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Kushner P, Khunti K, Cebrián A, Deed G. Early Identification and Management of Chronic Kidney Disease: A Narrative Review of the Crucial Role of Primary Care Practitioners. Adv Ther 2024; 41:3757-3770. [PMID: 39162984 PMCID: PMC11399210 DOI: 10.1007/s12325-024-02957-z] [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: 05/17/2024] [Accepted: 07/25/2024] [Indexed: 08/21/2024]
Abstract
Early-stage (stage 1-3) chronic kidney disease (CKD) has an asymptomatic presentation such that most people with CKD are unaware of their disease status and remain undiagnosed. CKD is associated with multiple long-term conditions (MLTC), or multimorbidity, the most common of these being cardiovascular disease, hypertension, and type 2 diabetes. Primary care practitioners (PCPs) are crucial in the early identification and management of patients with CKD. For individuals at high risk of CKD, measurements of estimated glomerular filtration rate, urine albumin-creatinine ratio, and blood pressure should be obtained regularly and recorded in a timely manner. The importance of lifestyle changes in the prevention and management of CKD should also be highlighted. A recent addition to the treatment of CKD in people with and without type 2 diabetes has been the recommendation by clinical practice guidelines of a sodium-glucose co-transporter 2 (SGLT2) inhibitor alongside a renin-angiotensin-aldosterone system inhibitor as foundational therapy. SGLT2 inhibitors prevent CKD progression and reduce fatal and non-fatal kidney and cardiovascular events, hospitalization for heart failure, and all-cause mortality, and they have a favorable safety and tolerability profile. However, uptake has been slow, particularly in people with CKD without type 2 diabetes. A multifaceted approach is required to ensure that people with CKD receive optimal kidney protection. Measures to raise awareness of the importance of early identification and intervention include local/national campaigns via social media and practice-based education; clinical education programs; integration of clinical decision support tools into electronic health records; detection programs built around electronic health records; and good interdisciplinary communication. PCPs at the forefront of multidisciplinary care are best placed to implement the evidence-based clinical practice CKD guidelines for lifestyle modification and guideline-directed medical therapy.
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Affiliation(s)
- Pamela Kushner
- Department of Family Medicine, University of California Irvine Medical Center, Orange, CA, 92868, USA.
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Ana Cebrián
- Primary Care Center Cartagena Casco, Cartagena, Murcia, Spain
- Biomedical Research Institute of Murcia (IMIB), 30120, Murcia, Spain
| | - Gary Deed
- HealthCarePlus Medical Centre, Carindale, QLD, 4152, Australia
- Monash University, Clayton, VIC, 3800, Australia
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2
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Garg R, Sood N, Bansal O, Hoskote A. Euglycemic Ketoacidosis Associated with SGLT-2 Inhibitors in Non-diabetic Patients-A Narrative Review. J Gen Intern Med 2024:10.1007/s11606-024-09073-2. [PMID: 39354257 DOI: 10.1007/s11606-024-09073-2] [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: 06/11/2024] [Accepted: 09/21/2024] [Indexed: 10/04/2024]
Abstract
Euglycemic ketoacidosis is an acute, life-threatening emergency that is characterized by euglycemia, metabolic acidosis, and ketonemia. It is a well-recognized adverse event in diabetic patients taking sodium-glucose cotransporter-2 inhibitor (SGLT-2 inhibitor). However, there is limited data on SGLT-2 inhibitor-related euglycemic ketoacidosis in non-diabetic patients. The mechanism behind SGLT-2 inhibitor-associated euglycemic ketoacidosis involves a general state of starvation or relative insulin deficiency, which exacerbates the mild baseline ketonemia caused by this class of medications while normoglycemia is maintained. The incidence of euglycemic ketoacidosis will likely increase with the increasing use of SGLT-2 inhibitors for various indications in addition to diabetes mellitus type 2, predominantly for congestive heart failure (CHF). Recognizing the signs and symptoms of this life-threatening condition is essential to treat it effectively. Our objective is to comprehensively revisit the pathophysiology of euglycemic ketoacidosis associated with SGLT-2 inhibitors and the risk factors for the condition, review the available data, and summarize the reported cases of euglycemic ketoacidosis in non-diabetic patients on SGLT-2 inhibitors. Our literature search identified five articles with six cases of euglycemic ketoacidosis in non-diabetic patients who were on SGLT-2 inhibitors for heart failure with reduced ejection fraction. The common risk factor in five out of the six cases was decreased oral intake due to acute illness, fasting, or a perioperative state.
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Affiliation(s)
- Rohini Garg
- Department of Internal Medicine, CHI Health Mercy Hospital, Council Bluffs, IA, USA.
| | - Nikhil Sood
- Department of Medicine, Banner Health, Banner Gateway Medical Center, Gilbert, AZ, USA
| | - Ojas Bansal
- Department of Cardiology, Banner Desert Medical Center, Mesa, AZ, USA
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3
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Kent T, Loughran J, Halim B, Fourlanos S, Hayes L, Kyi M. Examining capillary ketone testing in hospitalised patients: indications and outcomes. Intern Med J 2024; 54:1572-1576. [PMID: 39194184 DOI: 10.1111/imj.16490] [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: 04/03/2024] [Accepted: 07/24/2024] [Indexed: 08/29/2024]
Abstract
Elevated blood ketone levels (ketosis) in inpatients with diabetes can herald diabetic ketoacidosis (DKA). However, ketosis can also occur in individuals without diabetes in certain settings. It is unclear what proportion of inpatients with ketosis are in DKA and which patients are at the highest risk of DKA. This study determined that many ketone tests are performed in individuals at low risk of DKA, and a β-hydroxybutyrate <1.0 mmol/L had a low incidence of DKA and less need for escalation in their management.
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Affiliation(s)
- Thomas Kent
- Northern Health, Melbourne, Victoria, Australia
| | | | - Bella Halim
- Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Spiros Fourlanos
- Diabetes and Endocrinology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Medicine at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia
- Australian Centre for Accelerating Diabetes Innovations, The University of Melbourne, Melbourne, Victoria, Australia
| | | | - Mervyn Kyi
- Northern Health, Melbourne, Victoria, Australia
- Diabetes and Endocrinology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Medicine at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia
- Australian Centre for Accelerating Diabetes Innovations, The University of Melbourne, Melbourne, Victoria, Australia
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4
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Meier M, Ansong B, Awobusuyi D, Lee-Oyagha R, Lopez S. Sodium-Glucose Co-Transporter-2 (SGLT2) Inhibitor-Related Euglycemic Diabetic Ketoacidosis: A Case Series. J Pharm Pract 2024:8971900241273169. [PMID: 39123293 DOI: 10.1177/08971900241273169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2024]
Abstract
Objectives: Sodium-glucose transporter-2 inhibitors (SGLT2i) are commonly used for the treatment of Type 2 Diabetes Mellitus, offering additional benefits in non-diabetic patients with conditions such as chronic kidney disease and heart failure. However, SGLT2i have been associated with an increased risk of euglycemic diabetic ketoacidosis (DKA). This case series describes three cases of patients who developed euglycemic DKA while taking SGLT2i. Key Findings: Each of the three patients with euglycemic DKA were taking SGLT2i for the treatment of diabetes and all had additional risk factors for the development of DKA. These factors included reduced oral intake, major acute illness, chronic pancreatitis, and a history of previous DKA episodes. Unfortunately, the absence of hallmark symptoms like hyperglycemia, polyuria, and polydipsia led to delayed diagnosis of euglycemic DKA in two of the three patients. Conclusion: Early recognition of risk factors and a high level of suspicion are critical in identifying euglycemic DKA in patients taking SGLT2i. Healthcare providers should conduct thorough medication reconciliation upon admission and closely monitor patients for concurrent issues, especially in cases of minimal oral intake, acute illnesses, and chronic pancreatitis. Prompt diagnosis and management of euglycemic DKA can significantly improve patient outcomes.
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Affiliation(s)
- Mackenzi Meier
- Department of Pharmacy, St. Joseph's/Candler Health System, Savannah, GA, USA
- School of Pharmacy, South University, Savannah, GA, USA
| | | | | | | | - Sarah Lopez
- Department of Pharmacy, St. Joseph's/Candler Health System, Savannah, GA, USA
- School of Pharmacy, South University, Savannah, GA, USA
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5
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Oosterom-Eijmael MJP, Hermanides J, van Raalte DH, Hulst AH. Risk of perioperative discontinuation of SGLT2 inhibitors. Br J Anaesth 2024; 133:239-240. [PMID: 38834489 DOI: 10.1016/j.bja.2024.05.004] [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: 01/31/2024] [Revised: 05/01/2024] [Accepted: 05/03/2024] [Indexed: 06/06/2024] Open
Abstract
When sodium-glucose cotransporter-2 (SGLT2) inhibitors were primarily prescribed for treatment of diabetes mellitus, guidelines recommended withholding SGLT2 inhibitors before surgery to mitigate the associated risk of ketoacidosis. However, currently, SGLT2 inhibitors are an established therapy for patients with heart failure, and there is evidence that withholding SGLT2 inhibitors can worsen these patients' cardiovascular risk profile. We present an updated risk-benefit analysis of withholding SGLT2 inhibitors before surgery, focusing on patients with heart failure and addressing the risk of ketoacidosis and its treatment in these patients. Clinicians should consider perioperative continuation of SGLT2 inhibitors when prescribed for treatment of heart failure.
