[EMPA-KIDNEY: empagliflozin in chronic kidney disease]

The inhibition of the renin-angiotensin system represents the first preventive treatment of the chronic kidney disease (CKD), especially in presence of albuminuria. Recently, sodium-glucose cotransporter type 2 inhibitors (SGLT2i, gliflozins) demonstrated a nephroprotective effect, first in patients with type 2 diabetes at cardiovascular risk, then in diabetic patients with CKD assessed by a reduction of the glomerular filtration rate (GFR) and albuminuria (CREDENCE with canagliflozin), and finally in patients with CKD and albuminuria, with or without diabetes (DAPA-CKD with dapagliflozin). EMPA-KIDNEY study compared the effects of empagliflozin 10 mg/day versus placebo in patients with CKD, with or without diabetes. In comparison with the two previous renal studies, this clinical trial randomised patients with a lower GFR (78 % of patients with GFR inferior to 45 mL/min/1.73 m²) and a lower level of albuminuria (20 % of patients without pathological albuminuria). EMPA-KIDNEY demonstrated a reduction by 28 % (p inferior to 0.001) of the primary composite outcome (progression of CKD or cardiovascular death) and of several renal endpoints, including the shift to terminal CKD (-33 %), independently of the presence of diabetes, and with a tolerance profile comparable to what is already known. EMPA-KIDNEY results reinforce the use of SGLT2is, in general, and of empagliflozin, in particular, in a broader population with CKD and, thus, the indication of this pharmacological class in nephrology in combination with inhibitors of the renin-angiotensin system.

[Inclisiran (Leqvio®), a potent cholesterol-lowering agent by inhibiting PCSK9 using small interfering RNA-based innovative therapy]

PCSK9 (Proprotein Convertase Subtilisin/Kexin type 9) inhibition has proven its interest to potentiate the cholesterol-lowering effects of statins. Indeed, this protein contributes to the intracellular degradation of LDL cholesterol receptors and thereby reduces their recycling and expression at the hepatocyte membrane. PCSK9 inhibition allows a major and sustained reduction of LDL cholesterol (LDL-c) in patients with familial hypercholesterolaemia or with established cardiovascular disease. Two monoclonal antibodies that inhibit the effect of PCSK9 are currently commercialized, alirocumab and evolocumab. Another approach consists in the inhibition of PCSK9 synthesis. Inclisiran is a novel small interfering RNA-based therapy (anti-sense). By binding to the messenger RNA (mRNA) precursor of PCSK9, inclisiran inhibits the PCSK9 gene expression, resulting in increased hepatocyte recycling and membrane expression of LDL receptors and decreased levels of LDL-c. This article summarizes the mode of action, pharmacokinetics, efficacy, safety profile, indications and reimbursement conditions of inclisiran. This novel cholesterol-lowering drug is indicated as add-on therapy in adults with atherosclerotic cardiovascular disease or with heterozygous familial hypercholesterolaemia in whom LDL-c level is ? 100 mg/dl and does not reach target LDL-c levels despite statin and ezetimibe or without statin or ezetimibe in case of intolerance or contra-indication for one of these medications.

[Prescribing a SGLT2 inhibitor for treating heart failure without inducing hypoglycaemia]

Sodium-glucose cotransporter type 2 inhibitors (SGLT2i or gliflozins) improve the prognosis of patients with heart failure, independently of the presence of diabetes. They are now recommended for the treatment of heart failure in international guidelines. The addition of a gliflozin driven by such a cardiological indication may require some adjustment of the antidiabetic therapy. The aim of this concise article is to discuss the potential risk of hypoglycaemia, highly deleterious in fragile patients at risk, following the prescription of a gliflozin in patients with heart failure. Different clinical situations will be considered, both in nondiabetic patients and in patients with type 2 diabetes already treated with a variety of antihyperglycaemic agents, metformin, sulphonylureas, gliptins, GLP-1 receptor agonists and insulin.

[Apexxnar®, 20-valent pneumococcal conjugate vaccine]

Streptococcus pneumoniae infections cause bacteremic and non-bacteremic community-acquired pneumonia and invasive pneumococcal diseases (IPD) such as bacteremia, sepsis and acute meningitis. They are potentially lethal. Although polysaccharide vaccines (PPV23, Pneumovax 23®) have already provided protection in at-risk individuals, they have been imperfect, mainly because the development of anti-polysaccharide antibodies occurs without the help of T cells. The introduction of immunogenic protein conjugate vaccines (ICVs) has overcome this problem and provided better and longer lasting protection. The first available vaccine of this type for adults was Prevenar 13®, targeting 13 polysaccharides of S. pneumoniae (PCV13). A new vaccine, Apexxnar®, targeting 20 polysaccharides (PCV20), the 13 of Prevenar 13®, to which 7 other serotypes considered to be equally responsible for invasive infections have been added, has recently been launched. Clinical studies have demonstrated a good immunogenic response against all 20 serotypes in adult patients who are either vaccine-naive or previously vaccinated with PPV23 and/or PCV13. Furthermore, the tolerance of the PCV20 vaccine was found to be comparable to that of Prevenar 13®. Vaccination with PCV20 involves a single injection. The Belgian Superior Health Council has recently reiterated the importance of vaccinating at-risk individuals against S. pneumoniae (a vaccination that is still under-performed). It now recommends vaccination with PCV20 (Apexxnar®) as the preferred primary vaccination regimen in high-risk adults with co-morbidities or in good health aged between 65 and 85 years.

