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Chinese Guidelines for Medical Nutrition Therapy for Patients with Diabetes (2022 Edition). Asia Pac J Clin Nutr 2024; 33:118-152. [PMID: 38794974 PMCID: PMC11170023 DOI: 10.6133/apjcn.202406_33(2).0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 05/05/2024] [Indexed: 05/27/2024]
Abstract
Medical nutrition therapy (MNT) is the foundation of the comprehensive treatment of patients with diabetes. In 2010, the Chinese Clinical Nutritionist Center of the Chinese Medical Doctor Association developed the first Chinese guideline on MNT for patients with diabetes, and it was updated in 2015. Since then, new evidence has emerged in the field of MNT and metabolic therapy in patients with diabetes. The Nutrition and Metabolic Management Branch of the China International Exchange and Promotive Association for Medical and Health Care organized a team of experts from related institutions, including the Clinical Nutrition Branch of the Chinese Nutrition Society, Chinese Diabetes Society, Chinese Society for Parenteral and Enteral Nutri-tion, and Chinese Clinical Nutritionist Center of the Chinese Medical Doctor Association. Their task was to develop the Chinese Guidelines of Medical Nutrition Therapy in Diabetes (2022 Edition) in accordance with the requirements of the Guidelines for the Formulation/Revision of Clinical Guidelines in China (2022 Edition) by combining the questions raised and evidence gathered in clinical practices in China, to guide and standardize the clinical MNT.
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Koutentakis M, Kuciński J, Świeczkowski D, Surma S, Filipiak KJ, Gąsecka A. The Ketogenic Effect of SGLT-2 Inhibitors-Beneficial or Harmful? J Cardiovasc Dev Dis 2023; 10:465. [PMID: 37998523 PMCID: PMC10672595 DOI: 10.3390/jcdd10110465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/09/2023] [Accepted: 11/14/2023] [Indexed: 11/25/2023] Open
Abstract
Sodium-glucose cotransporter-2 (SGLT-2) inhibitors, also called gliflozins or flozins, are a class of drugs that have been increasingly used in the management of type 2 diabetes mellitus (T2DM) due to their glucose-lowering, cardiovascular (CV), and renal positive effects. However, recent studies suggest that SGLT-2 inhibitors might also have a ketogenic effect, increasing ketone body production. While this can be beneficial for some patients, it may also result in several potential unfavorable effects, such as decreased bone mineral density, infections, and ketoacidosis, among others. Due to the intricate and multifaceted impact caused by SGLT-2 inhibitors, this initially anti-diabetic class of medications has been effectively used to treat both patients with chronic kidney disease (CKD) and those with heart failure (HF). Additionally, their therapeutic potential appears to extend beyond the currently investigated conditions. The objective of this review article is to present a thorough summary of the latest research on the mechanism of action of SGLT-2 inhibitors, their ketogenesis, and their potential synergy with the ketogenic diet for managing diabetes. The article particularly discusses the benefits and risks of combining SGLT-2 inhibitors with the ketogenic diet and their clinical applications and compares them with other anti-diabetic agents in terms of ketogenic effects. It also explores future directions regarding the ketogenic effects of SGLT-2 inhibitors.