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Affiliation(s)
- Maartina J P Oosterom-Eijmael
- Department of Anaesthesiology, Amsterdam University Medical Center, Amsterdam, The Netherlands; Department of Endocrinology and Metabolism, Amsterdam University Medical Center, Amsterdam, The Netherlands; Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands
| | - Jeroen Hermanides
- Department of Anaesthesiology, Amsterdam University Medical Center, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.
| | - Daniel H van Raalte
- Department of Endocrinology and Metabolism, Amsterdam University Medical Center, Amsterdam, The Netherlands; Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands
| | - Abraham H Hulst
- Department of Anaesthesiology, Amsterdam University Medical Center, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
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6
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Lai JW, Wang CCN, Chou CY. SGLT-2 inhibitors in chronic peritoneal dialysis patients: a follow-up study. BMC Nephrol 2024; 25:238. [PMID: 39075357 PMCID: PMC11285309 DOI: 10.1186/s12882-024-03683-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 07/22/2024] [Indexed: 07/31/2024] Open
Abstract
BACKGROUND Sodium-glucose transporter-2 inhibitors (SGLT-2i) are recommended for use in patients with type 2 diabetes comorbid atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease. Limited reports are currently available for their use in dialysis patients. In an observational, retrospective follow-up study, we reported the clinical characteristics of chronic peritoneal dialysis (PD) patients on SGLT-2i. METHODS We enrolled 50 diabetic chronic PD patients, and 11 continued SGLT-2i after PD treatment. We reported the patients' ultrafiltration, HbA1c, urinary tract infection episodes, and venous CO2 during follow-up and compared the differences in these factors between patients with and without SGLT-2i. RESULTS The mean age of the patients was 65 ± 15 years, and 16 (32%) patients were female. The age, gender, heart failure, and primary kidney disease were not different between patients with and without SGLT-2i at enrollment. In an average of 31 months follow-up, patients with SGLT-2i had higher ultrafiltration (1322 ± 200 ml/day vs. 985 ± 415 ml/day, p = 0.013), hemoglobin (11.2 ± 1.7 vs. 10.2 ± 1.7 g/dl), white blood cell count (9.2 ± 3.7 vs. 7.4 ± 2.1 109/L), and a lower venous CO2 (p = 0.036). The urine amount, the overall survival, the technical survival, and the chance of UTI were not different between patients with and without SGLT2i. CONCLUSION SGLT-2i may increase ultrafiltration volume and hemoglobin levels in chronic PD patients. SGLT-2i did not increase urinary tract infection but was linked to subclinical metabolic acidosis. WHAT WAS KNOWN The effect of SGLT-2i in chronic PD patients is not clear? THIS STUDY ADDS SGLT-2i is associated with increased ultrafiltration, hemoglobin, white blood cell counts, and a decreased CO2 in PD patient. POTENTIAL IMPACT SGLT-2i may increase ultrafiltration in PD patients.
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Affiliation(s)
- Jia-Wen Lai
- Division of Nephrology, Asia University Hospital, Taichung, Taiwan
| | - Charles C N Wang
- Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan
| | - Che-Yi Chou
- Division of Nephrology, Asia University Hospital, Taichung, Taiwan.
- Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan.
- College of Medicine, China Medical University, Taichung, Taiwan.
- Division of Nephrology and Kidney Institute, China Medical University Hospital, Taichung, Taiwan.
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Bellomo F, Pugliese S, Cairoli S, Krohn P, De Stefanis C, Raso R, Rega LR, Taranta A, De Leo E, Ciolfi A, Cicolani N, Petrini S, Luciani A, Goffredo BM, Porzio O, Devuyst O, Dionisi-Vici C, Emma F. Ketogenic Diet and Progression of Kidney Disease in Animal Models of Nephropathic Cystinosis. J Am Soc Nephrol 2024:00001751-990000000-00369. [PMID: 38995697 DOI: 10.1681/asn.0000000000000439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 07/09/2024] [Indexed: 07/14/2024] Open
Abstract
Key Points
Ketogenic diet can change the metabolism in the body and helped restore the function of altered pathways in nephropathic cystinosis.Ketogenic diet had significant benefits for preventing kidney damage, even when initiated after the onset of kidney impairment.Ketogenic diet may provide a partial therapeutic alternative in countries where cysteamine therapy is too expensive.
Background
Nephropathic cystinosis is a rare inherited lysosomal storage disorder caused by mutations in the CTNS gene that encodes for cystinosin, a lysosomal cystine/H+ symporter. From the standpoint of the kidneys, patients develop early-onset renal Fanconi syndrome and progressive CKD. Current therapy with cysteamine delays but does not prevent kidney failure and has significant side effects that limit adherence and reduce the quality of life of patients.
Methods
We have tested biochemically and histologically the effects of ketogenic diet on kidney disease of two animal models of nephropathic cystinosis.
Results
When Ctns
−/− mice were fed with ketogenic diet from 3 to 12 months of age, we observed significant nearly complete prevention of Fanconi syndrome, including low molecular weight proteinuria, glycosuria, and polyuria. Compared with wild-type animals, BUN at 12 months was higher in cystinotic mice fed with standard diet (P < 0.001), but not with ketogenic diet. At sacrifice, kidneys of knockout mice fed with ketogenic diet appeared macroscopically similar to those of wild-type animals, which was reflected microscopically by a significant reduction of interstitial cell infiltration (CD3 and CD68 positive cells, P < 0.01), of interstitial fibrosis (Masson and α-smooth muscle actin staining, P < 0.001), and of apoptosis (cleaved caspase-3 levels; P < 0.001), and by indirect evidence of restoration of a normal autophagic flux (SQSTM1/p62 and LC3-II expression, P < 0.05). Beneficial effects of ketogenic diet on tubular function were also observed after mice were fed with this ketogenic diet from the age of 6 months to the age of 15 months, after they had developed proximal tubular dysfunction. Although slightly less pronounced, these results were replicated in Ctns
−/− rats fed with ketogenic diet from 2 to 8 months of life.
Conclusions
These results indicate significant mitigation of the kidney phenotype in cystinotic animals fed with ketogenic diet.
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Affiliation(s)
- Francesco Bellomo
- Laboratory of Nephrology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Sara Pugliese
- Laboratory of Nephrology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Sara Cairoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Patrick Krohn
- Institute of Physiology, University of Zurich, Zurich, Switzerland
| | | | - Roberto Raso
- Laboratory of Nephrology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Laura Rita Rega
- Laboratory of Nephrology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Anna Taranta
- Laboratory of Nephrology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Ester De Leo
- Laboratory of Nephrology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Andrea Ciolfi
- Molecular Genetics and Functional Genomics, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Nicolò Cicolani
- Confocal Microscopy Core Facility, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Stefania Petrini
- Confocal Microscopy Core Facility, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | | | - Bianca Maria Goffredo
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Ottavia Porzio
- Clinical Biochemistry Laboratory, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Olivier Devuyst
- Institute of Physiology, University of Zurich, Zurich, Switzerland
| | - Carlo Dionisi-Vici
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Francesco Emma
- Laboratory of Nephrology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
- Division of Nephrology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
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Wanner C, Iliev H, Duarte N, Schueler E, Soares AR, Thanam V, Pfarr E. Safety of Empagliflozin: An Individual Participant-Level Data Meta-Analysis from Four Large Trials. Adv Ther 2024; 41:2826-2844. [PMID: 38771475 PMCID: PMC11213770 DOI: 10.1007/s12325-024-02879-w] [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: 03/04/2024] [Accepted: 04/17/2024] [Indexed: 05/22/2024]
Abstract
INTRODUCTION Empagliflozin is a sodium-glucose co-transporter-2 inhibitor used to treat type 2 diabetes (T2D) to improve glycemic control, reduce risk of cardiovascular death in patients with T2D, and treat patients with symptomatic chronic heart failure (HF) and chronic kidney disease (CKD). The safety profile of empagliflozin is well documented, although adverse events (AEs) remain of interest to clinicians. This study provides an up-to-date safety evaluation of empagliflozin. METHODS Data were pooled from four long-term trials which included: patients with T2D and established cardiovascular disease (EMPA-REG OUTCOME), patients with HF, with/without diabetes (EMPEROR-Reduced and EMPEROR-Preserved), and patients with CKD, with/without diabetes (EMPA-KIDNEY). Since three of the four trials evaluated empagliflozin 10 mg, the meta-analysis was restricted to this dose. RESULTS Total trial medication exposure was 19,727 patient-years for patients who received empagliflozin (n = 10,472) and 19,447 patient-years for placebo (n = 10,461). The percentages of patients with serious AEs, fatal AEs, and AEs leading to discontinuation were similar for both groups. The incidences of serious urinary tract infection and serious pyelonephritis or urosepsis were similar for both groups but higher for women taking empagliflozin versus placebo. Serious genital infections were not increased with empagliflozin versus placebo. There was a slight increase in ketoacidosis and serious volume depletion in patients who received empagliflozin versus placebo. The occurrence of serious acute kidney injury was lower with empagliflozin versus placebo. Empagliflozin was not associated with an increased incidence of severe hypoglycemia, bone fractures, or lower limb amputations. Empagliflozin is therefore considered safe in people without diabetes, the elderly, patients with very low estimated glomerular filtration rate, low body mass index, and HF. Safety is unaltered by blood pressure, concomitant medication for hypertension, HF, and immunosuppression. CONCLUSION This meta-analysis of long-term safety data extends current knowledge and confirms the safety and tolerability of empagliflozin.
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Affiliation(s)
| | - Hristo Iliev
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | | | | | | | - Vikram Thanam
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Egon Pfarr
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
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Alcantar-Vallin L, Zaragoza JJ, Díaz-Villavicencio B, Hernandez-Morales K, Camacho-Guerrero JR, Perez-Venegas MA, Carmona-Morales EJ, Oseguera-Gonzalez AN, Murguia-Soto C, Chávez-Alonso G, Arredondo-Dubois JM, Orozco-Chan CE, Gómez-Fregoso JA, Rodríguez-García FG, Navarro-Blackaller G, Medina-González R, Martínez Gallardo-González A, Abundis-Mora GJ, Vega-Vega O, García-García G, Chávez-Iñiguez JS. SGLT2i treatment during AKI and its association with major adverse kidney events. Front Pharmacol 2024; 15:1356991. [PMID: 38933678 PMCID: PMC11199731 DOI: 10.3389/fphar.2024.1356991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 05/28/2024] [Indexed: 06/28/2024] Open
Abstract
Background The association between the administration of sodium-glucose cotransporter 2 inhibitors (SGLT2is) during acute kidney injury (AKI) and the incidence of major adverse kidney events (MAKEs) is not known. Methods This retrospective cohort study included patients with AKI and compared the outcomes for those who were treated with SGLT2is during hospitalization and those without SGLT2i treatment. The associations of SGLT2i use with MAKEs at 10 and 30-90 days, each individual MAKE component, and the pre-specified patient subgroups were analyzed. Results From 2021 to 2023, 374 patients were included in the study-316 without SGLT2i use and 58 with SGLT2i use. Patients who were treated with SGLT2is were older; had a greater prevalence of diabetes, hypertension, chronic heart failure, and chronic kidney disease; required hemodialysis less often; and presented stage 3 AKI less frequently than those who were not treated with SGLT2is. Logistic regression analysis with nearest-neighbor matching revealed that SGLT2i use was not associated with the risk of MAKE10 (OR 1.08 [0.45-2.56]) or with MAKE30-90 (OR 0.76 [0.42-1.36]). For death, the stepwise approach demonstrated that SGLT2i use was associated with a reduced risk (OR 0.08; 0.01-0.64), and no effect was found for kidney replacement therapy (KRT). The subgroups of patients who experienced a reduction in the risk of MAKEs in patients with AKI treated with SGLT2is were those older than 61 years, those with an eGFR >81, and those without a history of hypertension or DM (p ≤ 0.05 for all). Conclusion The use of SGLT2is during AKI had no effect on short- or medium-term MAKEs, but some subgroups of patients may have experienced benefits from SGLT2i treatment.