[Anti-inflammatory drugs : from old classical ones to biotherapies and JAK inhibitors]

Anti-inflammatory medications are known since a long time and still remain among the most used drugs in clinical practice. They belong to a variety of pharmacological classes and act via very different biochemical mechanisms. Nonsteroid anti-inflammatory drugs, which are derived from acetylsalicylic acid, and cortisone with its multiple derivative molecules (glucocorticoids) remain the background therapy of diseases associated with inflammation, either acute or chronic. Some old molecules, known to exert an anti-inflammatory activity, still have specific indications, colchicine and methotrexate as examples. However, the greatest innovation of the last two decades results from the launch of biological therapies, starting with the use of anti-TNF? agents to move towards monoclonal antibodies targeting various pro-inflammatory interleukins (IL-1, IL-6, IL-5, IL-17, IL-23, …). Finally, small molecules acting as JANUS kinase inhibitors or tyrosine kinase 2 inhibitors open new alternatives in severe diseases that are resistant to other anti-inflammatory drugs. The interest for anti-inflammatory medications has been reinforced since the COVID-19 outbreak.

[Non-alcoholic steatohepatitis (NASH) : a model of metabolic inflammation («metaflammation»)]

Diseases related to fatty liver, independently of alcohol consumption («non-alcoholic fatty liver disease» or NAFLD), are increasing because of the epidemics of obesity and type 2 diabetes. These disorders reflect a continuum that comprises isolated steatosis, steatohepatitis (NASH) and fibrosis, with, at the end, an increased risk of cirrhosis and hepatocarcinoma. It has been recently proposed to replace the term NAFLD by MAFLD, i.e. «Metabolic (dysfunction) Associated Fatty Liver Disease», which better reflects the pathogenesis of the disease. Inflammation plays a crucial role in the aggravation of the disorder and profoundly influences the prognostic evolution. This article illustrates the natural history of this underestimated metabolic disorder, recall the diagnostic criteria used in clinical practice, emphasizes the deleterious role of inflammation and discusses some therapeutic perspectives.

[Inflammation and cancer : a complex two-way relationship]

The relationships between inflammation and cancer are known since the original work by Virchow in the 19th century and have been largely confirmed after-wards. An interesting question is what might be the primum movens. Numerous clinical observations have shown that a chronic inflammatory state, as that observed with some infections, toxic agents or dysimmune diseases, may be associated with the development of cancer later on. Besides, cancer is generally accompanied by an inflammatory microenvironment, with numerous cellular and humoral components, which promotes both tumorigenesis and the invasivity of the tumour. This article aims at defining the pathophysiology of this association, with a description of underlying mechanisms and mediators, and at determining possible therapeutic implications.

[About the safety profile of SGLT2 inhibitors]

Since their launch, sodium-glucose cotransporter type 2 inhibitors (SGLT2is) were suspected to be associated with various adverse events. They contributed to delay, as in France, or to restrict the use of this new pharmacological class in clinical practice, despite remarkable results reported in large cardiovascular or renal clinical trials. This article is devoted to three major adverse events that were imputed to SGLT2is : lower-limb extremity amputations, euglycaemic ketoacidosis and acute kidney injuries. In contrast to pharmacovigilance reports that raised suspicion, analysis of all data from the literature, either placebo-controlled trials or retrospective observational cohort studies, led to rather reassuring conclusions. The incidence of amputations does not appear to be increased while cases of acute kidney injury are reduced instead of increased as suspected earlier. Ketoacidosis events are almost doubled with SGLT2is versus comparators, yet their incidence remains extremely low among patients with type 2 diabetes. Of note, this potentially severe complication contributes to the denial of marketing authorization and reimbursement of SGLT2is in the population with type 1 diabetes.

[From the discovery of phlorizin (a Belgian story) to SGLT2 inhibitors]

Most physicians do not know, or do not remember, the name of phlorizin. Hence this molecule has a major historical importance because it was the precursor of gliflozins, a new class of oral antidiabetic drugs with recent therapeutic perspectives beyond diabetes. This article recalls the history of phlorizin: its discovery in the 19th century by De Koninck and Stas, the demonstration of its ability to induce glucosuria and reduce hyperglycaemia by von Mering, its use to demonstrate the concept of glucose toxicity by the team of DeFronzo and finally the development of selective (phlorizin being not selective) sodium-glucose cotransporter type 2 inhibitors (gliflozins) which block glucose reabsorption in renal tubules. Gliflozins have increasing therapeutic indications, not only in type 2 diabetes, but also in cardiology and nephrology among non-diabetic people with heart failure or renal insufficiency.