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Affiliation(s)
- Michail Koutentakis
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Banacha 1A, 02-097 Warsaw, Poland;
| | - Jakub Kuciński
- Central Clinical Hospital, Medical University of Warsaw, Banacha 1A, 02-097 Warsaw, Poland;
| | - Damian Świeczkowski
- Department of Toxicology, Faculty of Pharmacy, Medical University of Gdansk, 80-416 Gdańsk, Poland;
| | - Stanisław Surma
- Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland;
| | - Krzysztof J. Filipiak
- Department of Clinical Sciences, Maria Sklodowska-Curie Medical Academy, 00-001 Warsaw, Poland;
- Department of Hypertensiology, Angiology and Internal Medicine, Poznań University of Medical Sciences, 61-848 Poznań, Poland
| | - Aleksandra Gąsecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Banacha 1A, 02-097 Warsaw, Poland;
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Xia X, Xu M, Gu Y, Li Y, Li L, Yin J. Low-carbohydrate diet in the treatment of type 2 diabetes mellitus (LoCaT): study protocol for a multicenter, randomized controlled trial. Trials 2023; 24:411. [PMID: 37337229 DOI: 10.1186/s13063-023-07427-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 06/02/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Low-carbohydrate diet (LCD) is an emerging therapy for type 2 diabetes mellitus (T2DM). Although its effect on glucose control has been confirmed in previous clinical trials, most of those studies have focused on comparing calorie-restricted LCD to iso-caloric low-fat diets. In this study, we aim to compare the effects of LCD and canagliflozin, a sodium-glucose cotransporter 2 inhibitor, in patients with T2DM. METHODS This is a multicenter, randomized controlled trial. We will recruit 120 patients with poor-controlled T2DM. Participants will be randomly divided into canagliflozin and LCD groups in a 1:1 ratio. The primary outcome is the change in hemoglobin A1C levels after the 3-month intervention. The secondary outcomes are the time in range and cost of antihyperglycemic agents. Exploratory outcomes include physical examination, body composition, glucose variability, appetite, glycolipid metabolism, liver lipid content, and urine glucose threshold. DISCUSSION No previous study has compared an LCD with antihyperglycemic agents. In LoCaT, participants' metabolism will be assessed from multiple perspectives. It is believed that the finding obtained from this trial will optimize the treatments for patients with T2DM. TRIAL REGISTRATION Chinese Clinical Trial Registry ChiCTR1900027592. Registered on November 20, 2019.
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Affiliation(s)
- Xinyi Xia
- Department of Endocrinology and Metabolism, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai Clinical Center for Diabetes, Shanghai Diabetes Institute, Shanghai Key Laboratory of Diabetes Mellitus, 600 Yishan Rd, Shanghai, 200233, China
| | - Miao Xu
- Department of Endocrinology and Metabolism, Ningbo First Hospital, 59 Liuting Street, Ningbo, 315000, Zhejiang Province, China
| | - Yunjie Gu
- Department of Endocrinology and Metabolism, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai Clinical Center for Diabetes, Shanghai Diabetes Institute, Shanghai Key Laboratory of Diabetes Mellitus, 600 Yishan Rd, Shanghai, 200233, China
| | - Yangxue Li
- Department of Endocrinology and Metabolism, Shanghai Eighth People's Hospital, 8 Caobao Road, Shanghai, 200235, China
| | - Li Li
- Department of Endocrinology and Metabolism, Ningbo First Hospital, 59 Liuting Street, Ningbo, 315000, Zhejiang Province, China.
| | - Jun Yin
- Department of Endocrinology and Metabolism, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai Clinical Center for Diabetes, Shanghai Diabetes Institute, Shanghai Key Laboratory of Diabetes Mellitus, 600 Yishan Rd, Shanghai, 200233, China.
- Department of Endocrinology and Metabolism, Shanghai Eighth People's Hospital, 8 Caobao Road, Shanghai, 200235, China.
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Dutta D, Kadian J, Mahajan K, Dhall A, Sharma M. Efficacy and safety of luseogliflozin in improving glycaemic and non-glycaemic outcomes in type-2 diabetes: A meta-analysis. Diabetes Metab Syndr 2023; 17:102742. [PMID: 36933330 DOI: 10.1016/j.dsx.2023.102742] [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: 01/20/2023] [Revised: 03/05/2023] [Accepted: 03/06/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND & AIMS No meta-analysis is available analysing the role of luseogliflozin in type-2 diabetes. We undertook this meta-analysis to address this knowledge-gap. METHODS Electronic databases were searched for RCTs involving diabetes patients receiving luseogliflozin in intervention arm, and placebo/active comparator in control arm. Primary outcome was to evaluate changes in HbA1c. Secondary outcomes were to evaluate alterations in glucose, blood pressure, weight, lipids, and adverse events. RESULTS From initially screened 151 articles, data from 10 RCTs involving 1304 patients was analysed. Individuals receiving luseogliflozin 2.5 mg/d had a significantly lower HbA1c [MD -0.76% (95% CI: 1.01 to -0.51); P < 0.01; I2 = 83%], fasting glucose [MD -26.69 mg/dl (95% CI: 35.41 to -17.96); P < 0.01; I2 = 80%], systolic blood pressure [MD -4.19 mm Hg (95% CI: 6.31 to -2.07); P < 0.01; I2 = 0%], body-weight [MD -1.61 kg (95% CI: 3.14 to -0.08); P = 0.04; I2 = 0%], triglycerides PCG [MD -12.60 mg/dl (95% CI: 24.25 to -0.95); P = 0.03; I2 = 0%], uric acid [MD -0.48 mg/dl (95% CI: 0.73 to -0.23); P < 0.01; I2 = 49%] and alanine aminotransferase [MD -4.11 IU/L (95% CI: 6.12 to -2.10); P < 0.01; I2 = 0%] compared to placebo. Occurrence of treatment-emergent adverse-events [RR 0.93 (95% CI: 0.72-1.20); P = 0.58; I2 = 0%], severe adverse-events [RR 1.19 (95% CI: 0.40-3.55); P = 0.76; I2 = 0%], hypoglycaemia [RR 1.56 (95% CI: 0.85-2.85); P = 0.15; I2 = 0%] and genital infections [RR 1.42 (95% CI: 0.48-4.18); P = 0.53; I2 = 0%] were not increased with luseogliflozin. Cardiovascular outcome trials are lacking and are urgently required. CONCLUSION Luseogliflozin has good glycaemic and non-glycaemic benefits similar to other SGLT2 inhibitors and is well tolerated.
