50%, 95%CI:-2. 12 to -0. 87, P<0. 00001), lean mass(WMD:-0. 76kg, 95%CI:-1. 53 to 0. 01, P = 0. 05) and skeletal muscle mass(WMD:-1. 01kg, 95%CI:-1. 91 to -0. 11, P = 0. 03).

CONCLUSION

SGLT-2 inhibitors improve body composition in T2DM including body weight, body mass index, waist circumference, visceral fat area, subcutaneous fat area, percentage body fat and fat mass reduction, but cause adverse effects of reducing muscle mass. Therefore, until more evidence is obtained to support that SGLT-2 inhibitors increase the risk of sarcopenia, not only the benefit on body composition, but also the adverse effect of the reduction in muscle mass by SGLT-2 inhibitors in T2DM should be considered.

The concept of aggressive nutrition therapy and clinical indication: A position paper

Aggressive nutrition therapy is a nutritional management method that sets energy intake requirements by adding the amount of energy accumulated to energy consumption. It is used to treat patients with undernutrition and sarcopenia. However, evidence for aggressive nutrition therapy is insufficient, and validation through high-quality clinical research is essential. Therefore, this paper aimed to clarify the concept of aggressive nutrition therapy, present indications and contraindications; and describe the effects, limitations, and the need to individualize aggressive nutrition therapy for different pathological conditions. Aggressive nutrition therapy should be accompanied by the etiology of undernutrition, sarcopenia, and nutritional metabolism in various states. In addition to calculating nutritional requirements, the nutritional management methods of oral intake, tube feeding, and parenteral nutrition should be appropriately selected. A nutrition plan with the amount of energy accumulated should also be a vital issue. This position paper was authored by the Registered Dietitian Subcommittee of the Japanese Association of Rehabilitation Nutrition and was approved by the Japanese Association of Rehabilitation Nutrition.

Dapagliflozin for the treatment of chronic kidney disease

INTRODUCTION

Sodium-dependent glucose cotransporter 2 (SGLT2) is a glucose transporter expressed on the proximal tubular cells, where it reabsorbs glucose from the glomerular filtrate. SGLT2 inhibitors (SGLT2is), initially developed as an antidiabetic drug, have recently attracted considerable attention because they have cardiorenal protective effects. Among SGLT2is, dapagliflozin was the first to demonstrate the renoprotective effect in patients with and without diabetes and has been approved for chronic kidney disease (CKD) treatment.

AREAS COVERED

This review covers the pharmacological characteristics and the clinical efficacy and safety profiles of dapagliflozin, including comparison with other SGLT2is and risk modification strategies.

EXPERT OPINION

In DAPA-CKD, dapagliflozin reduced the primary outcome (≥50% estimated glomerular filtration rate [eGFR] decline, end-stage kidney disease [ESKD], or renal or cardiovascular [CV] death) by 39% in CKD patients. This beneficial effect was consistent across prespecified subgroups, including those based on the presence of diabetes. Dapagliflozin also decreased the CV composite outcome and all-cause death by 29% and 31%, respectively. Although an increased risk of adverse events such as ketoacidosis and volume depletion has been reported, the robust renal and CV benefits of dapagliflozin are expected to outweigh potential risks. SGLT2is, including dapagliflozin, will constitute the mainstay of CKD treatment.

Hypoglycaemic therapy in frail older people with type 2 diabetes mellitus-a choice determined by metabolic phenotype

Frailty is a newly emerging complication of diabetes in older people and increasingly recognised in national and international clinical guidelines. However, frailty remains less clearly defined and frail older people with diabetes are rarely characterised. The general recommendation of clinical guidelines is to aim for a relaxed glycaemic control, mainly to avoid hypoglycaemia, in this often-vulnerable group of patients. With increasing age and development of frailty, body composition changes are characterised by an increase in visceral adipose tissue and a decrease in body muscle mass. Depending on the overall body weight, differential loss of muscle fibre types and body adipose/muscle tissue ratio, the presence of any associated frailty can be seen as a spectrum of metabolic phenotypes that vary in insulin resistance of which we have defined two specific phenotypes. The sarcopenic obese (SO) frail phenotype with increased visceral fat and increased insulin resistance on one side of spectrum and the anorexic malnourished (AM) frail phenotype with significant muscle loss and reduced insulin resistance on the other. In view of these varying metabolic phenotypes, the choice of hypoglycaemic therapy, glycaemic targets and overall goals of therapy are likely to be different. In the SO phenotype, weight-limiting hypoglycaemic agents, especially the new agents of GLP-1RA and SGLT-2 inhibitors, should be considered early on in therapy due to their benefits on weight reduction and ability to achieve tight glycaemic control where the focus will be on the reduction of cardiovascular risk. In the AM phenotype, weight-neutral agents or insulin therapy should be considered early on due to their benefits of limiting further weight loss and the possible anabolic effects of insulin. Here, the goals of therapy will be a combination of relaxed glycaemic control and avoidance of hypoglycaemia; and the focus will be on maintenance of a good quality of life. Future research is still required to develop novel hypoglycaemic agents with a positive effect on body composition in frailty and improvements in clinical outcomes.