[Bempedoïc acid, new cholesterol-lowering drug]

Patients at high or very high cardiovascular risk should have a LDL cholesterol level as low as possible, a target that may be difficult to be reached with statin monotherapy, especially when this treatment is not well tolerated. It is generally recommended to use pharmacological combinations to reach more and more strict objectives. Bempedoic acid is a new oral cholesterol-lowering medication that reduces hepatic cholesterol synthesis by inhibiting the enzyme adenosine triphosphate (ATP)-citrate lyase enzyme. Because this medication is a prodrug that is selectively activated in the liver, it is deprived of any muscular adverse effect. This article summarizes the mode of action, pharmacokinetics, efficacy, safety profile, indications and reimbursement conditions of bempedoic acid. This novel cholesterol-lowering drug is indicated in combination with statins (with or without ezetimibe) in patients who do not attain LDL goals despite administration of a statin at the maximum tolerated dose or in case of statin intolerance.

[SGLT2 inhibitors and RAAS blockers : similarities, differences and complementarity]

Both renin-angiotensin-aldosterone system inhibitors (RAASi) and sodium-glucose cotransporter type 2 inhibitors (SGLT2i, gliflozins) reduce the risk of heart failure and of progressing towards end-stage renal disease, especially in patients with type 2 diabetes (T2D). Positive results reported in patients with T2D have been confirmed in people without diabetes. These two pharmacological classes now occupy a privileged place in international guidelines, in diabetology, cardiology and nephrology. The present article describes similarities and differences between these two types of medications. It emphasizes the importance of combining both approaches in order to optimize the cardiovascular and renal prognosis, while maintaining a good safety profile.

[Environment and cancer : not easy to dissect the exposome !]

Environment contains numerous potentially toxic substances among which certain have demonstrated to be carcinogenic. They can reach the human organism mainly through the repiratory or digestive routes. Even if it is not always easy to demonstrate a causal relationship in observational studies whose interpretation is limited by numerous confounding factors, some compounds from the environment are clearly associated with a higher risk of cancers. The present article describes the effects of both outdoor and indoor air pollution, pesticides, some endocrine disruptors and radiations. The identification of environmental factors associated with a higher risk of cancer allows implement eradication strategies and thereby efficacious prevention.

[Editorial. Oncology, at a turning point in its history]

No abstract available.

[SGLT2 inhibitors, new option to prevent or treat heart failure]

Gliflozins (sodium-glucose cotransporter type 2 inhibitors or SGLT2is) are the only glucose-lowering agents that have proven their ability to reduce major cardiovascular events, hospitalisations for heart failure and the progression to end-stage kidney disease in at risk patients with type 2 diabetes (T2D). One of the most marked and reproducible effects is the reduction in hospitalisations for heart failure. This protective effect was observed in all large prospective cardiovascular outcome trials, independently of the presence of heart failure at inclusion, and was confirmed in two dedicated trials that specifically targeted patients with heart failure and reduced left ventricular ejection fraction, with or without diabetes : DAPA-HF with dapagliflozin and EMPEROR-reduced with empagliflozin. The reduction in hospitalisations for heart failure appeared more marked when baseline renal function was impaired, including when estimated glomerular filtration rate (eGFR) was inferior to 45 ml/min/1.73 m². These favourable results contribute to give a privileged position to SGLT2is in more recent international guidelines produced by diabetologists, cardiologists and nephrologists. According to these guidelines, the prescription of SGLT2is should be extended to patients with an eGFR between 30 and 60 ml/min/1.73 m² as well to non-diabetic patients with heart failure and reduced ejection fraction. For other patients with preserved ejection fraction, one has to wait for further results from ongoing large prospective trials.

[Crossed eyes on arterial blood pressure in sitting position]

Prolonged standing or even sitting position can induce a fall in arterial blood pressure because of gravity that provokes a blood volume sequestration in lower limbs. Such a phenomenon may be associated with orthostatic dizziness or sometimes syncope. We present the image of a continuous monitoring using a Finometer® of systolic blood pressure and heart rate. Crossing legs while in sitting position allows immediate increase of arterial blood pressure. This pathophysiological mechanism explains why numerous people cross legs in sitting position, for instance during a prolonged meeting, in an auditorium or in a movie theater. This common phenomenon has potential diagnostic, therapeutic and prognostic implications.

[Continuing or stopping metformin in patients with type 2 diabetes exposed to SARS-CoV-2 ?]

Both obesity and type 2 diabetes (T2D) are recognized risk factors for developing a more severe form of COVID-19, with a higher death rate. Metformin is considered as the first-line medication for the treatment of T2D, especially in obese patients. Beyond its glucose-lowering activity, metformin exerts pleiotropic effects, among which an anti-inflammatory effect that could be beneficial. However, metformin is contraindicated in case of severe renal insufficiency, liver failure and/or unstable heart failure, because of a risk of lactic acidosis. Yet, COVID-19, besides the well-known pneumonia that can be responsible for severe hypoxemia, may be associated with multisystemic organ failure, among which kidneys, liver and heart. Thus, the question arises whether metformin, which represents the background therapy in above 80 % of patients with T2D, should be continued in patients exposed to SARS-CoV-2 or instead be stopped. This article summarizes the most important results of observational studies, which all argue for a beneficial effect of metformin therapy that is associated with a significant reduction in mortality among hospitalized patients with T2D due to COVID-19. Finally, some practical advices will be given.