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Affiliation(s)
- Deep Dutta
- Department of Endocrinology, Center for Endocrinology, Diabetes, Arthritis & Rheumatism (CEDAR) Super-speciality Healthcare, Dwarka, New Delhi, India.
| | - Jyoti Kadian
- Department of Medicine, Kalpana Chawla Government Medical College, Karnal, Haryana, India.
| | - Kunal Mahajan
- Department of Cardiology, Himachal Heart Institute, Mandi, Himachal Pradesh, India.
| | - Anil Dhall
- Department of Cardiology, Janakpuri Superspeciality Hospital, New Delhi, India.
| | - Meha Sharma
- Department of Rheumatology, CEDAR Superspeciality Healthcare, Dwarka, New Delhi, India.
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Lee CH, Wu MZ, Lui DTW, Chan DSH, Fong CHY, Shiu SWM, Wong Y, Lee ACH, Lam JKY, Woo YC, Lam KSL, Yiu KKH, Tan KCB. Comparison of Serum Ketone Levels and Cardiometabolic Efficacy of Dapagliflozin versus Sitagliptin among Insulin-Treated Chinese Patients with Type 2 Diabetes Mellitus. Diabetes Metab J 2022; 46:843-854. [PMID: 35483674 PMCID: PMC9723203 DOI: 10.4093/dmj.2021.0319] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 02/16/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Insulin-treated patients with long duration of type 2 diabetes mellitus (T2DM) are at increased risk of ketoacidosis related to sodium-glucose co-transporter 2 inhibitor (SGLT2i). The extent of circulating ketone elevation in these patients remains unknown. We conducted this study to compare the serum ketone response between dapagliflozin, an SGLT2i, and sitagliptin, a dipeptidyl peptidase-4 inhibitor, among insulin-treated T2DM patients. METHODS This was a randomized, open-label, active comparator-controlled study involving 60 insulin-treated T2DM patients. Participants were randomized 1:1 for 24-week of dapagliflozin 10 mg daily or sitagliptin 100 mg daily. Serum β-hydroxybutyrate (BHB) levels were measured at baseline, 12 and 24 weeks after intervention. Comprehensive cardiometabolic assessments were performed with measurements of high-density lipoprotein cholesterol (HDL-C) cholesterol efflux capacity (CEC), vibration-controlled transient elastography and echocardiography. RESULTS Among these 60 insulin-treated participants (mean age 58.8 years, diabetes duration 18.2 years, glycosylated hemoglobin 8.87%), as compared with sitagliptin, serum BHB levels increased significantly after 24 weeks of dapagliflozin (P=0.045), with a median of 27% increase from baseline. Change in serum BHB levels correlated significantly with change in free fatty acid levels. Despite similar glucose lowering, dapagliflozin led to significant improvements in body weight (P=0.006), waist circumference (P=0.028), HDL-C (P=0.041), CEC (P=0.045), controlled attenuation parameter (P=0.007), and liver stiffness (P=0.022). Average E/e', an echocardiographic index of left ventricular diastolic dysfunction, was also significantly lower at 24 weeks in participants treated with dapagliflozin (P=0.037). CONCLUSION Among insulin-treated T2DM patients with long diabetes duration, compared to sitagliptin, dapagliflozin modestly increased ketone levels and was associated with cardiometabolic benefits.