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Affiliation(s)
- Luz Alcantar-Vallin
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
- University of Guadalajara Health Sciences Center, Guadalajara, Jalisco, Mexico
| | | | - Bladimir Díaz-Villavicencio
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
- University of Guadalajara Health Sciences Center, Guadalajara, Jalisco, Mexico
| | - Karla Hernandez-Morales
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
- University of Guadalajara Health Sciences Center, Guadalajara, Jalisco, Mexico
| | - Jahir R. Camacho-Guerrero
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
- University of Guadalajara Health Sciences Center, Guadalajara, Jalisco, Mexico
| | - Miguel A. Perez-Venegas
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
- University of Guadalajara Health Sciences Center, Guadalajara, Jalisco, Mexico
| | - Edgar J. Carmona-Morales
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
- University of Guadalajara Health Sciences Center, Guadalajara, Jalisco, Mexico
| | - Alexa N. Oseguera-Gonzalez
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
- University of Guadalajara Health Sciences Center, Guadalajara, Jalisco, Mexico
| | - Cesar Murguia-Soto
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
- University of Guadalajara Health Sciences Center, Guadalajara, Jalisco, Mexico
| | - Gael Chávez-Alonso
- University of Guadalajara Health Sciences Center, Guadalajara, Jalisco, Mexico
| | | | | | - Juan A. Gómez-Fregoso
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | | | - Guillermo Navarro-Blackaller
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
- University of Guadalajara Health Sciences Center, Guadalajara, Jalisco, Mexico
| | - Ramón Medina-González
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - Alejandro Martínez Gallardo-González
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
- University of Guadalajara Health Sciences Center, Guadalajara, Jalisco, Mexico
| | - Gabriela J. Abundis-Mora
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - Olynka Vega-Vega
- Departamento Nefrología y Metabolismo Mineral, Instituto Nacional de Ciencia Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | - Jonathan S. Chávez-Iñiguez
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
- University of Guadalajara Health Sciences Center, Guadalajara, Jalisco, Mexico
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10
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Raphael KL. Metabolic Acidosis in CKD: Pathogenesis, Adverse Effects, and Treatment Effects. Int J Mol Sci 2024; 25:5187. [PMID: 38791238 PMCID: PMC11121226 DOI: 10.3390/ijms25105187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 04/28/2024] [Accepted: 05/05/2024] [Indexed: 05/26/2024] Open
Abstract
Metabolic acidosis is a frequent complication of chronic kidney disease and is associated with a number of adverse outcomes, including worsening kidney function, poor musculoskeletal health, cardiovascular events, and death. Mechanisms that prevent metabolic acidosis detrimentally promote further kidney damage, creating a cycle between acid accumulation and acid-mediated kidney injury. Disrupting this cycle through the provision of alkali, most commonly using sodium bicarbonate, is hypothesized to preserve kidney function while also mitigating adverse effects of excess acid on bone and muscle. However, results from clinical trials have been conflicting. There is also significant interest to determine whether sodium bicarbonate might improve patient outcomes for those who do not have overt metabolic acidosis. Such individuals are hypothesized to be experiencing acid-mediated organ damage despite having a normal serum bicarbonate concentration, a state often referred to as subclinical metabolic acidosis. Results from small- to medium-sized trials in individuals with subclinical metabolic acidosis have also been inconclusive. Well-powered clinical trials to determine the efficacy and safety of sodium bicarbonate are necessary to determine if this intervention improves patient outcomes.
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Affiliation(s)
- Kalani L. Raphael
- Division of Nephrology & Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT 84112, USA;
- Medicine Section, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT 84148, USA
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Morace C, Lorello G, Bellone F, Quartarone C, Ruggeri D, Giandalia A, Mandraffino G, Minutoli L, Squadrito G, Russo GT, Marini HR. Ketoacidosis and SGLT2 Inhibitors: A Narrative Review. Metabolites 2024; 14:264. [PMID: 38786741 PMCID: PMC11122992 DOI: 10.3390/metabo14050264] [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: 03/08/2024] [Revised: 04/29/2024] [Accepted: 05/01/2024] [Indexed: 05/25/2024] Open
Abstract
An acute metabolic complication of diabetes mellitus, especially type 1, is diabetic ketoacidosis (DKA), which is due to an increase in blood ketone concentrations. Sodium/glucose co-transporter-2 inhibitor (SGLT2-i) drugs have been associated with the occurrence of a particular type of DKA defined as euglycemic (euDKA), characterized by glycemic levels below 300 mg/dL. A fair number of euDKA cases in SGLT2-i-treated patients have been described, especially in the last few years when there has been a significant increased use of these drugs. This form of euDKA is particularly insidious because of its latent onset, associated with unspecific symptomatology, until it evolves (progressing) to severe systemic forms. In addition, its atypical presentation can delay diagnosis and treatment. However, the risk of euDKA associated with SGLT2-i drugs remains relatively low, but it is essential to promptly diagnose and manage it to prevent its serious life-threatening complications. In this narrative review, we intended to gather current research evidence on SGLT2i-associated euDKA from randomized controlled trials and real-world evidence studies, its diagnostic criteria and precipitating factors.
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Affiliation(s)
- Carmela Morace
- Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (C.M.); (F.B.); (G.M.); (L.M.); (G.S.); (G.T.R.)
- Lipid Clinic and Cardiometabolic Disease Center, University Hospital of Messina, 98124 Messina, Italy
| | - Giuseppe Lorello
- Internal Medicine and Diabetology Unit, University Hospital of Messina, 98124 Messina, Italy; (G.L.); (C.Q.); (D.R.); (A.G.)
| | - Federica Bellone
- Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (C.M.); (F.B.); (G.M.); (L.M.); (G.S.); (G.T.R.)
- Lipid Clinic and Cardiometabolic Disease Center, University Hospital of Messina, 98124 Messina, Italy
| | - Cristina Quartarone
- Internal Medicine and Diabetology Unit, University Hospital of Messina, 98124 Messina, Italy; (G.L.); (C.Q.); (D.R.); (A.G.)
| | - Domenica Ruggeri
- Internal Medicine and Diabetology Unit, University Hospital of Messina, 98124 Messina, Italy; (G.L.); (C.Q.); (D.R.); (A.G.)
| | - Annalisa Giandalia
- Internal Medicine and Diabetology Unit, University Hospital of Messina, 98124 Messina, Italy; (G.L.); (C.Q.); (D.R.); (A.G.)
- Department of Human Pathology of Adulthood and Childhood “G. Barresi”, University of Messina, 98125 Messina, Italy
| | - Giuseppe Mandraffino
- Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (C.M.); (F.B.); (G.M.); (L.M.); (G.S.); (G.T.R.)
- Lipid Clinic and Cardiometabolic Disease Center, University Hospital of Messina, 98124 Messina, Italy
| | - Letteria Minutoli
- Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (C.M.); (F.B.); (G.M.); (L.M.); (G.S.); (G.T.R.)
| | - Giovanni Squadrito
- Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (C.M.); (F.B.); (G.M.); (L.M.); (G.S.); (G.T.R.)
- Internal Medicine and Diabetology Unit, University Hospital of Messina, 98124 Messina, Italy; (G.L.); (C.Q.); (D.R.); (A.G.)
| | - Giuseppina T. Russo
- Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (C.M.); (F.B.); (G.M.); (L.M.); (G.S.); (G.T.R.)
- Internal Medicine and Diabetology Unit, University Hospital of Messina, 98124 Messina, Italy; (G.L.); (C.Q.); (D.R.); (A.G.)
| | - Herbert Ryan Marini
- Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (C.M.); (F.B.); (G.M.); (L.M.); (G.S.); (G.T.R.)
- Internal Medicine and Diabetology Unit, University Hospital of Messina, 98124 Messina, Italy; (G.L.); (C.Q.); (D.R.); (A.G.)
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12
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Box JR, Oyama MA, Mosenco AS, Hess RS. Effect of sodium-glucose cotransporter 2 inhibitor canagliflozin on interstitial glucose concentration in insulin-treated diabetic dogs. J Vet Intern Med 2024; 38:1353-1358. [PMID: 38528660 PMCID: PMC11099740 DOI: 10.1111/jvim.17053] [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: 10/27/2023] [Accepted: 03/08/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND The utility of sodium-glucose cotransporter 2 inhibitors (SGLT2i) has not been reported in insulin-treated diabetic dogs. HYPOTHESIS Canagliflozin, a PO-administered SGLT2i, decreases interstitial glucose concentration (IG) in insulin-treated diabetic dogs. ANIMALS Five insulin-treated diabetic dogs. METHODS Uncontrolled open label longitudinal study. Canagliflozin (2-4 mg/kg/day PO) was added to an unchanged insulin dose for 7 days. Fractional excretion of glucose was calculated by dividing the product of urine glucose and serum creatinine concentrations by the product of serum glucose and urine creatinine concentrations. Hypoglycemia was defined as IG <60 mg/dL. RESULTS Median IG in 2869 measurements obtained while dogs were treated with insulin and canagliflozin was 87 mg/dL (range, 40-500 mg/dL) and was significantly lower than median IG in 1426 measurements obtained while dogs were treated with insulin alone (212 mg/dL; range, 41-500 mg/dL; P < .001). Median fractional excretion of glucose when dogs were treated with insulin and canagliflozin was 1.1% (range, 0.9%-2.0%), significantly higher than when dogs were treated with insulin alone (0.3%; range, 0.01%-1.0%; P = .04). The frequency of hypoglycemia was higher in dogs treated with insulin and canagliflozin (544 of 2869 IG measurements, 19%) compared with the frequency of hypoglycemia in dogs treated with insulin alone (52 of 1426 IG measurements, 4%; P < .001). CONCLUSIONS AND CLINICAL IMPORTANCE Canagliflozin may have a role in improving glycemic control in insulin-treated diabetic dogs, but the dose of insulin should be decreased when adding canagliflozin to insulin treatment.