[SGLT2 inhibitors in patients with chronic kidney disease : from clinical trials to guidelines and new prospects for clinical practice]

Sodium-glucose cotransporter type 2 inhibitors (iSGLT2 or gliflozins) exert their antidiabetic action through a specific renal mechanism, by inhibiting tubular glucose reabsorption. These agents have proven their efficacy to reduce major cardiovascular events and hospitalisation for heart failure, but also the progression of chronic kidney disease (CKD), in patients with type 2 diabetes (T2DM) at high risk, independently of glucose control. While the glucose-lowering effect of iSGLT2 is decreasing with the decline of estimated glomerular filtration rate (eGFR), both cardiovascular and renal protections remain present until an eGFR as low as 30 ml/min/1,73 m². These effects were demonstrated in several meta-analyses and in two trials specifically dedicated to renal outcomes in patients with CKD and macroalbuminuria : CREDENCE with canagliflozin and Dapa-CKD with dapagliflozin. In addition, Dapa-CKD showed similar positive results whatever the presence or absence of T2DM. Safety profile of SGLT2is among patients with CKD is good and similar to that of patients with normal renal function. These favourable findings led to a privileged place of SGLT2i in recent international guidelines promoted by diabetologists, cardiologists and nephrologists. Current restrictive criteria for the prescription and reimbursement of SGLT2i in Belgium according to eGFR level (initiation only if eGFR superior to 60 and interruption if eGFR inferior to 45 ml/min/1.73 m²) should be enlarged very soon owing to convincing results of published controlled trials.

[Anticoagulation of diabetic patients with nonvalvular atrial fibrillation]

Patients with diabetes have a higher risk of nonvalvular atrial fibrillation (NVAF), cerebral embolisms and anticoagulant-related intracranial bleeding when compared to nondiabetic patients. Non-vitamin K oral anticoagulants (NOACs) are progressively replacing antivitamin K agents among patients with NVAF. They are as efficacious as warfarin to reduce the risk of cerebral and systemic embolisms while reducing the risk of both severe and cerebral hemorrhages. Four studies reported results of prespecified subanalyses that compared results of efficacy and safety of NOACs (dabigatran, rivaroxaban, apixaban, edoxaban) in patients with and without diabetes, overall with similar results in both subgroups. ENGAGE AF-TIMI 48 is the only trial that reported a significant reduction of severe hemorrhages with edoxaban compared with warfarin in diabetic patients with NVAF.

[Fixed combination atorvastatin-perindopril (Lipercosyl®) for substitution treatment of cardiovascular risk management]

Fixed combination atorvastatin-perindopril (Lipercosyl®) for substitution treatment of cardiovascular risk management Lipercosyl® is a fixed combination of atorvastatin and perindopril, a cholesterol-lowering and an antihypertensive agent, which allows blood pressure and cholesterol levels to be controlled in hypertensive patients with dyslipidemia : atorvastatin, an inhibitor of HMG-CoA reductase, and perindopril, an angiotensin converting enzyme inhibitor. Six presentations with different dosages of each molecule are available so the treatment can be individualized. Specific precautions of use to each medication must obviously be observed. The use of such a combination helps to ensure a good level of cholesterol while controlling blood pressure.

[Which place to be reserved to sulphonylureas and which precautions to be taken ?]

Sulphonylureas (SU) for a long time occupied an essential role in the management of type 2 diabetes (T2D). However, the launch of new oral antidiabetic drugs (OAD), firstly DPP-4 inhibitors (gliptins) and more recently SGLT2 inhibitors (gliflozins), has markedly changed the scene. Indeed, in contrast to SU, these new OAD (of course more expensive) offer the advantage of a very low risk of hypoglycaemia and a beneficial impact on bodyweight. Furthermore, gliflozins have proven to exert a cardiovascular and renal protection in patients at high risk. SU keep a place in the management of T2D, yet it becomes more and more limited. For sure, SU should be avoided among elderly frailty people and patients at high risk of hypoglycaemia.

[Pharmacological therapies against COVID-19 : state of the art, between hopes and disappointments]

The COVID-19 outbreak has raised numerous attempts of diverse pharmacological interventions to improve the prognosis of the infection, especially among hospitalized patients due to an acute respiratory distress syndrome (ARDS). Initially, these interventions used known medications capable to directly target SARS-CoV-2 by investigating several antiviral therapies already applied with some success in other viral infections. Among them remdesivir appears to be the most promising drug against SARS-CoV-2. Then, owing to the deleterious impact of the cytokine storm, medications that more specifically inhibit proinflammatory cytokines (especially interleukin-1 and interleukin-6) were tested. Hydroxychloroquine, sometines combined with azithromycin, has benefited for a while from a media buzz. However, hopes initially founded in all such drugs turned into disappointments because the specificities of SARS-CoV-2 make this virus resistant to most pharmacological interventions. Only glucocorticoids, dexamethasone and hydrocortisone, were associated with a significant reduction in mortality of patients with ARDS due to COVID-19, most probably via non-specific anti-inflammatory effects. These corticosteroids are currently recommended by the World Health Organisation. An intensive research is ongoing worldwide to find effective combined therapies or innovative drugs which could unequivocally improve the prognosis of COVID-19 at the different stages of the infection.