The current role of sodium-glucose cotransporter 2 inhibitors in type 2 diabetes mellitus management

Type 2 diabetes mellitus (T2DM) is a chronic, complex metabolic disease characterized by chronic hyperglycemia causing from insufficient insulin signaling because of insulin resistance or defective insulin secretion, and may induce severe complications and premature death. Sodium-glucose cotransporter-2 (SGLT2) inhibitors are oral drugs used to reduce hyperglycemia in patients with T2DM, including empagliflozin, ertugliflozin, dapagliflozin and canagliflozin. The primary objective of this article is to examine the clinical benefit, safety, and tolerability of the four SGLT2 inhibitors approved by the US FDA. SGLT2 inhibitors increase urinary glucose excretion via inhibiting SGLT2 to decrease renal reabsorption of filtered glucose and reduce the renal threshold for glucose. Rather than stimulating insulin release, SGLT2 inhibitors improve β-cell function by improving glucotoxicity, as well as reduce insulin resistance and increase insulin sensitivity. Early clinical trials have confirmed the beneficial effects of SGLT2 in T2DM with acceptable safety and excellent tolerability. In recent years, SGLT2 inhibitors has been successively approved by the FDA to decrease cardiovascular death and decrease the risk of stroke and cardiac attack in T2DM adults who have been diagnosed with cardiovascular disease, treating heart failure (HF) with reduced ejection fraction and HF with preserved ejection fraction, and treat diabetic kidney disease (DKD), decrease the risk of hospitalization for HF in T2DM and DKD patients. SGLT2 inhibitors are expected to be an effective treatment for T2DM patients with non alcoholic fatty liver disease. SGLT2 inhibitors have a similar safety profile to placebo or other active control groups, with major adverse events such as Ketoacidosis or hypotension and genital or urinary tract infections.

Skeletal muscle as a treatment target for older adults with diabetes mellitus: The importance of a multimodal intervention based on functional category

Although the lifespan of people with diabetes has increased in many countries, the age-related increase in comorbidities (sarcopenia, frailty and disabilities) and diabetic complications has become a major issue. Diabetes accelerates the aging of skeletal muscles and blood vessels through mechanisms, such as increased oxidative stress, chronic inflammation, insulin resistance, mitochondrial dysfunction, genetic polymorphism (fat mass and obesity-associated genes) and accumulation of advanced glycation end-products. Diabetes is associated with early onset, and progression of muscle weakness and sarcopenia, thus resulting in diminished daily life function. The type and duration of diabetes, insulin section/resistance, hyperglycemia, diabetic neuropathy, malnutrition and low physical activity might affect muscular loss and weakness. To prevent the decline in daily activities in older adults with diabetes, resistance training or multicomponent exercise should be recommended. To maintain muscle function, optimal energy and sufficient protein intake are necessary. Although no specific drug enhances muscle mass and function, antidiabetic drugs that increase insulin sensitivity or secretion could be candidates for improvement of sarcopenia. The goals of glycemic control for older patients are determined based on three functional categories through an assessment of cognitive function and activities of daily living, and the presence or absence of medications that pose a hypoglycemic risk. As these functional categories are associated with muscle weakness, frailty and mortality risk, providing multimodal interventions (exercise, nutrition, social network or support and optimal medical treatment) is important, starting at the category II stage for maintenance or improvement in daily life functions. Geriatr Gerontol Int 2022; ••: ••-••.

Rehabilitation nutrition for individuals with frailty, disability, sarcopenic dysphagia, or sarcopenic respiratory disability

PURPOSE OF REVIEW

We describe the recent advances in rehabilitation nutrition, which is especially important for disabled or frail older individuals.

RECENT FINDINGS

Recent evidence pertaining to rehabilitation nutrition conducted in rehabilitation wards and acute care hospitals has been accumulating. The combination of rehabilitation nutrition and rehabilitation pharmacotherapy is important for eliciting higher functions. The 2020 update of the clinical practice guidelines for rehabilitation nutrition provides a weak recommendation for enhanced nutritional care for patients with cerebrovascular disease, hip fracture, cancer, or acute illness who are undergoing rehabilitation. Rehabilitation nutritional care process and the International Classification of Functioning, Disability and Health-Dietetics are used to implement high-quality rehabilitation nutrition. Aggressive nutrition therapy incorporates the daily energy expenditure plus daily energy accumulation to increase body weight and muscle mass. Preventing and treating sarcopenic dysphagia should include iatrogenic sarcopenia prevention and aggressive nutrition therapy. The diagnosis criteria for respiratory sarcopenia and sarcopenic respiratory disability have been established.