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Affiliation(s)
- Jessica R. Box
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Mark A. Oyama
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Ariel S. Mosenco
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Rebecka S. Hess
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
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13
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Marinescu SC(N, Apetroaei MM, Nedea MI(I, Arsene AL, Velescu BȘ, Hîncu S, Stancu E, Pop AL, Drăgănescu D, Udeanu DI. Dietary Influence on Drug Efficacy: A Comprehensive Review of Ketogenic Diet-Pharmacotherapy Interactions. Nutrients 2024; 16:1213. [PMID: 38674903 PMCID: PMC11054576 DOI: 10.3390/nu16081213] [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: 03/28/2024] [Revised: 04/11/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
It is widely acknowledged that the ketogenic diet (KD) has positive physiological effects as well as therapeutic benefits, particularly in the treatment of chronic diseases. Maintaining nutritional ketosis is of utmost importance in the KD, as it provides numerous health advantages such as an enhanced lipid profile, heightened insulin sensitivity, decreased blood glucose levels, and the modulation of diverse neurotransmitters. Nevertheless, the integration of the KD with pharmacotherapeutic regimens necessitates careful consideration. Due to changes in their absorption, distribution, metabolism, or elimination, the KD can impact the pharmacokinetics of various medications, including anti-diabetic, anti-epileptic, and cardiovascular drugs. Furthermore, the KD, which is characterised by the intake of meals rich in fats, has the potential to impact the pharmacokinetics of specific medications with high lipophilicity, hence enhancing their absorption and bioavailability. However, the pharmacodynamic aspects of the KD, in conjunction with various pharmaceutical interventions, can provide either advantageous or detrimental synergistic outcomes. Therefore, it is important to consider the pharmacokinetic and pharmacodynamic interactions that may arise between the KD and various drugs. This assessment is essential not only for ensuring patients' compliance with treatment but also for optimising the overall therapeutic outcome, particularly by mitigating adverse reactions. This highlights the significance and necessity of tailoring pharmacological and dietetic therapies in order to enhance the effectiveness and safety of this comprehensive approach to managing chronic diseases.
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Affiliation(s)
- Simona Cristina (Nicolescu) Marinescu
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania (A.L.A.); (B.Ș.V.); (S.H.); (E.S.); (A.L.P.); (D.D.); (D.I.U.)
- Amethyst Radiotherapy Center, 42, Drumul Odăi, 075100 Otopeni, Romania
| | - Miruna-Maria Apetroaei
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania (A.L.A.); (B.Ș.V.); (S.H.); (E.S.); (A.L.P.); (D.D.); (D.I.U.)
| | - Marina Ionela (Ilie) Nedea
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania (A.L.A.); (B.Ș.V.); (S.H.); (E.S.); (A.L.P.); (D.D.); (D.I.U.)
| | - Andreea Letiția Arsene
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania (A.L.A.); (B.Ș.V.); (S.H.); (E.S.); (A.L.P.); (D.D.); (D.I.U.)
- Marius Nasta Institute of Pneumophthiology, 90, Viilor Street, 050159 Bucharest, Romania
| | - Bruno Ștefan Velescu
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania (A.L.A.); (B.Ș.V.); (S.H.); (E.S.); (A.L.P.); (D.D.); (D.I.U.)
| | - Sorina Hîncu
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania (A.L.A.); (B.Ș.V.); (S.H.); (E.S.); (A.L.P.); (D.D.); (D.I.U.)
- Fundeni Clinical Institute, 258, Fundeni Street, 022328 Bucharest, Romania
| | - Emilia Stancu
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania (A.L.A.); (B.Ș.V.); (S.H.); (E.S.); (A.L.P.); (D.D.); (D.I.U.)
| | - Anca Lucia Pop
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania (A.L.A.); (B.Ș.V.); (S.H.); (E.S.); (A.L.P.); (D.D.); (D.I.U.)
| | - Doina Drăgănescu
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania (A.L.A.); (B.Ș.V.); (S.H.); (E.S.); (A.L.P.); (D.D.); (D.I.U.)
| | - Denisa Ioana Udeanu
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania (A.L.A.); (B.Ș.V.); (S.H.); (E.S.); (A.L.P.); (D.D.); (D.I.U.)
- Marius Nasta Institute of Pneumophthiology, 90, Viilor Street, 050159 Bucharest, Romania
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14
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Heijne A, Bronkhorst EM. Dose-dependent relationship between SGLT2 inhibitor hold time and risk for postoperative anion gap acidosis. Comment on Br J Anaesth 2023; 131: 682-686. Br J Anaesth 2024; 132:822-823. [PMID: 38320879 DOI: 10.1016/j.bja.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 01/12/2024] [Indexed: 02/08/2024] Open
Affiliation(s)
- Amon Heijne
- Department of Anaesthesiology, Pain and Palliative Care, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Ewald M Bronkhorst
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
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15
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Azim A, Hu B, Gilligan S, Sarwal A, Hartsell S, Pandya V, Raphael KL. How I Evaluate a High Anion Gap Metabolic Acidosis. Clin J Am Soc Nephrol 2024; 19:525-527. [PMID: 37976122 PMCID: PMC11020432 DOI: 10.2215/cjn.0000000000000381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/09/2023] [Indexed: 11/19/2023]
Affiliation(s)
- Aniqa Azim
- Department of Internal Medicine, Oregon Health & Science University, Portland, Oregon
| | - Boyu Hu
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Sarah Gilligan
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Amara Sarwal
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Sydney Hartsell
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Vrajesh Pandya
- Department of Pathology, University of Utah, Salt Lake City, Utah
| | - Kalani L. Raphael
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
- Medicine Section, VA Salt Lake City Health Care System, Salt Lake City, Utah
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16
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Jang SW, Lee H. Euglycemic diabetic ketoacidosis following traumatic brain injury. Am J Emerg Med 2024; 77:232.e1-232.e3. [PMID: 38216364 DOI: 10.1016/j.ajem.2024.01.006] [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: 11/25/2023] [Revised: 01/01/2024] [Accepted: 01/04/2024] [Indexed: 01/14/2024] Open
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors lower glucose levels by reducing glucose reabsorption in the kidneys, which can lead to ketogenesis. Euglycemic diabetic ketoacidosis (DKA) is a rare but potentially life-threatening complication of SGLT2 inhibitors that can be triggered by trauma. However, the absence of significant hyperglycemia can delay its diagnosis and treatment, which may lead to detrimental consequences. Herein, we report a case of euglycemic DKA following traumatic brain injury in a patient with type 2 diabetes who was taking an SGLT2 inhibitor. Delayed recognition of euglycemic DKA in this case led to progressive metabolic deterioration. This report emphasizes the importance of promptly suspecting, diagnosing, and treating euglycemic DKA in patients with traumatic injuries who exhibit high anion-gap metabolic acidosis, ketonuria, and glucosuria-even if they do not have significant hyperglycemia.
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Affiliation(s)
- Sung Woo Jang
- Department of Surgery, National Trauma Center, National Medical Center, 245 Eulji-ro, Jung-gu, Seoul 04564, Republic of Korea
| | - Haekyung Lee
- Division of Nephrology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, 59 Daesagwan-ro, Yongsan-gu, Seoul 04401, Republic of Korea; Hyonam Kidney Laboratory, Soonchunhyang University Seoul Hospital, Seoul, 59 Daesagwan-ro, Yongsan-gu, Seoul 04401, Republic of Korea.
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17
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Palmer BF, Clegg DJ. SGLT2 Inhibition and Tubular Sodium Handling. J Am Soc Nephrol 2024; 35:131-133. [PMID: 38129943 PMCID: PMC10843184 DOI: 10.1681/asn.0000000000000280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Affiliation(s)
- Biff F. Palmer
- Internal Medicine, Department of Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Deborah J. Clegg
- Internal Medicine, Vice President for Research, Texas Tech Health Sciences Center, El Paso, Texas
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18
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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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19
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Garg S, Kanagala SG, Anamika F, Parikh K, Kaur H, Garg N, Jain R. Beyond Glycemic Control: Mechanistic Insights Into SGLT-2 Inhibitors in Heart Failure Management. Cardiol Rev 2023:00045415-990000000-00178. [PMID: 38019033 DOI: 10.1097/crd.0000000000000632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
Heart failure is a common and clinically significant cardiac condition that causes significant morbidity and mortality in the United States. Diabetes and hypertension are 2 of the most common comorbidities associated with heart failure. Other risk factors for heart failure include smoking, obesity, and intrinsic cardiac diseases such as myocardial infarction and valvular pathologies. All of these conditions, to some extent, cause remodeling within the cardiomyocyte, which eventually leads to the development of congestive heart failure. Over the years, using diuretics and medications that inhibit the Renin-Angiotensin-Aldosterone System has been the traditional treatment for congestive heart failure. But in recent years studies in the diabetic population revealed that sodium-glucose cotransporter-2 inhibitors had a negative impact on the remodeling of cardiomyocytes. In this review, we discuss the numerous molecular mechanisms by which these recently developed medicines inhibit remodeling in cardiomyocytes, independent of their intended effect of decreasing blood glucose levels. Furthermore, it emphasizes the use of these drugs in diabetic as well as non-diabetic patients as a promising adjunct to ongoing heart failure treatment.
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Affiliation(s)
- Shreya Garg
- From the Department of Internal Medicine, Dayanand Medical College & Hospital, Punjab, India
| | | | - Fnu Anamika
- Department of Internal Medicine, University College of Medical Sciences, Delhi, India
| | - Kinna Parikh
- Department of Internal Medicine, GMERS Medical College, Gujarat, India
| | - Harmanjit Kaur
- Department of Internal Medicine, Government Medical College, Punjab, India
| | - Nikita Garg
- Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, IL
| | - Rohit Jain
- Department of Internal Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA
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20
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Sarno MJF, Hernandez DPF, Matulac MO. "Normal but Catastrophic" Euglycemic Diabetic Ketoacidosis Precipitated by Sodium-Glucose Cotransporter-2 Inhibitor Use: A Case Report. Cureus 2023; 15:e49236. [PMID: 38143642 PMCID: PMC10740381 DOI: 10.7759/cureus.49236] [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: 11/22/2023] [Indexed: 12/26/2023] Open
Abstract
Euglycemic diabetic ketoacidosis (EuDKA) is an uncommon diabetic complication. Just like diabetic ketoacidosis (DKA), EuDKA is a medical emergency. EuDKA is primarily related to the imbalance between insulin and counter-regulatory hormones, with an elevated insulin/glucagon ratio, and is characterized by blood glucose near normal (blood glucose less than 250 mg/dL) in the background of DKA. There are many factors associated with EuDKA, but the overall mechanism is based on a relative state of carbohydrate deficit, resulting in ketosis while maintaining near-normal glucose levels. Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a new oral antidiabetic medication category that can precipitate EuDKA. EuDKA is more common in patients with diabetes mellitus on SGLT2 inhibitors with lower mass index and decreased glycogen store which can be triggered by surgery, infection, trauma, a major illness or reduced food intake and persistent vomiting, gastroparesis, dehydration, and reduced insulin dosages. This is a case of a 34-year-old male, Filipino, diagnosed with type 2 diabetes mellitus, who was maintained on dapagliflozin + metformin 5mg/1000mg taken twice a day with good compliance and was admitted with EuDKA precipitated by decreased food intake and managed with intravenous insulin. Throughout admission, the blood glucose levels did not exceed 250mg/dL. His clinical condition improved through insulin therapy, administration of sodium bicarbonate, and intravenous hydration. EuDKA is an uncommon diabetic complication. High clinical suspicion is required to avoid delay in diagnosis and management since normal blood sugar levels masquerade the underlying DKA. Nevertheless, the cornerstone for the management of DKA and EuDKA remains the same: intravenous hydration and insulin therapy.