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Affiliation(s)
- Chi-Ho Lee
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
- State Key Laboratory of Pharmaceutical Biotechnology, University of Hong Kong, Hong Kong, China
| | - Mei-Zhen Wu
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - David Tak-Wai Lui
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - Darren Shing-Hei Chan
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - Carol Ho-Yi Fong
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - Sammy Wing-Ming Shiu
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - Ying Wong
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - Alan Chun-Hong Lee
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - Joanne King-Yan Lam
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - Yu-Cho Woo
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - Karen Siu-Ling Lam
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
- State Key Laboratory of Pharmaceutical Biotechnology, University of Hong Kong, Hong Kong, China
| | - Kelvin Kai-Hang Yiu
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - Kathryn Choon-Beng Tan
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
- Corresponding author: Kathryn Choon-Beng Tan https://orcid.org/0000-0001-9037-0416 Department of Medicine, Queen Mary Hospital, University of Hong Kong, 102 Pokfulam Road, Pokfulam, Hong Kong, China E-mail:
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Davidson JA, Sukor N, Hew F, Mohamed M, Hussein Z. Safety of sodium-glucose cotransporter 2 inhibitors in Asian type 2 diabetes populations. J Diabetes Investig 2022; 14:167-182. [PMID: 36260389 PMCID: PMC9889611 DOI: 10.1111/jdi.13915] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 09/02/2022] [Accepted: 09/10/2022] [Indexed: 02/04/2023] Open
Abstract
The prevalence of type 2 diabetes mellitus continues to increase in many Asian countries, with possible contributing factors, such as younger-onset disease, diabetes development at lower body mass index, higher visceral fat accumulation and poorer β-cell function, among Asian populations. Sodium-glucose cotransporter 2 inhibitors have been shown to confer favorable effects in type 2 diabetes mellitus patients, such as improved glycemic control, weight and blood pressure reduction, and importantly, cardiorenal benefits. Sodium-glucose cotransporter 2 inhibitors are generally well-tolerated, and have a well-defined safety profile based on evidence from numerous clinical trials and post-marketing pharmacovigilance reporting. To our knowledge, this review is the first to provide a comprehensive coverage of the adverse events of sodium-glucose cotransporter 2 inhibitors, as well as their management and counseling aspects for Asian type 2 diabetes mellitus populations.
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Affiliation(s)
- Jaime A Davidson
- Touchstone Diabetes CenterThe University of Texas Southwestern Medical CenterDallasTexasUSA
| | - Norlela Sukor
- Universiti Kebangsaan Malaysia Medical CentreKuala LumpurMalaysia
| | - Fen‐Lee Hew
- Subang Jaya Medical CentreSubang JayaSelangorMalaysia
| | - Mafauzy Mohamed
- School of Medical SciencesUniversiti Sains MalaysiaKelantanMalaysia
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Lee G. Luseogliflozin Additively Enhances the Glucose-Lowering Effect of an Incretin Modulator in a High-Carbohydrate Diet. Cureus 2022; 14:e30410. [PMID: 36407160 PMCID: PMC9671274 DOI: 10.7759/cureus.30410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2022] [Indexed: 11/06/2022] Open
Abstract
Background and objectives Sodium/glucose co-transporter 2 inhibitors (SGLT2i) have been shown to have a glucose-lowering effect related to carbohydrate intake. It has also been reported that the combined effect of incretin modulators and SGLT2i is useful in improving blood glucose and reducing blood glucose variability. However, there have been no reports examining the effects of these two drugs together and while considering carbohydrate intake in an outpatient setting. In the present study, Hi-Speed Food Analysis was used to assess the exact intake of carbohydrates, and the glucose-lowering effects of luseogliflozin, an SGLT2i, and incretin modulators were examined under high- and low-carbohydrate intakes. Methods Thirty-five enrolled diabetic patients continued their regular medications for one week. All patients took luseogliflozin in the second week for seven days. During the two weeks, ingested carbohydrates were accurately calculated by Hi-Speed Food Analysis. The glucose-lowering effect of luseogliflozin with and without incretin modulators was checked according to the amount of ingested carbohydrates. A general linear model (GLM) was used to analyze the effect of luseogliflozin with or without an incretin modulator, with carbohydrate intake as a confounding factor. Results Luseogliflozin had an additive effect in patients who had taken the incretin modulator. There was a significant decrease in the time above range (TAR) with glucose above 140 mg/dL as expressed as TAR(min140), and this effect was affected by carbohydrate intake. Conclusions The glucose-lowering effect of luseogliflozin was enhanced with high-carbohydrate intake more than with low-carbohydrate intake. In this study, the observed number was small; however, combined treatment with an incretin modulator and luseogliflozin had an additive effect in high- versus low-carbohydrate intake, indicating the possible effectiveness of the combined therapy.