SUMMARY

The International Association of Rehabilitation Nutrition and Total Nutrition Therapy Rehabilitation program may contribute to international expansion of rehabilitation nutrition. Improving evidence-practice gaps in rehabilitation nutrition and increasing national health insurance coverage of aggressive nutrition therapy and rehabilitation nutrition teams are warranted.

Overestimation of glomerular filtration rate calculated from creatinine as compared with cystatin C in patients with type 2 diabetes receiving sodium-glucose cotransportor 2 inhibitors

AIM

The aim of this cross-sectional study is to compare creatinine-based estimated glomerular filtration rate (eGFRcr) and cystatin C-based estimated glomerular filtration rate (eGFRcys) between patients with type 2 diabetes receiving and not receiving sodium-glucose cotransporter 2 (SGLT2) inhibitors.

METHODS

The plasma specimens from 90 patients with type 2 diabetes who had been receiving SGLT2 inhibitors for at least 24 weeks (SGLT2 inhibitors group) were selected. Meanwhile, the plasma specimens from age-, sex- and BMI-matched patients with type 2 diabetes not receiving SGLT2 inhibitors (non-SGLT2 inhibitors group) in 1:1 matching were also selected for comparison. eGFRcr and eGFRcys were calculated using the Chronic Kidney Disease Epidemiology Collaboration equation.

RESULTS

When compared with the non-SGLT2 inhibitors group, eGFRcr was significantly higher in the SGLT2 inhibitors group (70.54 ± 24.87 vs. 79.95 ± 19.57 mL/min/1.73 m² , p = 0.014) while eGFRcys was not different (66.32 ± 24.98 vs 69.17 ± 20.10 ml/min/1.73 m² , p = 0.401). Based on eGFRcr, the chronic kidney disease (CKD) stage in the SGLT2 inhibitors group was lower than that in the non-SGLT2 inhibitors group, but it was not different when CKD stage was classified by eGFRcys. The difference between eGFRcr and eGFRcys (eGFRcr-cys) was significantly higher in the SGLT2 inhibitors group (4.22 ± 11.20 vs. 10.78 ± 10.42 ml/min/1.73 m² , p < 0.001). In male patients, there was significant correlation between the eGFRcr-cys and duration of receiving SGLT-2 inhibitors (r = 0.398, p = 0.004). This correlation was not found in female patients.

CONCLUSIONS

There was a discrepancy between eGFRcr and eGFRcys in patients with type 2 diabetes receiving SGLT2 inhibitors when compared with those not receiving SGLT2 inhibitors.

Sodium-glucose co-transporter 2 inhibitors on weight change and cardiometabolic profiles in individuals with overweight or obesity and without diabetes: A meta-analysis

Several meta-analyses have been conducted to evaluate the weight loss effect of sodium-glucose cotransporter 2 (SGLT-2) inhibitors in patients with type 2 diabetes, whereas pooled analysis focusing on individuals without diabetes is lacking. The objective of this systematic review and meta-analysis is to evaluate the effect of SGLT-2 inhibitor monotherapy on weight change and cardiometabolic profiles. Multiple databases were searched for randomized controlled trials reporting weight change effect of SGLT-2 inhibitor treatment compared with placebo for more than 12 weeks among individuals with overweight or obesity and without diabetes. A total of eight randomized controlled trials with 750 subjects were identified. SGLT-2 monotherapy was associated with significant reduction in body weight of -2.32 kg, compared to -1.01 kg for placebo, giving a mean difference of -1.31 kg. Significant reductions in body mass index and fasting blood glucose were observed, but not for the changes in waist circumference, fat mass, blood pressure, and lipid profile compared with placebo. SGLT-2 inhibitor monotherapy for 12 weeks or more can result in modest weight loss among people with overweight or obesity and without diabetes. Depending on pre-existing comorbidities or risk factors, SGLT-2 inhibitors can be considered adjuncts in the treatment of obesity.