[Renin-angiotensin-aldosterone system : brief history and questions related to the COVID-19 pandemic]

The breakthrough of the secrets of hypertension and the renin-angiotensin-aldosterone system (RAAS) is one of the legends of medicine. The first chapter is the one of Tigerstedt's experiments about renin, and Loesch and Gollblatt's model of renal hypertension. The race to elucidate the mechanisms of angiotensin, angiotensinogen and the angiotensin conversion enzyme cascade, by Braun Menéndez and Page teams, is a second chapter. The puzzle of this elegant cascade is completed by aldosterone isolation by the collaboration of Tait spouses and Tadeus Rechstein. As a corollary of these findings, Conn made the first description of primary hyperaldosteronism. The elucidation of RAAS pathophysiology naturally led to the synthesis of the antihypertensive captopril by Ondetti and Cushman, thereby opening the modern era of ACE inhibitors and ARII blockers. In March 2020, a viral pandemic caused by SARS-Cov-2 ignites the entire planet. This new coronavirus uses the RAAS angiotensin conversion enzyme type 2 (ACE-2) as a gateway. The SARS-CoV-2/ACE-2 signalling pathway and its pathological effects on the cardio-respiratory and renal system of these patients initiate a new chapter. The interaction of SARS-Cov-2/ACE-2 axis with anti-hypertensive agents, as well as with ACE-2 activators and ACE-2 homologs, takes a part of an active international study searching for therapeutic targets. This modern research, summarized in this article, will further develop our knowledge of RAAS and, hopefully, will improve the management of COVID-19 patients.

[Severe COVID-19, a new complication to be added to numerous comorbidities associated to obesity]

Obesity is associated with a huge number of well-known comorbidities. Nowadays, it represents a higher risk of severe COVID-19 infection, which may lead to the requirement of a mechanical ventilation in intensive care units and premature death. The increase in relative risk of poor prognosis in presence of obesity is particularly high in patients at a younger age. The underlying mechanisms are multiple: alteration of the respiratory performance, presence of frequent comorbidities (diabetes, hypertension or obstructive sleep apnea), finally inadequate and excessive immunological responses, with massive liberation of cytokines (especially interkeukin-1 and interleukin-6). Thus, COVID-19 may challenge the so-called «obesity paradox» in intensive care units among patients with acute respiratory distress syndrome where obesity is commonly reported as associated with a better prognosis. In the special case of COVID-19, a condition where obviously obesity aggravates the prognosis, hypothetical mechanisms remain to be well-defined and deserve further validation.

Metformin and COVID-19: From cellular mechanisms to reduced mortality

Type 2 diabetes mellitus (T2DM) is associated with both poorer clinical outcomes during the COVID-19 pandemic and an increased risk of death in such hospitalized patients. While the role of glucose control has been emphasized to improve the prognosis, the impact of different glucose-lowering agents remains largely unknown. Metformin remains the first-line pharmacological choice for the management of hyperglycaemia in T2DM. Because metformin exerts various effects beyond its glucose-lowering action, among which are anti-inflammatory effects, it may be speculated that this biguanide might positively influence the prognosis of patients with T2DM hospitalized for COVID-19. The present concise review summarizes the available data from observational retrospective studies that have shown a reduction in mortality in metformin users compared with non-users, and briefly discusses the potential underlying mechanisms that might perhaps explain this favourable impact. However, given the potential confounders inherently found in observational studies, caution is required before drawing any firm conclusions in the absence of randomized controlled trials.

Prognostic factors in patients with diabetes hospitalized for COVID-19: Findings from the CORONADO study and other recent reports

Diabetes mellitus is challenging in the context of the COVID-19 pandemic. The prevalence of diabetes patients hospitalized in intensive care units for COVID-19 is two- to threefold higher, and the mortality rate at least double, than that of non-diabetes patients. As the population with diabetes is highly heterogeneous, it is of major interest to determine the risk factors of progression to a more serious life-threatening COVID-19 infection. This brief review discusses the main findings of CORONADO, a prospective observational study in France that specifically addressed this issue as well as related observations from other countries, mainly China and the US. Some prognostic factors beyond old age have been identified: for example, an increased body mass index is a major risk factor for requiring respiratory assistance. Indeed, obesity combines several risk factors, including impaired respiratory mechanics, the presence of other comorbidities and inappropriate inflammatory responses, partly due to ectopic fat deposits. While previous diabetic microvascular (renal) and macrovascular complications also increase risk of death, the quality of past glucose control had no independent influence on hospitalized diabetes patient outcomes, but whether the quality of glucose control might modulate risk of COVID-19 in non-hospitalized diabetes patients is still unknown. In addition, no negative signs regarding the use of RAAS blockers and DPP-4 inhibitors and outcomes of COVID-19 could be identified. Hyperglycaemia at the time of hospital admission is associated with poor outcomes, but it may simply be considered a marker of severity of the infection. Thus, the impact of glucose control during hospitalization on outcomes related to COVID-19, which was not investigated in the CORONADO study, is certainly deserving of specific investigation.