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Bando S, Ichikawa R, Taguchi T, Fujimoto K, Motomiya T, Taguchi M, Takano K, Shichiri M, Miyatsuka T. Effects of luseogliflozin on the secretion of islet hormones and incretins in patients with type 2 diabetes. Endocr J 2022; 69:681-687. [PMID: 35067495 DOI: 10.1507/endocrj.ej21-0696] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The insufficient activity of insulin and the hyperactivity of glucagon are responsible for glucose intolerance in patients with type 2 diabetes. Whereas sodium-glucose cotransporter-2 (SGLT2) inhibitors improve blood glucose levels in patients with type 2 diabetes, their effects on the secretion profiles of glucagon and incretins remain unclear. Therefore, to investigate the effects of the SGLT2 inhibitor luseogliflozin on metabolic and endocrine profiles, 19 outpatients with type 2 diabetes were administered luseogliflozin for 12 weeks. It is of note that all subjects were treated only with diet and exercise therapy, and we were able to investigate the effects of luseogliflozin separately from the effects of other antidiabetic agents. Body weight, body fat mass, fat-free mass, and muscle mass were significantly reduced after 12 weeks of luseogliflozin administration. Glycosylated hemoglobin significantly decreased from the baseline of 8.2% ± 0.8% to 7.3% ± 0.7% (p < 0.0001). The meal tolerance test demonstrated that luseogliflozin significantly recovered glucose tolerance, accompanied by improved insulin resistance and β-cell function, whereas glucagon secretion was unaffected. Furthermore, GLP-1 secretion was significantly increased after luseogliflozin administration. Thus, luseogliflozin improved metabolic and endocrine profiles accompanied by increased GLP-1 secretion in type 2 diabetic patients without any antidiabetic medication, but did not affect glucagon secretion.
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Affiliation(s)
- Satoru Bando
- Department of Endocrinology, Diabetes and Metabolism, Kitasato University School of Medicine, Sagamihara 252-0374, Japan
| | - Raishi Ichikawa
- Department of Endocrinology, Diabetes and Metabolism, Kitasato University School of Medicine, Sagamihara 252-0374, Japan
| | - Tomomi Taguchi
- Department of Endocrinology, Diabetes and Metabolism, Kitasato University School of Medicine, Sagamihara 252-0374, Japan
| | - Kazumi Fujimoto
- Department of Endocrinology, Diabetes and Metabolism, Kitasato University School of Medicine, Sagamihara 252-0374, Japan
| | | | | | - Koji Takano
- Department of Endocrinology, Diabetes and Metabolism, Kitasato University School of Medicine, Sagamihara 252-0374, Japan
| | - Masayoshi Shichiri
- Department of Endocrinology, Diabetes and Metabolism, Kitasato University School of Medicine, Sagamihara 252-0374, Japan
| | - Takeshi Miyatsuka
- Department of Endocrinology, Diabetes and Metabolism, Kitasato University School of Medicine, Sagamihara 252-0374, Japan
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Saucedo-Orozco H, Voorrips SN, Yurista SR, de Boer RA, Westenbrink BD. SGLT2 Inhibitors and Ketone Metabolism in Heart Failure. J Lipid Atheroscler 2022; 11:1-19. [PMID: 35118019 PMCID: PMC8792821 DOI: 10.12997/jla.2022.11.1.1] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/06/2022] [Accepted: 01/06/2022] [Indexed: 11/09/2022] Open
Abstract
Sodium-glucose cotransporter-2 (SGLT2) inhibitors have emerged as powerful drugs that can be used to treat heart failure (HF) patients, both with preserved and reduced ejection fraction and in the presence or absence of type 2 diabetes. While the mechanisms underlying the salutary effects of SGLT2 inhibitors have not been fully elucidated, there is clear evidence for a beneficial metabolic effect of these drugs. In this review, we discuss the effects of SGLT2 inhibitors on cardiac energy provision secondary to ketone bodies, pathological ventricular remodeling, and inflammation in patients with HF. While the specific contribution of ketone bodies to the pleiotropic cardiovascular benefits of SGLT2 inhibitors requires further clarification, ketone bodies themselves may also be used as a therapy for HF.