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Affiliation(s)
| | - Dan Philip F Hernandez
- Endocrinology, Diabetes and Metabolism, Adventist Medical Center Manila, Pasay City, PHL
| | - Melgar O Matulac
- Interventional Cardiology, Adventist Medical Center Manila, Pasay City, PHL
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21
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Veneti S, Grammatikopoulou MG, Kintiraki E, Mintziori G, Goulis DG. Ketone Bodies in Diabetes Mellitus: Friend or Foe? Nutrients 2023; 15:4383. [PMID: 37892458 PMCID: PMC10609881 DOI: 10.3390/nu15204383] [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: 09/18/2023] [Revised: 10/12/2023] [Accepted: 10/14/2023] [Indexed: 10/29/2023] Open
Abstract
In glucose-deprived conditions, ketone bodies are produced by the liver mitochondria, through the catabolism of fatty acids, and are used peripherally, as an alternative energy source. Ketones are produced in the body under normal conditions, including during pregnancy and the neonatal period, when following a ketogenic diet (KD), fasting, or exercising. Additionally, ketone synthesis is also augmented under pathological conditions, including cases of diabetic ketoacidosis (DKA), alcoholism, and several metabolic disorders. Nonetheless, diet is the main regulator of total body ketone concentrations. The KDs are mimicking the fasting state, altering the default metabolism towards the use of ketones as the primary fuel source. Recently, KD has gained recognition as a medical nutrition therapy for a plethora of metabolic conditions, including obesity and diabetes mellitus (DM). The present review aims to discuss the role of ketones, KDs, ketonemia, and ketonuria in DM, presenting all the available new evidence in a comprehensive manner.
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Affiliation(s)
- Stavroula Veneti
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (S.V.); (E.K.)
| | - Maria G. Grammatikopoulou
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (S.V.); (E.K.)
- Unit of Immunonutrition and Clinical Nutrition, Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, GR-41110 Larissa, Greece
| | - Evangelia Kintiraki
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (S.V.); (E.K.)
| | - Gesthimani Mintziori
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (S.V.); (E.K.)
| | - Dimitrios G. Goulis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (S.V.); (E.K.)
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22
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Sanghavi SF, Swenson ER. Arterial Blood Gases and Acid-Base Regulation. Semin Respir Crit Care Med 2023; 44:612-626. [PMID: 37369215 DOI: 10.1055/s-0043-1770341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
Disorders of acid-base status are common in the critically ill and prompt recognition is central to clinical decision making. The bicarbonate/carbon dioxide buffer system plays a pivotal role in maintaining acid-base homeostasis, and measurements of pH, PCO2, and HCO3 - are routinely used in the estimation of metabolic and respiratory disturbance severity. Hypoventilation and hyperventilation cause primary respiratory acidosis and primary respiratory alkalosis, respectively. Metabolic acidosis and metabolic alkalosis have numerous origins, that include alterations in acid or base intake, body fluid losses, abnormalities of intermediary metabolism, and renal, hepatic, and gastrointestinal dysfunction. The concept of the anion gap is used to categorize metabolic acidoses, and urine chloride excretion helps define metabolic alkaloses. Both the lungs and kidneys employ compensatory mechanisms to minimize changes in pH caused by various physiologic and disease disturbances. Treatment of acid-base disorders should focus primarily on correcting the underlying cause and the hemodynamic and electrolyte derangements that ensue. Specific therapies under certain conditions include renal replacement therapy, mechanical ventilation, respiratory stimulants or depressants, and inhibition of specific enzymes in intermediary metabolism disorders.
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Affiliation(s)
- Sarah F Sanghavi
- Division of Nephrology, Department of Medicine, University of Washington, Puget Sound Veterans Affairs Healthcare System, Seattle, Washington
| | - Erik R Swenson
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Puget Sound Veterans Affairs Healthcare System, Seattle, Washington
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23
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Steinhorn B, Wiener-Kronish J. Dose-dependent relationship between SGLT2 inhibitor hold time and risk for postoperative anion gap acidosis: a single-centre retrospective analysis. Br J Anaesth 2023; 131:682-686. [PMID: 37541949 DOI: 10.1016/j.bja.2023.06.063] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/17/2023] [Accepted: 06/19/2023] [Indexed: 08/06/2023] Open
Abstract
BACKGROUND Use of sodium-glucose transporter-2 (SGLT2) inhibitors has dramatically increased over the past decade. This medication class predisposes patients to euglycaemic diabetic ketoacidosis, particularly during times of physiologic stress, including fasting and surgery. Beyond case reports and series, a systematic description of perioperative metabolic effects of SGLT2 inhibitors is lacking. METHODS We examined the degree of anion gap acidosis, controlling for non-ketone anions, in patients undergoing surgery at Massachusetts General Hospital in 2016-22. We constructed a multivariable regression model incorporating known non-ketone contributors to the postoperative anion gap (albumin, lactate, estimated glomerular filtration rate, and preoperative anion gap), hold time, and interaction terms between hold time and three previously suggested risk factors for euglycaemic diabetic ketoacidosis: emergency surgery, cardiac surgery, and insulin use. RESULTS In 463 patients on SGLT2 inhibitors, we observed a strong association between decreased hold time and postoperative anion gap (P<0.001 in a univariable analysis; -0.43, 95% confidence interval [-0.76 to -0.11] change in anion gap per day held, P=0.01 in a multivariable analysis). A significant interaction between hold time and emergency surgery was observed, whereas there was no apparent interaction with insulin use or cardiac surgery. CONCLUSIONS These findings provide the first evidence that an anion gap acidosis, likely from ketoacids, develops in all patients who do not hold SGLT2 inhibitors before surgery rather than in an idiosyncratic few. If an SGLT2 inhibitor is unable to be stopped, postoperative monitoring of anion gap and serum ketones can help detect clinically significant euglycaemic diabetic ketoacidosis, particularly in those undergoing emergency surgery.
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Affiliation(s)
- Benjamin Steinhorn
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA.
| | - Jeanine Wiener-Kronish
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
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24
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Guarnotta V, Emanuele F, Salzillo R, Bonsangue M, Amato C, Mineo MI, Giordano C. Practical therapeutic approach in the management of diabetes mellitus secondary to Cushing's syndrome, acromegaly and neuroendocrine tumours. Front Endocrinol (Lausanne) 2023; 14:1248985. [PMID: 37842314 PMCID: PMC10569460 DOI: 10.3389/fendo.2023.1248985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 08/28/2023] [Indexed: 10/17/2023] Open
Abstract
Cushing's syndrome, acromegaly and neuroendocrine disorders are characterized by an excess of counterregulatory hormones, able to induce insulin resistance and glucose metabolism disorders at variable degrees and requiring immediate treatment, until patients are ready to undergo surgery. This review focuses on the management of diabetes mellitus in endocrine disorders related to an excess of counterregulatory hormones. Currently, the landscape of approved agents for treatment of diabetes is dynamic and is mainly patient-centred and not glycaemia-centred. In addition, personalized medicine is more and more required to provide a precise approach to the patient's disease. For this reason, we aimed to define a practical therapeutic algorithm for management of diabetes mellitus in patients with glucagonoma, pheochromocytoma, Cushing's syndrome and acromegaly, based on our practical experience and on the physiopathology of the specific endocrine disease taken into account. This document is addressed to all specialists who approach patients with diabetes mellitus secondary to endocrine disorders characterized by an excess of counterregulatory hormones, in order to take better care of these patients. Care and control of diabetes mellitus should be one of the primary goals in patients with an excess of counterregulatory hormones requiring immediate and aggressive treatment.
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Affiliation(s)
| | | | | | | | | | | | - Carla Giordano
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Section of Endocrinology, University of Palermo, Piazza delle Cliniche 2, Palermo, Italy
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25
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Hammond DB, Ingram CC. Euglycemic diabetic ketoacidosis in a patient on sodium-glucose cotransporter 2 inhibitors. JAAPA 2023; 36:1-3. [PMID: 37668485 DOI: 10.1097/01.jaa.0000937256.39070.5d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
ABSTRACT Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a novel drug class for treating type 2 diabetes and are unique among diabetes medications because they increase urinary glucose excretion. SGLT2 inhibitors also have shown benefit beyond reducing blood glucose in patients with cardiovascular disease, renal disease, or heart failure. The American Diabetes Association recommends SGLT2 inhibitors for patients with type 2 diabetes who have one or more of these comorbidities. This article discusses one life-threatening adverse reaction to SGLT2 inhibitors, euglycemic diabetic ketoacidosis, and recommendations about patients on SGLT2 inhibitors who need surgery.