Polypharmacy and Malnutrition Management of Elderly Perioperative Patients with Cancer: A Systematic Review

Malnutrition, which commonly occurs in perioperative patients with cancer, leads to decreased muscle mass, hypoalbuminemia, and edema, thereby increasing the patient's risk of various complications. Thus, the nutritional management of perioperative patients with cancer should be focused on to ensure that surgical treatment is safe and effective, postoperative complications are prevented, and mortality is reduced. Pathophysiological and drug-induced factors in elderly patients with cancer are associated with the risk of developing malnutrition. Pathophysiological factors include the effects of tumors, cachexia, and anorexia of aging. Metabolic changes, such as inflammation, excess catabolism, and anabolic resistance in patients with tumor-induced cancer alter the body's ability to use essential nutrients. Drug-induced factors include the side effects of anticancer drugs and polypharmacy. Drug-drug, drug-disease, drug-nutrient, and drug-food interactions can significantly affect the patient's nutritional status. Furthermore, malnutrition may affect pharmacokinetics and pharmacodynamics, potentiate drug effects, and cause side effects. This review outlines polypharmacy and malnutrition, the impact of malnutrition on drug efficacy, drug-nutrient and drug-food interactions, and intervention effects on polypharmacy or cancer cachexia in elderly perioperative patients with cancer.

Rationale and design of the EMPA-ELDERLY trial: a randomised, double-blind, placebo-controlled, 52-week clinical trial of the efficacy and safety of the sodium-glucose cotransporter-2 inhibitor empagliflozin in elderly Japanese patients with type 2 diabetes

INTRODUCTION

Elderly people (≥65 years) with type 2 diabetes mellitus (T2DM) are becoming increasingly prevalent, notably in Japan. As cardiovascular (CV) risk increases with age and sodium-glucose cotransporter-2 (SGLT2) inhibitors reduce CV risk, elderly patients with T2DM are increasingly likely to be prescribed these glucose-lowering drugs. There is controversy surrounding the effects of SGLT2 inhibitors on muscle mass, particularly in elderly patients for whom loss of muscle is especially undesirable; however, robust evidence on this important issue is lacking. Consequently, we have designed a clinical trial of the SGLT2 inhibitor empagliflozin in elderly Japanese patients with T2DM (Empagliflozin in Elderly T2DM Patients (EMPA-ELDERLY)) to assess its effects on body composition as well as glycaemic control. EMPA-ELDERLY will be the first randomised clinical trial of an SGLT2 inhibitor in elderly patients with T2DM to evaluate effects on skeletal muscle mass, muscle strength and physical performance concurrently.

METHODS AND ANALYSIS

EMPA-ELDERLY is a randomised, double-blind, placebo-controlled, parallel-group clinical trial to be conducted in Japan. Patients with T2DM aged ≥65 years are eligible if they are Japanese with a body mass index of ≥22 kg/m² and glycated haemoglobin (HbA1c) levels from ≥7.0% to ≤10.0% from either diet and exercise alone or treatment with oral glucose-lowering drugs. Approximately 128 participants will be randomised 1:1 to once per day, oral, double-blind treatment with empagliflozin 10 mg or matching placebo for 52 weeks. The primary endpoint is the change in HbA1c level from baseline at week 52. Secondary endpoints include changes from baseline to 52 weeks in body composition, including muscle mass and body fat, measured by bioelectrical impedance analysis, as well as skeletal muscle index, grip strength and time in the five-time chair stand test. Other endpoints include changes in patient-reported outcomes (including quality of life), cognitive function and safety.

ETHICS AND DISSEMINATION

We will submit the trial results to conferences and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04531462.

Myopathy Associated With Statins and SGLT2 - A Review of Literature

Drug-induced myopathy is a well-described clinical entity characterized by muscle damage leading to symptoms ranging from myalgias to rhabdomyolysis and acute kidney injury. Many pharmacotherapies are known to precipitate myopathic symptoms. Recent case reports suggest a potential relationship between the use of sodium/glucose cotransport 2 (SGLT2) inhibitors and onset of myopathy. The pathogenesis of this has yet to be elucidated. The relevance of this association is augmented by the recent popularity of SGLT2 inhibitors as well as the tendency for them to be prescribed alongside statins. This study reviewed the literature on the incidence and mechanism of drug-induced myopathy in patients with type 2 diabetes mellitus who are taking SGLT2 inhibitors with and without the use of statins.

The Impact of Antidiabetic Agents on Sarcopenia in Type 2 Diabetes: A Literature Review

Sarcopenia is a geriatric syndrome characterized by decline of skeletal muscle mass and function. Contributing factors include nutritional, genetic, inflammatory, and endocrinal factors. The reported prevalence of sarcopenia in type 2 diabetes mellitus is high, especially in patients with poor glycemic control. Additionally, antidiabetic agents may alter the balance between protein synthesis and degradation through various mechanisms of skeletal muscle mass regulation. This study reviewed the literature on the pathogenesis of sarcopenia in diabetes mellitus and the current understanding of whether antidiabetic agents contribute positively or negatively to sarcopenia and muscle wasting.