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Affiliation(s)
- Huitzilihuitl Saucedo-Orozco
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Suzanne N. Voorrips
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Salva R. Yurista
- Cardiology Division, Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Rudolf A. de Boer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - B. Daan Westenbrink
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Cucuzzella M, Riley K, Isaacs D. Adapting Medication for Type 2 Diabetes to a Low Carbohydrate Diet. Front Nutr 2021; 8:688540. [PMID: 34434951 PMCID: PMC8380766 DOI: 10.3389/fnut.2021.688540] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 07/06/2021] [Indexed: 12/11/2022] Open
Abstract
Healthcare professionals in the primary care setting need to be competent to safely adapt diabetes medications when patients with Type 2 Diabetes (T2D) alter their diet. Safe prescribing practice is supported through an understanding of the clinical evidence, basic science, and pharmacology of medications. This review article supports clinicians in the practical application of this knowledge to achieve safe practice. Traditional medical training and clinical practice for chronic disease has long revolved around the teaching of intensifying therapy and evidenced based prescribing, a crucial skill when chronic disease progresses. Now that we are witnessing remission of Type 2 Diabetes through nutritional interventions specifically low carbohydrate diets (LCD) we must apply the same effort and thought to de-prescribing as the underlying metabolic condition improves. There is minimal guidance in the literature on how to actively de-prescribe. The American Diabetes Association in their Standards of Medical Care in Diabetes–2021 acknowledges low carbohydrate nutritional therapy (LCD) as a viable option in the management of Type 2 Diabetes (T2D). Thus, the goal of our paper is to help close the gap between the clinical evidence, basic science, and pharmacology of T2D medications to the practical application and teamwork needed to facilitate safe medication reduction in the primary care setting when applied to a LCD. The LCD is an increasingly popular and effective option for managing T2D and can lead to an improvement in the condition, reduced medication burden, and contribute to significant weight loss. Safe initiation of a LCD in patients on medications requires significant monitoring and medication adjustments to decrease and eliminate the risk of hypoglycemia and hypotension. The health care team including clinicians in primary care, nursing, pharmacy and nutrition need to be competent in adjusting diabetes and antihypertensive medications to achieve safe and effective care. The most immediate and important adjustments are to insulin, sulfonylureas, SGLT2 inhibitors, blood pressure medications and diuretics. Interdisciplinary care teams can individualize therapy while following the guidance, which includes monitoring blood glucose and blood pressure closely, decreasing medications that can cause hypoglycaemia and hypotension, evaluating blood glucose and blood pressure data responses regularly, and open access communication with the team. The article is an international consensus document on de-prescribing that was put together by a multidisciplinary team of clinicians.
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Affiliation(s)
- Mark Cucuzzella
- West Virginia University School of Medicine, Morgantown, WV, United States
| | - Karen Riley
- Institute for Personalized Therapeutic Nutrition, Vancouver, BC, Canada
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Kapoor N, Sahay R, Kalra S, Bajaj S, Dasgupta A, Shrestha D, Dhakal G, Tiwaskar M, Sahay M, Somasundaram N, Reddy R, Bhattacharya S, Reddy VB, Viswanathan V, Krishnan D, Baruah M, Das AK. Consensus on Medical Nutrition Therapy for Diabesity (CoMeND) in Adults: A South Asian Perspective. Diabetes Metab Syndr Obes 2021; 14:1703-1728. [PMID: 33889005 PMCID: PMC8057793 DOI: 10.2147/dmso.s278928] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 02/24/2021] [Indexed: 02/06/2023] Open
Abstract
Diabetes and obesity are both increasing at a fast pace and giving rise to a new epidemic called diabesity. Lifestyle interventions including diet play a major role in the treatment of diabetes, obesity and diabesity. There are many guidelines on dietary management of diabetes or obesity globally and also from South Asia. However, there are no global or South Asian guidelines on the non-pharmacological management of diabesity. South Asia differs from the rest of the world as South Asians have different phenotype, cooking practices, food resources and exposure, medical nutrition therapy (MNT) practices, and availability of trained specialists. Therefore, South Asia needs its own guidelines for non-pharmacological management of diabesity in adults. The aim of the Consensus on Medical Nutrition Therapy for Diabesity (CoMeND) in Adults: A South Asian Perspective is to recommend therapeutic and preventive MNT in the South-Asians with diabesity.