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Affiliation(s)
- Daniel B Hammond
- Daniel B. Hammond is director of admissions and recruitment for the PA program at the University of California San Diego. Claire C. Ingram is an instructor in the Division of Endocrinology, Metabolism, and Diabetes and the Section of Maternal-Fetal Medicine at the University of Colorado School of Medicine. The authors have disclosed no potential conflicts of interest, financial or otherwise
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26
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Stamatiades GA, D'Silva P, Elahee M, Viana GM, Sideri-Gugger A, Majumdar SK. Diabetic Ketoacidosis Associated with Sodium-Glucose Cotransporter 2 Inhibitors: Clinical and Biochemical Characteristics of 29 Cases. Int J Endocrinol 2023; 2023:6615624. [PMID: 37441367 PMCID: PMC10335870 DOI: 10.1155/2023/6615624] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 06/21/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
Objective To describe the clinical and biochemical characteristics of all reported cases of DKA associated with SGLT2 inhibitor use in patients with type 2 diabetes mellitus and to identify potential risk factors. Design A retrospective case series was conducted between March 2013 and August 2019 using an electronic medical record search algorithm. Results 25 patients met the criteria for DKA associated with SGLT2i use (total of 29 cases), 15 were female, average age was 54.24 years, and mean diabetes duration was 8.76 years. The majority of the patients (23 patients) had no history of prior DKA. Average blood glucose concentrations at presentation were 298.9 ± 152.7 mg/dl. Interestingly, nearly half of the episodes (14) met the criteria of euglycemic DKA (glucose <250 mg/dl). Average anion gap values were 26.59 ± 6.15 mg/dl, bicarbonate values were 11.14 ± 5.57 mg/dl, and pH values were 7.16 ± 0.12. All had positive serum and urine ketones. The most common presenting symptoms were nausea, vomiting (18 cases), and abdominal pain (10 cases). Common precipitants were poor oral intake (18 cases) and infection (10 cases). A variety of drugs were prescribed along with an SGLT2i, and 11 of the patients were using insulin. None of the cases were fatal. Comparison between euglycemic DKA and hyperglycemic DKA did not identify any significant difference. A major limitation factor of the study was the lack of control group or comparison to other antiglycemic agents to assess the relative risk. Conclusions The majority of SGLT2i-associated DKA cases occurred in patients with T2DM without prior episodes of DKA. The most common presenting symptoms were nausea, vomiting, and abdominal pain, while poor food intake and infection were the main precipitants. Clinicians should consider the possibility of DKA in SGLT2i-treated patients presenting with these symptoms, even in absence of marked hyperglycemia.
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Affiliation(s)
- G A Stamatiades
- Department of Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT 06610, USA
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - P D'Silva
- Department of Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT 06610, USA
| | - M Elahee
- Department of Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT 06610, USA
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - G M Viana
- Department of Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT 06610, USA
| | - A Sideri-Gugger
- Department of Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT 06610, USA
- Division of Endocrinology, Columbia University Medical Center, New York, NY 10032, USA
| | - S K Majumdar
- Department of Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT 06610, USA
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27
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Wu G, Wu S, Tang J, Wu H. Delayed euDKA Associated With Dapagliflozin After Pancreatitis. Clin Ther 2023; 45:e167-e170. [PMID: 37248092 DOI: 10.1016/j.clinthera.2023.05.006] [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: 10/17/2022] [Revised: 02/26/2023] [Accepted: 05/06/2023] [Indexed: 05/31/2023]
Abstract
Euglycemic diabetic ketoacidosis (euDKA) is a rare but life-threatening adverse effect of sodium-glucose cotransporter 2 (SGLT2) inhibitors. We present a case of delayed euDKA seven days after cure of acute pancreatitis and discharge from the hospital of a 51-year-old man with type 2 diabetes mellitus (T2DM) managed with a combination of antidiabetic medications, including the SGLT2 inhibitor dapagliflozin. Prior acute pancreatitis was postulated to be a contributing factor to the development of SGLT2 inhibitor-associated euDKA in this patient discharged from the hospital. The patient was managed accordingly and improved clinically while his oral hypoglycemic agents were stopped. The risk of euDKA from SGLT2 inhibitor therapy may be increased by some stress factors (eg, infection, surgery, acute illness, low-carbohydrate diet, excessive alcohol intake). As these SGLT2 inhibitors become a popular therapeutic strategy for the management of hyperglycemia in T2DM, clinicians should be aware that acute illnesses such as pancreatitis in patients with T2DM can be potential predisposing factors for the development of SGLT2 inhibitor-associated euDKA.
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Affiliation(s)
- Gao Wu
- Department of Pharmacy, First Affiliated Hospital of Naval Military Medical University, Shanghai, China
| | - Shuxie Wu
- Hospital of Obstetrics and Gynecology, Fudan University, Shanghai, China
| | - Jin Tang
- Department of Intensive Care Unit, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hanbin Wu
- Clinical Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China.
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28
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Stöllberger C, Finsterer J, Schneider B. Adverse events and drug-drug interactions of sodium glucose co-transporter 2 inhibitors in patients treated for heart failure. Expert Rev Cardiovasc Ther 2023; 21:803-816. [PMID: 37856368 DOI: 10.1080/14779072.2023.2273900] [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: 08/16/2023] [Accepted: 10/18/2023] [Indexed: 10/21/2023]
Abstract
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.
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29
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Tommerdahl KL, Kula AJ, Bjornstad P. Pharmacological management of youth with type 2 diabetes and diabetic kidney disease: a comprehensive review of current treatments and future directions. Expert Opin Pharmacother 2023; 24:913-924. [PMID: 37071054 PMCID: PMC10198950 DOI: 10.1080/14656566.2023.2203319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 04/12/2023] [Indexed: 04/19/2023]
Abstract
INTRODUCTION Diabetic kidney disease (DKD) is a leading cause of mortality in people with type 2 diabetes (T2D), and over 50% of individuals with youth-onset T2D will develop DKD as a young adult. Diagnosis of early-onset DKD remains a challenge in young persons with T2D secondary to a lack of available biomarkers for early DKD, while the injuries may still be reversible. Furthermore, multiple barriers exist to initiate timely prevention and treatment strategies for DKD, including a lack of Food and Drug Administration approval of medications in pediatrics; provider comfort with medication prescription, titration, and monitoring; and medication adherence. AREAS COVERED Therapies that have promise for slowing DKD progression in youth with T2D include metformin, renin-angiotensin-aldosterone system inhibitors, glucagon-like peptide-1 receptor agonists, sodium glucose co-transporter 2 inhibitors, thiazolidinediones, sulfonylureas, endothelin receptor agonists, and mineralocorticoid antagonists. Novel agents are also in development to act synergistically on the kidneys with the aforementioned medications. We comprehensively review the available pharmacologic strategies for DKD in youth-onset T2D including mechanisms of action, potential adverse effects, and kidney-specific effects, with an emphasis on published pediatric and adult trials. EXPERT OPINION Large clinical trials evaluating pharmacologic interventions targeting the treatment of DKD in youth-onset T2D are strongly needed.
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Affiliation(s)
- Kalie L. Tommerdahl
- Department of Pediatrics, Section of Pediatric Endocrinology, Children’s Hospital Colorado and University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
- Ludeman Family Center for Women’s Health Research, Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Alexander J. Kula
- Department of Pediatrics, Section of Pediatric Nephrology, Lurie Children’s Hospital and Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Petter Bjornstad
- Department of Pediatrics, Section of Pediatric Endocrinology, Children’s Hospital Colorado and University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Ludeman Family Center for Women’s Health Research, Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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30
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Sitina M, Lukes M, Sramek V. Empagliflozin-associated postoperative mixed metabolic acidosis. Case report and review of pathogenesis. BMC Endocr Disord 2023; 23:81. [PMID: 37060078 PMCID: PMC10103020 DOI: 10.1186/s12902-023-01339-w] [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: 11/24/2022] [Accepted: 04/10/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND Euglycemic diabetic ketoacidosis associated with SGLT2 inhibitors is a rare, relatively new and potentially fatal clinical entity, characterized by metabolic acidosis with normal or only moderately elevated glycemia. The mechanisms are not fully understood but involve increased ketogenesis and complex renal metabolic dysfunction, resulting in both ketoacidosis and hyperchloremic acidosis. We report a rare case of fatal empagliflozin-associated acidosis with profound hyperchloremia and review its pathogenesis. CASE PRESENTATION A patient with type 2 diabetes mellitus treated with empagliflozin underwent an elective hip replacement surgery. Since day 4 after surgery, he felt generally unwell, leading to cardiac arrest on the day 5. Empagliflozin-associated euglycemic diabetic ketoacidosis with severe hyperchloremic acidosis was identified as the cause of the cardiac arrest. CONCLUSIONS This unique case documents the possibility of severe SGLT2 inhibitor-associated mixed metabolic acidosis with a predominant hyperchloremic component. Awareness of this possibility and a high index of suspicion are crucial for correct and early diagnosis.
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Affiliation(s)
- Michal Sitina
- Department of anesthesiology and intensive care medicine, St. Anne´s University Hospital, Pekarska 664/53, Brno, 656 91, Czech Republic.
- Department of Biostatistics, International Clinical Research Center, St. Anne´s University Hospital, Pekarska 664/53, Brno, 656 91, Czech Republic.
- Faculty of Medicine, Masaryk University, Kamenice 5, Brno, 625 00, Czech Republic.
| | - Marek Lukes
- Department of anesthesiology and intensive care medicine, St. Anne´s University Hospital, Pekarska 664/53, Brno, 656 91, Czech Republic
- Faculty of Medicine, Masaryk University, Kamenice 5, Brno, 625 00, Czech Republic
| | - Vladimir Sramek
- Department of anesthesiology and intensive care medicine, St. Anne´s University Hospital, Pekarska 664/53, Brno, 656 91, Czech Republic
- Faculty of Medicine, Masaryk University, Kamenice 5, Brno, 625 00, Czech Republic
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31
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Rosner MH, Ha N, Palmer BF, Perazella MA. Acquired Disorders of Hypomagnesemia. Mayo Clin Proc 2023; 98:581-596. [PMID: 36872194 DOI: 10.1016/j.mayocp.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 12/05/2022] [Accepted: 12/07/2022] [Indexed: 03/06/2023]
Abstract
Magnesium disorders are common in clinical practice and when present can manifest clinically as cardiovascular, neuromuscular, or other organ dysfunction. Hypomagnesemia is far more common than hypermagnesemia, which is largely seen in patients with reduced glomerular filtration rates receiving magnesium-containing medications. In addition to inherited disorders of magnesium handling, hypomagnesemia is also seen with excessive gastrointestinal or renal losses and due to medications such as amphotericin B, aminoglycosides, and cisplatin. Laboratory assessment of body magnesium stores largely relies on the measurement of serum magnesium levels that are a poor proxy for total body stores but does correlate with the development of symptoms. Replacement of magnesium can be challenging, with oral replacement strategies being generally more effective at slowly replacing body stores but intravenous replacement being more effective at treating the more life-threatening and severe cases of hypomagnesemia. We conducted a thorough review of the literature using PubMed (1970-2022) and the search terms magnesium, hypomagnesemia, drugs, medications, treatment, and therapy. In the absence of clear data on optimal management of hypomagnesemia, we have made recommendations on magnesium replacement based on our clinical experience.