[Ertugliflozin alone and in fixed-dose combinations : «pass of three»]

Ertugliflozin is a new sodium-glucose cotransporter type 2 inhibitor (SGLT2i) that is indicated in the treatment of type 2 diabetes. It has been investigated in the large phase 3 development programme VERTIS, in monotherapy and in association with different antidiabetic medications, including insulin. The add-on of ertugliflozin to metformin (VERTIS MET) and the association ertugliflozin-sitagliptin (VERTIS-SITA, VERTIS FACTORIAL, VERTIS SITA2) showed a significant reduction in glycated haemoglobin, without hypoglycaemia, together with a diminution of body weight and arterial blood pressure. As expected, more genital mycotic infections were observed, the only adverse event consistently reported. The cardiovascular safety of ertugliflozin has been demonstrated in VERTIS CV. Ertugliflozin is commercialized with two doses 5 mg and 15 mg. This SGLT2i is also available in fixed-dose combinations, ertugliflozin-metformin and ertugliflozin-sitagliptin. The three presentations offer a greater flexibility to the practitioner to optimize therapeutic choices for a complex disease where the treatment should be individualized according to the patient profile.

[A revolution in the management of type 2 diabetes : antidiabetic agents providing a cardiovascular and renal protection independently of glucose control !]

Type 2 diabetes is a complex disease with an increasing prevalence and a huge morbidity and premature mortality, essentially due to cardiovascular and renal complications. Classical glucose-lowering agents (metformin, sulphonylureas) exert little protective effects on these complications so that emphasis has been put on a multifactorial management targeting all risk factors. Gliptins offer the advantage of an excellent tolerance profile, with no hypoglycaemia or weight gain, but have not shown any specific cardiovascular or renal protection. Over the last decade, new antidiabetic medications (glucagon-like peptide-1 receptor agonists and gliflozins) have demonstrated a cardiovascular and renal protection, independently of glucose control. These data of evidence-based medicine have revolutionized the therapeutic approach of patients with type 2 diabetes who are at high risk of atherosclerotic cardiovascular disease, heart failure and progressive renal disease. Unexpectedly, the protective effect of gliflozins is currently investigated in patients with heart failure or renal disease, in the absence of diabetes.

[Extended indications for antidiabetic agents with cardio-renal protection in updated international recommendations for themanagement of at risk patients with type2 diabetes]

The strategy for the management of type 2 diabetes (T2D) has been updated late 2019-2020 by a group of experts of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). The indications of two pharmacological classes that have demonstrated a cardiovascular and renal protection, i.e. sodium-glucose cotransporter type 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1AR), are now extended because of the favourable results of recent clinical trials. In patients with T2D at high cardiovascular risk (even without previous event, but with indicators of atherosclerotic disease), the addition of these antidiabetic agents to metformin background therapy is now recommended independently of the glycated haemo¬globin (HbA1c) level. For SGLT2i, the prescription may be extended to patients with an estimated glomerular filtration rate down to 30 (instead of 60) ml/min/1.73 m², in particular in patients with progressive renal disease and albuminuria and in patients at risk of heart failure, especially if left ventricular ejection fraction is reduced. However, these new proposals could not be applied stricto sensu because of strict reimbursement criteria based upon HbA1c currently applied in our country.

[Ezetimibe-rosuvastatin fixed-dose combination (Myrosor®)]

LDL cholesterol targets are increasingly strict in recent international guidelines, especially in patients at very high or high cardiovascular risk. To reach these targets, it is recommended to use a potent statin, with a titration up to the maximal tolerated dose and, if not sufficient, to combine ezetimibe, a medication that blocks the intestinal absorption of cholesterol. This association allows reduce the dose of statin, while keeping an excellent cholesterol-lowering efficacy and favouring a good tolerance profile. This article describes the characteristics of a fixed-dose combination of rosuvastatin, the most potent statin, and ezetimibe, commercialized in Belgium under the trade name Myrosor®.

[Recommendations in the diagnosis and management of syncope due to orthostatic hypotension]

Syncope is a frequent reason for admission to emergency department or consultations. The common pathophysiological mechanism is a drop in systemic blood pressure leading to cerebral hypoperfusion, and ultimately to total loss of consciousness. The causes are multiple, with varying degrees of severity, classified into three main types : reflex syncope, syncope due to orthostatic hypotension and cardiac syncope. Among these, orthostatic hypotension can be easily detected, particularly by performing an orthostatic challenge with active standing, which is recommended in the presence of any syncope. Simple measures can reduce the recurrence of this type of syncope, even if sometimes drug treatments are necessary. In this article, we will detail the characteristics, diagnostic methods and therapies recommended by the latest guidelines of the European Society of Cardiology.

Reduction in HbA1c with SGLT2 inhibitors vs. DPP-4 inhibitors as add-ons to metformin monotherapy according to baseline HbA1c: A systematic review of randomized controlled trials

AIMS

This study compared the reduction of glycated haemoglobin (HbA1c) with sodium-glucose cotransporter type-2 inhibitors (SGLT2is) vs. dipeptidyl peptidase-4 inhibitors (DPP-4is) as add-ons to metformin in patients with type 2 diabetes mellitus (T2DM), with a specific focus on HbA1c changes according to baseline HbA1c.

