The SGLT-2 Inhibitors in Personalized Therapy of Diabetes Mellitus Patients

SGLT2 Inhibitor Use and Risk of Breast Cancer Among Adult Women with Type 2 Diabetes

INTRODUCTION

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a relatively new class of antihyperglycemic agents, with the potential to inhibit breast cancer development. However, the association between SGLT2 inhibitors and risk of breast cancer in human studies is unclear.

OBJECTIVE

The aim of our study is to use a large national claims database to assess the association between SGLT2 inhibitor use and risk of breast cancer.

METHODS

We considered a study population of 158,483 adult women with type 2 diabetes who newly initiated SGLT2 inhibitors or dipeptidyl peptidase 4 (DPP4) inhibitors using Optum's deidentified Clinformatics Data Mart Database between 1 January 2013 and 31 March 2022. The association between SGLT2 inhibitor use and risk of breast cancer was examined using Cox proportional hazard models stratified by age in the overall sample and in a subsample based on propensity score and medication initiation time matching. The effect of medication use duration was explored.

RESULTS

With an average follow-up of 2.2 years, 2154 breast cancer cases were identified. There was no significant association between SGLT2 inhibitor use and the risk of breast cancer in overall sample (HR = 0.96; 95% CI 0.87, 1.06), in women younger than 51 years old (HR = 0.88; 95% CI 0.59, 1.32), or in women aged 51 years or older (HR = 0.95; 95% CI 0.86, 1.04). The results remained nonsignificant using matching, medication use duration, and sensitivity analyses.

CONCLUSION

Our findings suggest SGLT2 inhibitors use was not associated with breast cancer risk compared with DPP4 inhibitors use. Studies with longer follow-up and better adjustments are needed to confirm the finding.

[Synergistic effects of GABA and hypoglycemic drugs]

Diabetes mellitus (DM) is the leading cause of premature death and disability. Despite a significant number of drugs, the effectiveness of therapy aimed at normalizing the level of glycemia and preventing complications does not fully satisfy doctors and patients. Therefore, the search for new approaches for the prevention and treatment of DM and its complications continues. Significant resources are used to develop new drugs, but recently the possibility of using «old» widely available drugs with newly discovered pleiotropic properties has been substantiated. These may include preparations of gammaaminobutyric acid (GABA) and agents that directly or indirectly activate GABAergic transmission, which have a pronounced pancreatic protective effect, which has been widely discussed in foreign literature over the past 10-15 years. However, there are few such publications in the domestic literature.It has been established that the content of GABA in β-cells in patients with type 1 and type 2 diabetes is reduced and this correlates with the severity of the disease. Genetic suppression of GABA receptors causes a significant decrease in the mass of β-cells and glucose-stimulated insulin secretion, which confirms the importance of GABA in ensuring glucose homeostasis and the advisability of replenishing the GABA deficiency in DM with its additional administration. It has been established that in animals with DM, GABA suppresses apoptosis and stimulates the regeneration of β-cells, increases β-cell mass and insulin production.Experimental data have been obtained indicating a synergistic effect of GABA when combined with glucagon-like peptide-1 (GLP-1) receptor agonists, DPP-4 inhibitors and sodium-glucose cotransporter 2 (SGLT-2) inhibitors, when a more pronounced pancreoprotective effect is observed, due to decrease in oxidative and nitrosative stress, inflammation, increase in the level of Klotho protein, Nrf-2 activity and antioxidant defense enzymes, suppression of NF-kB activity and expression of pro-inflammatory cytokines. As a result, all this leads to a decrease in apoptosis and death of β-cells, an increase in β-cell mass, insulin production and, at the same time, a decrease in glucagon levels and insulin resistance.The review substantiates the feasibility of using GABA and drugs with a positive GABAeric effect in combination with new generation antidiabetic agents: GLP-1 receptor agonists, DPP-4 inhibitors and SGLT-2 inhibitors in order to increase their antidiabetic potential.The search was carried out in the databases Pubmed, eLibrary, Medline. Keywords: diabetes mellitus, gamma-aminobutyric acid, glucagon-like peptide-1, GLP-1 receptor agonists, glucose-dependent insulinotropic peptide, dipeptidyl peptidase inhibitors, sodium-glucose cotransporter 2 inhibitors. The search was carried out from 2000 to 2022, but the review presents the results studies published mainly in the last 3 years, due to the requirements of the journal for the maximum amount of work and the number of sources.

Sodium-Glucose Co-transporter-2 Inhibitors in Heart Failure with Preserved Ejection Fraction: A Breakthrough in Improvement of Clinical Outcomes?

The conventional conception of the therapy of heart failure (HF) with reduced ejection fraction has been recently modified by adding sodium-glucose co-transporter-2 (SGLT2) inhibitors to the combination consisting of beta blockers, mineralocorticoid receptor antagonists, and angiotensin receptor-neprilysin inhibitors, with the aim of improving clinical outcomes. It remains unclear whether other sub-populations of patients with HF, having either HF with preserved ejection fraction (HFpEF) or HF with mildly reduced ejection fraction, are relevant candidates for the effective therapeutic intervention that includes SGLT2 inhibitors. The purpose of the narrative review is to elucidate plausible perspectives for the clinical implementation of SGLT2 inhibitors into optimal medical therapy in patients with HFpEF. The authors searched the bibliographic databases (Embase, Medline, and the Web of Science) and the Cochrane Central to find English-written publications satisfying the purpose of this study. The authors included eight studies and two meta-analyses that have been reported as completed and found that there were high heterogeneous data regarding the fact that SGLT2 inhibitors had strict resemblance in their efficacy among patients with HFpEF with and without Type 2 diabetes. Due to the use of unpublished data and findings from the trials ended early, there is a lack of upper left ventricular ejection fraction threshold levels to identify inclusion criteria and no agreement in heart failure with reduced ejection fraction determination. However, the results of the meta-analysis, especially come from subgroups’ analysis, appeared to be relevantly optimistic for use of SGLT2 inhibitors in HFpEF therapy.

Inflammatory Mechanisms of Diabetes and Its Vascular Complications

The main cause of death in patients with type 2 DM is cardiovascular complications resulting from the progression of atherosclerosis. The pathophysiology of the association between diabetes and its vascular complications is complex and multifactorial and closely related to the toxic effects of hyperglycemia that causes increased generation of reactive oxygen species and promotes the secretion of pro-inflammatory cytokines. Subsequent oxidative stress and inflammation are major factors of the progression of type 2 DM and its vascular complications. Data on the pathogenesis of the development of type 2 DM and associated cardiovascular diseases, in particular atherosclerosis, open up broad prospects for the further development of new diagnostic and therapeutic approaches.

Personalized Care and Treatment Compliance in Chronic Conditions

Chronic diseases are commonly defined as conditions that last one year or more and require ongoing medical attention, limit activities of daily living, or both [...].