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Affiliation(s)
- Mitchell H Rosner
- Division of Nephrology, University of Virginia Health, Charlottesville.
| | - Nam Ha
- Division of Nephrology, University of Virginia Health, Charlottesville
| | - Biff F Palmer
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas
| | - Mark A Perazella
- Section of Nephrology, Yale University School of Medicine and Section of Nephrology, West Haven VA Medical Center, West Haven, CT
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Abstract
The sodium-glucose cotransporter 2 (SGLT2) inhibitors have become an integral part of clinical practice guidelines to slow the progression of CKD in patients with and without diabetes mellitus. Although initially developed as antihyperglycemic drugs, their effect on the kidney is multifactorial resulting from profuse glycosuria and natriuresis consequent to their primary site of action. Hemodynamic and metabolic changes ensue that mediate kidney-protective effects, including ( 1 ) decreased workload of proximal tubular cells and prevention of aberrant increases in glycolysis, contributing to a decreased risk of AKI; ( 2 ) lowering of intraglomerular pressure by activating tubular glomerular feedback and reductions in BP and tissue sodium content; ( 3 ) initiation of nutrient-sensing pathways reminiscent of starvation activating ketogenesis, increased autophagy, and restoration of carbon flow through the mitochondria without production of reactive oxygen species; ( 4 ) body weight loss without a reduction in basal metabolic rate due to increases in nonshivering thermogenesis; and ( 5 ) favorable changes in quantity and characteristics of perirenal fat leading to decreased release of adipokines, which adversely affect the glomerular capillary and signal increased sympathetic outflow. Additionally, these drugs stimulate phosphate and magnesium reabsorption and increase uric acid excretion. Familiarity with kidney-specific mechanisms of action, potential changes in kidney function, and/or alterations in electrolytes and volume status, which are induced by these widely prescribed drugs, will facilitate usage in the patients for whom they are indicated.
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Affiliation(s)
- Biff F. Palmer
- Division of Nephrology, Department of Medicine, Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Deborah J. Clegg
- Internal Medicine, Texas Tech Health Sciences Center, El Paso, Texas
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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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Sex-dependent effects of canagliflozin and dapagliflozin on hemostasis in normoglycemic and hyperglycemic mice. Sci Rep 2023; 13:932. [PMID: 36650229 PMCID: PMC9845220 DOI: 10.1038/s41598-023-28225-8] [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: 11/24/2022] [Accepted: 01/16/2023] [Indexed: 01/19/2023] Open
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are antihyperglycemic drugs that decrease mortality from cardiovascular diseases. However, their effects on hemostasis in the cardioprotective effects have not been evaluated. Therefore, the effects of canagliflozin (CANA, 100 mg/kg, p.o.) and dapagliflozin (DAPA, 10 mg/kg, p.o.) on the parameters of hemostasis were investigated in female and male normoglycemic and streptozotocin (180 mg/kg, i.p.)-induced diabetic mice. CANA and DAPA reduced platelet activity in thrombus in male and female mice both normoglycemic and diabetic. CANA decreased thrombus formation in diabetic male mice, and platelet activation to ADP in diabetic female and male mice. Activation of fibrinolysis was observed in female mice, both normoglycemic and diabetic. DAPA reduced thrombus formation in diabetic male and female mice, and decreased platelet activation to ADP and fibrin formation in diabetic male mice. DAPA increased fibrin formation in normoglycemic female mice and activated fibrinolysis in diabetic female mice. CANA and DAPA exerted sex-specific effects, which were more pronounced in hyperglycemia. The antithrombotic effect of CANA and DAPA was more noticeable in male mice and could be due to platelet inhibition. The effect on coagulation and fibrinolysis was not clear since an increased coagulation and fibrinolysis were observed only in female mice.
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Yaribeygi H, Maleki M, Butler AE, Jamialahmadi T, Sahebkar A. New insights into cellular links between sodium-glucose cotransporter-2 inhibitors and ketogenesis. J Cell Biochem 2022; 123:1879-1890. [PMID: 36153819 DOI: 10.1002/jcb.30327] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/30/2022] [Accepted: 09/02/2022] [Indexed: 12/24/2022]
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT2is) are a newly developed class of highly effective antidiabetic therapies that normalize hyperglycemia via urinary glucose excretion. However, they may be accompanied by certain side effects that negatively impact their therapeutic benefits. SGLT2is induce a metabolic shift from glucose to fatty acids and thus increase lipolysis which, in turn, induces ketogenesis. The complete pathways linking SGLT2is to ketoacidosis have not yet been fully elucidated, though much is now known. Therefore, in this mechanistic study, we present the current knowledge and shed light upon the possible cellular pathways involved. A deeper understanding of the possible links between SGLT2is and ketogenesis could help to prevent adverse side effects in diabetic patients treated with these drugs.
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Affiliation(s)
- Habib Yaribeygi
- Research Center of Physiology, Semnan University of Medical Sciences, Semnan, Iran
| | - Mina Maleki
- Urology and Nephrology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alexandra E Butler
- Research Department, Royal College of Surgeons in Ireland Bahrain, Adliya, Bahrain
| | - Tannaz Jamialahmadi
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,Surgical Oncology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amirhossein Sahebkar
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran.,School of Medicine, The University of Western Australia, Perth, Australia.,Department of Biotechnology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
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Alicic R, Nicholas SB. Diabetic Kidney Disease Back in Focus: Management Field Guide for Health Care Professionals in the 21st Century. Mayo Clin Proc 2022; 97:1904-1919. [PMID: 36202498 DOI: 10.1016/j.mayocp.2022.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 03/28/2022] [Accepted: 05/03/2022] [Indexed: 12/02/2022]
Abstract
Chronic kidney disease due to diabetes, or diabetic kidney disease (DKD), is a worldwide leading cause of chronic kidney disease and kidney failure and an increasingly important global public health issue. It is associated with poor quality of life, high burden of chronic diseases, and increased risk of premature death. Until recently, people with DKD had limited therapeutic options. Treatments have focused largely on glycemic and blood pressure control and renin-angiotensin system blockade, leaving patients with significant residual risk for progression of DKD. The availability of newer classes of glucose-lowering agents, namely, sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists, has changed the therapeutic landscape for these patients. These therapies have offered unprecedented opportunities to reduce the risk for progression of kidney disease and the risk of death that have led to recent updates to clinical guidelines. As such, the American Diabetes Association, the Kidney Disease: Improving Global Outcomes, and the European Association for the Study of Diabetes now recommend the use of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists for patients with DKD to provide both kidney and cardiovascular protective benefits. This review highlights the importance of early detection of DKD and summarizes the latest recommendations in the clinical guidelines on management of patients with DKD with hope of facilitating their uptake into everyday clinical practice. An integrated approach to patient care with a multidisciplinary focus can help achieve the necessary shift in clinical care of patients with DKD.
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Affiliation(s)
- Radica Alicic
- Providence Medical Research Center, Providence Health Care, University of Washington, Spokane and Seattle
| | - Susanne B Nicholas
- David Geffen School of Medicine at University of California, Los Angeles.
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Kula AJ. Considerations and possibilities for sodium-glucose cotransporter 2 inhibitors in pediatric CKD. Pediatr Nephrol 2022; 37:2267-2276. [PMID: 35088160 DOI: 10.1007/s00467-022-05456-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 12/28/2021] [Accepted: 12/28/2021] [Indexed: 10/19/2022]
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT2is) were originally developed as glucose-lowering agents. These medications function by inhibiting glucose and sodium reabsorption in the S1 segment of the proximal tubule. Early clinical trials in adults with type 2 diabetes mellitus (T2DM) suggested a significant improvement in kidney and cardiovascular outcomes with SGLT2i therapy. Since then, SGLT2is have become a mainstay treatment for adult patients with CKD. A growing body of research has explored deploying these medications in new clinical contexts and investigated the mechanisms underlying their physiologic effects. However, patients under the age of 18 years have been largely excluded from all major trials of SGLT2i. This review aims to summarize the available clinical evidence, physiology, and mechanisms relating to SGLT2is to inform discussions about their implementation in pediatrics.
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Affiliation(s)
- Alexander J Kula
- Division of Pediatric Nephrology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA. .,Division of Pediatric Nephrology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 Chicago Ave., IL, Chicago, USA.
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Kurata Y, Nangaku M. Dapagliflozin for the treatment of chronic kidney disease. Expert Rev Endocrinol Metab 2022; 17:275-291. [PMID: 35822873 DOI: 10.1080/17446651.2022.2099373] [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: 05/17/2022] [Accepted: 07/05/2022] [Indexed: 10/17/2022]
Abstract
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.
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Affiliation(s)
- Yu Kurata
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Bunkyo-ku, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Bunkyo-ku, Japan
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Yau K, Dharia A, Alrowiyti I, Cherney DZ. Prescribing SGLT2 Inhibitors in Patients with Chronic Kidney Disease: Expanding Indications and Practical Considerations. Kidney Int Rep 2022; 7:1463-1476. [PMID: 35812300 PMCID: PMC9263228 DOI: 10.1016/j.ekir.2022.04.094] [Citation(s) in RCA: 71] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/08/2022] [Accepted: 04/25/2022] [Indexed: 12/20/2022] Open
Affiliation(s)
- Kevin Yau
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Atit Dharia
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ibrahim Alrowiyti
- 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
- Correspondence: David Z.I. Cherney, Division of Nephrology, Department of Medicine, Toronto General Hospital, 585 University Avenue, 8N-845, Toronto, Ontario, M5G 2N2, Canada.
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Morillas H, Galcerá E, Alania E, Seller J, Larumbe A, Núñez J, Valle A. Sodium-glucose Co-transporter 2 Inhibitors in Acute Heart Failure: A Review of the Available Evidence and Practical Guidance on Clinical Use. Rev Cardiovasc Med 2022; 23:139. [PMID: 39076216 PMCID: PMC11273890 DOI: 10.31083/j.rcm2304139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/04/2022] [Accepted: 02/22/2022] [Indexed: 07/31/2024] Open
Abstract
Sodium-glucose co-transporter 2 (SGLT2) inhibitors were initially conceived as glucose-lowering agents. However, striking renal and cardiovascular benefits were observed in type 2 diabetes trials. This led to evaluate it in dedicated studies in chronic heart failure (HF) and chronic kidney disease, which also showed remarkable clinical results. Given this findings, and taking into account the multiple mechanisms of action, the use of SGLT2 inhibitors in acute heart failure seemed promising. Sotagliflozin was the first SGLT2 inhibitor to reduce heart failure hospitalizations within the acute setting in the SOLOIST-WHF trial. Only type 2 diabetes patients were included, with a preserved and reduced ejection fraction. In slightly less than half of the cohort, this medication was started when the diuretic therapy was transitioned from intravenous to oral, during the hospital admission. In the rest of the patients, sotagliflozin was started early after discharge. Empagliflozin proved to be safe, well-tolerated, increased diuresis, and reduced a combined clinical endpoint (worsening HF, rehospitalization for HF, or death at 60 days) when administered within the first 24 hours of an acute heart failure hospitalization in the EMPA-RESPONSE-AHF trial. More recently, empagliflozin showed a reduction in a composite primary endpoint of death, heart failure events, and quality of life compared to placebo in the EMPULSE trial. Empagliflozin was started after the initial stabilization phase, but while patients were still admitted and receiving intravenous loop diuretics. Less than half of the patients were diabetic and two-thirds had a left ventricular ejection fraction below 40%. Dapagliflozin is currently being tested in the DAPA ACT HF-TIMI 68 trial, which plans to enroll 2400 patients admitted with acute heart failure and reduced ejection fraction. We envision SGLT2 inhibitors as a useful tool in acute heart failure syndrome given the additive diuretic effect, and minimal impact on blood pressure, kidney function, and electrolytes. Its dosage schedule is simple and can help initiation and tolerance of other medical therapy. However, there is an increased risk of genital infections and euglycaemic ketoacidosis. Notwithstanding, once critically ill and fasting patients are excluded, early administration of SGLT2 inhibitors is safe. This review summarizes the development of SGLT2 inhibitors and the available evidence supporting their use during an acute heart failure admission. We also propose a practical guideline for in-hospital initiation and monitoring.