MATERIALS AND METHODS

Electronic databases were scrutinized for randomized controlled trials (RCTs) evaluating the reduction of HbA1c from baseline (Δ HbA1c) with an SGLT2i or DPP-4i in patients with T2DM not well controlled by metformin monotherapy. The endpoint was Δ HbA1c using both indirect and direct comparisons.

RESULTS

Overall, Δ HbA1c was slightly greater with SGLT2is (-0.80±0.20% from 8.03±0.35%; 44 analyses, 29 RCTs, 15 with two doses, n=9321) than with DPP-4is (-0.71±0.23% from 8.05±0.43%; 61 analyses, 59 RCTs, n=17,914; P=0.0354). When the mean baseline HbA1c was<8% ([64mmol/mol] 7.79±0.15% vs. 7.71±0.23%), Δ HbA1c averaged -0.735±0.17% vs. -0.62±0.16% (P=0.0117) with SGLT2is vs. DPP-4is, respectively. However, this difference vanished when the mean baseline HbA1c was≥8% (-0.87±0.22% from 8.27±0.32% with SGLT2is vs. -0.80±0.24% from 8.35±0.33% with DPP-4is; P=0.2756). The relationship between Δ HbA1c and baseline HbA1c was only slightly stronger with SGLT2is (slope: -0.39, r²=-0.43; P<0.0001) than with DPP-4is (slope: -0.26, r²=-0.25; P<0.0001).

CONCLUSION

Because of the small difference in Δ HbA1c whatever the baseline HbA1c level with SGLT2is vs. DPP-4is as add-ons to metformin, choosing between these glucose-lowering agents in clinical practice should be based on other efficacy criteria (such as weight and blood pressure changes, cardiovascular and renal protection) or on safety profiles rather than on HbA1c levels.

[Which injectable therapy after failure of oral antidiabetic agents in type 2 diabetes ?]

The shift to injection therapy, after failure of oral antidiabetic agents, is often considered as a difficult step by both the patient with type 2 diabetes and the physician, a situation that may lead to clinical inertia. Schematically, two options may be considered, either starting insulin therapy with a preference for basal insulin analogues, or adding a glucagon-like peptide-1 receptor agonist (GLP-1 RA). Each option has its advantages and disadvantages, which opens the road to personalized medicine. Nevertheless, the preference is increasingly given to GLP-1 AR, yet this solution is more limited by reimbursement conditions. A combination of the two approaches is also possible, with the recent commercialisation of fixed-ratio specialities combining a basal insulin analogue and a GLP-1 RA. This clinical case offers the opportunity to discuss all these different therapeutic options in a patient with poorly controlled type 2 diabetes despite a combination of oral antidiabetic agents, taking also into account the current conditions for reimbursement in Belgium.

[Canaglifozin results in cardiovascular and renal protection in patients with type 2 diabetes : from CANVAS to CREDENCE]

Canagliflozin, a sodium-glucose cotransporter type 2 inhibitor, has been evaluated in two large clinical trials, CANVAS that focused on cardiovascular (CV) risk and CREDENCE that focused on renal risk. CANVAS recruited type 2 diabetic patients (T2D) at high CV risk (65 % in secondary prevention) and demonstrated that canagliflozin significantly reduces major CV events, hospitalisations for heart failure and renal outcomes when compared to placebo. CREDENCE specifically enrolled T2D patients with albuminuric renal disease (50 % in secondary CV prevention). This trial confirmed the cardiovascular protection reported in CANVAS with canagliflozin and more specifically demonstrated a renal protection, including a reduced progression towards end-stage renal disease, in this particular population. Finally, CREDENCE did not observe the increased risk for bone fractures and lower-limb amputations previously reported in CANVAS. Globally, these two studies emphasize a favourable benefit/risk balance of canagliflozin in a T2D population at CV or renal risk, including in patients with a glomerular filtration rate comprised between 30 et 60 ml/min/1.73 m².

[How I manage a patient with type 2 diabetes not well controlled with a metformin plus gliptin combination]

Type 2 diabetes (T2D) is an evolving disease that requires therapeutic adjustments to maintain adequate glucose control in the long run. An increasing number of patients with T2D are treated with a metformin plus gliptin (DPP-4 Inhibitor) combination, especially those for whom a sulfonylurea is avoided because of a risk of hypoglycaemia. When this dual metformin-gliptin therapy becomes insufficient to reach or maintain adequate glucose control, three solutions may be considered : the addition of a gliflozin (SGLT2 inhibitor), the replacement of the gliptin by a glucagon-like peptide-1 receptor agonist or the addition of a basal insulin whose posology should be progressively up-titrated according to fasting glycaemia. This article describes the pro and contra arguments of these three therapeutic regimens. According to the recent data of the literature, the triple oral therapy combining metformin, a gliptin and a gliflozin appears to offer a favourable alternative in terms of efficacy, tolerance, ease of use, patient adherence and cost.