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Affiliation(s)
- Herminio Morillas
- Cardiology Department, Hospital Marina-Salud de Denia, 03700 Alicante, Spain
| | - Emilio Galcerá
- Cardiology Department, Hospital Marina-Salud de Denia, 03700 Alicante, Spain
| | - Edgardo Alania
- Cardiology Department, Hospital Marina-Salud de Denia, 03700 Alicante, Spain
| | - Julia Seller
- Cardiology Department, Hospital Marina-Salud de Denia, 03700 Alicante, Spain
| | - Ainhoa Larumbe
- Cardiology Department, Hospital Marina-Salud de Denia, 03700 Alicante, Spain
| | - Julio Núñez
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universidad de Valencia, INCLIVA Health Research Institute, 46010 Valencia, Spain
- CIBER Cardiovascular, Spanish Cardiovascular Research Network, Carlos III Health Research Institute, 28029 Madrid, Spain
| | - Alfonso Valle
- Cardiology Department, Hospital Marina-Salud de Denia, 03700 Alicante, Spain
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Palmer BF, Clegg DJ. Metabolic Flexibility and Its Impact on Health Outcomes. Mayo Clin Proc 2022; 97:761-776. [PMID: 35287953 DOI: 10.1016/j.mayocp.2022.01.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 01/04/2022] [Accepted: 01/12/2022] [Indexed: 02/06/2023]
Abstract
A metabolically flexible state exists when there is a rapid switch between glucose and fatty acids during the transition between the fed and fasting state. This flexibility in fuel choice serves to prevent hyperglycemia following a meal and simultaneously ensures an adequate amount of blood glucose is available for delivery to the brain and exclusively glycolytic tissues during fasting. The modern era is characterized by chronic overnutrition in which a mixture of fuels is delivered to the mitochondria in an unabated manner thereby uncoupling the feast and famine situation. The continuous influx of fuel leads to accumulation of reducing equivalents in the mitochondria and an increase in the mitochondrial membrane potential. These changes create a microenvironment fostering the generation of reactive oxygen species and other metabolites leading to deleterious protein modification, cell injury, and ultimately clinical disease. Insulin resistance may also play a primary role in this deleterious effect. The imbalance between mitochondrial energy delivery and use is made worse with a sedentary lifestyle. Maneuvers that restore energy balance across the mitochondria activate pathways that remove or repair damaged molecules and restore the plasticity characteristic of normal energy metabolism. Readily available strategies to maintain energy balance across the mitochondria include exercise, various forms of caloric restriction, administration of sodium-glucose cotransporter-2 inhibitors, cold exposure, and hypobaric hypoxia.
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Affiliation(s)
- Biff F Palmer
- Department of Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Lin CW, Hung SY, Chen IW. Relationship of concomitant anti-diabetic drug administration with sodium-glucose co-transporter 2 inhibitor-related ketosis. J Int Med Res 2022; 50:3000605221090095. [PMID: 35352579 PMCID: PMC8973047 DOI: 10.1177/03000605221090095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE The use of sodium-glucose co-transporter 2 inhibitors (SGLT2is) may be associated with ketoacidosis. Therefore, the associated risk factors should be identified. In particular, information regarding the effects of the co-administration of anti-diabetic drugs is lacking. METHODS We performed a retrospective study of 68 consecutive patients with diabetes who were taking an SGLT2i and attending a single medical center. After a period of treatment (median 78 days), their circulating ketone concentrations were measured. The concomitant use of other anti-diabetic drugs was analyzed to identify independent risk factors associated with ketosis. RESULTS Twenty-five participants were taking empagliflozin, 23 were taking dapagliflozin, and 20 were taking canagliflozin. During the treatment period, no ketoacidotic events were recorded and their mean circulating ketone concentrations at the end of the study period were similar (0.3 mmol/L in the empagliflozin group, 0.26 mmol/L in the dapagliflozin group, and 0.25 mmol/L in the canagliflozin group). After adjustment for the use of anti-diabetic drugs, pioglitazone was found to be independently associated with a risk of high circulating ketone concentration (B value: 0.361, 95% confidence interval: 0.181-0.541). CONCLUSION SGLT2i-associated ketoacidosis was found to be infrequent, but the concomitant use of pioglitazone was associated with a higher risk of ketosis.
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Affiliation(s)
- Cheng-Wei Lin
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
| | - Shih-Yuan Hung
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
| | - I-Wen Chen
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
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Ujjawal A, Schreiber B, Verma A. Sodium-glucose cotransporter-2 inhibitors (SGLT2i) in kidney transplant recipients: what is the evidence? Ther Adv Endocrinol Metab 2022; 13:20420188221090001. [PMID: 35450095 PMCID: PMC9016587 DOI: 10.1177/20420188221090001] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 03/04/2022] [Indexed: 12/15/2022] Open
Abstract
Several recent randomized controlled trials (RCTs) have demonstrated the wide clinical application of sodium-glucose cotransporter-2 inhibitors (SGLT2i) in improving kidney and cardiovascular outcomes in patients with native kidney disease. In April 2021, Dapagliflozin became the first SGLT2 inhibitor to be approved by the Food and Drug Administration (FDA) for the treatment of chronic kidney disease (CKD) regardless of diabetic status. However, while these agents have drawn much acclaim for their cardiovascular and nephroprotective effects among patients with native kidney disease, little is known about the safety and efficacy of SGLT2i in the kidney transplant setting. Many of the mechanisms by which SGLT2i exert their benefit stand to prove equally as efficacious or more so among kidney transplant recipients as they have in patients with CKD. However, safety concerns have excluded transplant recipients from all large RCTs, and clinicians and patients alike are left to wonder if the benefits of these amazing drugs outweigh the risks. In this review, we will discuss the known mechanisms SGLT2i exploit to provide their beneficial effects, the potential benefits, and risks of these agents in the context of kidney transplantation, and finally, we will discuss current findings of the published literature for SGLT2i use in kidney transplant recipients and propose potential directions for future research.
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Jenssen TG. Efficacy and safety of Sodium-Glucose-Transporter-2 inhibitors in kidney transplant patients. Curr Opin Nephrol Hypertens 2021; 30:577-583. [PMID: 34507336 DOI: 10.1097/mnh.0000000000000749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review discusses current evidence and future perspectives for use of SLT2 inhibitors in kidney transplant recipients (KTRs). RECENT FINDINGS Sodium-Glucose-Transporter-2 inhibitors (SGLT2is) lower plasma glucose in patients with type 2 diabetes, and protect against heart failure and progression of chronic kidney disease by a glucose-independent mechanism. Most of the current studies with SGLT2is in kidney transplant patients are however short-term retrospective case studies. These, together with one small randomized clinical trial, show that SGLT2is lower glucose also in KTRs with type 2 diabetes or posttransplant diabetes mellitus. Larger reductions in HbA1c (-0.5 to 1.5% points) are seen only in patients with estimated GFR > 60 ml/min/1.73m2 and HbA1c > 8%. With lower gomerular filtration rate (GFR) or glycated hemoglobin (HbA1c) the glucose-lowering effect is trivial. However, a reduction in body weight, blood pressure and uric acid is also seen, whereas the frequency of side effects (mycotic or urinary tract infections) does not seem to exceed what is seen in nontransplanted patients. Long-term effects on GFR have not been studied in kidney transplanted patients, but SGLT2is induce an early dip in GFR also in these patients. This could signal a beneficial long-term effect on renal hemodynamics. SUMMARY SGLT2is lower glucose safely also in patients with single kidney grafts, but long-term kidney function and patient survival are yet to be explored.
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Affiliation(s)
- Trond G Jenssen
- University Hospital of Oslo, Rikshospitalet, Department of Organ Transplantation, University of Oslo, Institute of Clinical Medicine, Oslo, Norway
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Triozzi JL, Parker Gregg L, Virani SS, Navaneethan SD. Management of type 2 diabetes in chronic kidney disease. BMJ Open Diabetes Res Care 2021; 9:9/1/e002300. [PMID: 34312158 PMCID: PMC8314731 DOI: 10.1136/bmjdrc-2021-002300] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/04/2021] [Indexed: 12/20/2022] Open
Abstract
The management of patients with type 2 diabetes and chronic kidney disease (CKD) encompasses lifestyle modifications, glycemic control with individualized HbA1c targets, and cardiovascular disease risk reduction. Metformin and sodium-glucose cotransporter-2 inhibitors are first-line agents. Glucagon-like peptide-1 receptor agonists are second-line agents. The use of other antidiabetic agents should consider patient preferences, comorbidities, drug costs, and the risk of hypoglycemia. Renin-angiotensin-aldosterone system inhibitors are strongly recommended for patients with diabetes, hypertension, and albuminuria. Non-steroidal mineralocorticoid receptor antagonists, which pose less risk of hyperkalemia than steroidal agents, are undergoing further evaluation among patients with diabetic kidney disease. Here, we discuss important advancements in the management of patients with type 2 diabetes and CKD.
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Affiliation(s)
| | - L Parker Gregg
- VA Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Houston, Texas, USA
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Section of Nephrology, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Salim S Virani
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations, Houston, Texas, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Section of Cardiology, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Sankar D Navaneethan
- VA Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Houston, Texas, USA
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Section of Nephrology, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Institute of Clinical and Translational Research, Baylor College of Medicine, Houston, Texas, USA
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