[Semaglutide, once weekly GLP-1 receptor agonist (Ozempic®)]

Semaglutide (Ozempic®) is a new once-weekly agonist of glucagon-like peptide-1 receptors (GLP-1 AR) indicated in the treatment of type 2 diabetes (T2D). Phase III clinical trials of the SUSTAIN programme demonstrated both the efficacy and safety of semaglutide in patients with T2D treated by diet and exercise, oral antidiabetic agents or even insulin. Direct and indirect comparative clinical trials showed that semaglutide (subcutaneous 0.5 or 1.0 mg once weekly) exerts a better glucose-lowering activity and a greater weight loss than other GLP-1 AR. Presented as prefilled pens for subcutaneous injection, semaglutide is currently reimbursed in Belgium after failure of antidiabetic therapy including metformin (HbA1c superior to 7,5 % or 58 mmol/mol) in T2D patients with body mass index ? 30 kg/m².

[Alcohol, protective or risk factor for cardiovascular disease ?]

Alcohol may exert both positive and negative effects on cardiovascular system. Several factors may modulate these effects, among which, most importantly, the daily dose but also consumption modalities (type of beverage, regular or hectic consumption, for instance). Many epidemiological studies showed a J curve, with a greater risk of cardiovascular disease in non-consumers compared with light to moderate regular drinkers, but with a higher risk in heavy drinkers, in a dose-dependent manner. This article analyses the complex relationships between alcohol consumption and the risk of coronary and cerebrovascular diseases, including cardiovascular mortality. Owing to the remaining uncertainties, in absence of controlled trials, and the difficulty not to overcome the positive threshold, it is not currently recommended to drink alcohol in order to benefit of a cardiovascular protection.

[Alcohol and car driving]

Alcohol intoxication during car driving represents a well-recognized danger and is responsible for numerous accidents leading to premature death or infirmities. The objectives of this article are to describe some epidemiological data about driving under alcohol influence and associated car accidents, to remind which alcohol blood concentrations are acceptable from a legal point of view, to analyse the acute effects of alcohol on cortical function that could alter driving capacities and, finally, to consider some conditions that may reduce or increase the effects of alcohol on the performances during car driving. Keywords : Alcohol - Car accident - Driving - Brain.

[Metabolic complications and nutritional deficiencies related to excessive alcohol consumption]

Metabolic disturbances associated with chronic alcohol consumption, among which those affecting glucose regulation, lipid profile, uric acid and nutritional status, are described. In fact, alcohol abuse can lead to overweight and obesity, but also to protein-caloric malnutrition. Finally, we will discuss concerns about vitamin and mineral deficiencies that may be observed in alcoholic people and can contribute to aggravate somatic complications.

[Basal insulin degludec (Tresiba®)]

Insulin degludec (Tresiba®) is characterized by an original mode of prolonged and continuous insulin release after its subcutaneous injection. Thereby, it has a very long glucose-lowering effect, around 42 hours, and a better reproducibility from both a pharmacokinetic and pharmacodynamic point of view. Its efficacy and safety have been assessed in the phase 3 clinical programme BEGIN as compared with insulin glargine U100, in patients with type 1 diabetes (T1D) and type 2 (T2D). For a similar glucose control (reduction in glycated haemoglobin), less hypoglycaemic episodes were recorded, including severe hypoglycaemia, during the nocturnal period, with insulin degludec than with insulin glargine U100. This clinical benefit has been confirmed in the complementary SWITCH programme in T1D and T2D patients at higher risk of hypoglycaemia, in the double-blind cardiovascular outcome trial DEVOTE in T2D patients at high cardiovascular risk and in real-life conditions in the observational European EU-TREAT study in patients with T1D and T2D. Insulin degludec (Tresiba®) is indicated and reimbursed for the treatment of patients with T1D, combined with a prandial insulin, and T2D, alone or combined with oral antidiabetic agents, a glucagon-like peptide-1 receptor agonist or a short-acting insulin.

[Focus on empagliflozin : post hoc analyses of the cardiovascular outcome trial EMPA-REG OUTCOME]

EMPA-REG OUTCOME trial studied the cardiovascular safety of empagliflozin, a sodium-glucose cotransporter type 2 (SGLT2) inhibitor, compared to placebo, in patients with type 2 diabetes and high cardiovascular risk. It showed a significant reduction of major cardiovascular events (-14 %), cardiovascular mortality (-38 %), all-cause death (-32 %), hospitalisations for heart failure (-35 %) and progression of renal disease (-39 %). This article proposes an update, almost 4 years after the original publication, of recent post hoc analyses of this landmark study.

[Management of hypertriglyceridaemia]

Hypertriglyceridaemia is a common finding in medical practice. The reduction of triglyceride levels may contribute to reduce the cardiovascular risk (at least in patients with low HDL cholesterol) and to avoid the occurrence of acute pancreatitis (in case of severe hypertriglyceridaemia). The discovery of causes of hypertriglyceridaemia (comorbidities, medications) may lead to specific measures. Otherwise, the focus should be put on dietary advises first (reduced caloric intake to promote weight loss, less alcohol, less sucrose), which, if well conducted, may result in spectacular results. If they fail, some pharmacological approaches may be considered, but with generally a limited success rate. Among them, fenofibrate is the best studied and has been shown to be useful for cardiovascular prevention, especially if low HDL cholesterol is associated with hypertriglyceridaemia in patients with type 2 diabetes.