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Affiliation(s)
- Nitin Kapoor
- Department of Endocrinology, Christian Medical College, Vellore, Tamil Nadu, India
- Non Communicable Disease Unit, The Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Rakesh Sahay
- Department of Endocrinology, Osmania MedicalA30 College, Hyderabad, Telangana, India
| | - Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, Haryana, India
| | - Sarita Bajaj
- Department of Medicine, Moti Lal Nehru Medical College, Allahabad, Uttar Pradesh, India
| | - Arundhati Dasgupta
- Department of Endocrinology, Rudraksh Superspecialty Hospital, Siliguri, West Bengal, India
| | - Dina Shrestha
- Department of Endocrinology, Hospital for Advanced Medicine and Surgery (HAMS), Kathmandu, Nepal
| | - Guru Dhakal
- Department of Medicine, Khesar Gyalpo University of Medical Sciences, Thimphu, Bhutan
| | - Mangesh Tiwaskar
- Department of Diabetology, Shilpa Medical Research Centre, Mumbai, Maharashtra, India
| | - Manisha Sahay
- Department of Nephrology, Osmania Medical College and Osmania General Hospital, Hyderabad, Telangana, India
| | - Noel Somasundaram
- Department of Endocrinology, National Hospital of Sri Lanka, Colombo, Sri Lanka
| | - Ravinder Reddy
- Department of Gastroenterology, CARE Super Specialty Hospital & Transplant Centre, Hyderabad, Telangana, India
| | | | | | - Vijay Viswanathan
- Department of Medicine, M.V. Hospital for Diabetes & Prof M Viswanathan Diabetes Research Centre, Chennai, Tamil Nadu, India
| | - Dharini Krishnan
- Department of Food, Nutrition and Dietetics, Laksha Hospitals, Chennai, Tamil Nadu, India
| | - Manash Baruah
- Department of Endocrinology, Excel Care Hospitals, Guwahati, Assam, India
| | - A K Das
- Department of Medicine, JIPMER, Puducherry, India
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12
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SGLT2 inhibitors break the vicious circle between heart failure and insulin resistance: targeting energy metabolism. Heart Fail Rev 2021; 27:961-980. [PMID: 33713009 DOI: 10.1007/s10741-021-10096-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/03/2021] [Indexed: 02/07/2023]
Abstract
Heart failure (HF) often coexists with insulin resistance (IR), and the incidence of HF in type 2 diabetes mellitus (T2DM) patients is significantly higher. The reciprocal relationship between HF and IR has long been recognized, and the integration complicates the therapy of both. A number of mechanisms ascribe to the progression of cardiac IR, in which the main factors are the shift of myocardial substrate metabolism. Studies have found that SGLT2 inhibitors, an anti-diabetic drug, can improve the cardiac prognosis of patients with T2DM, which may be at least partially due to the relief of cardiac IR. Basic and clinical studies have revealed the important role of cardiac IR in the pathogenesis and progression of HF, and studies suggest that energy metabolism plays an important role in the pathogenesis of cardiac IR and HF. SGLT2 inhibitors mediated cardiovascular benefits through various mechanisms such as improving substrate utilization and improving myocardial energy. The regulation of SGLT2 inhibitors on cardiac energy status including carbohydrates, fatty acids (FA), amino acids and ketones, ATP transfer to the cytoplasm, and mitochondrial functional status have received extensive attention in HF, but its specific mechanism of action is still unclear. Therefore, this article reviews the relationship between IR and HF from the perspective of energy metabolism; subsequently, targeting energy metabolism discusses the pivotal role of SGLT2 inhibitors in improving cardiac IR and HF based on basic and clinical research evidences, and sought to clarify the molecular mechanism involved. (Fig. 1).
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13
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Affiliation(s)
- Y Tomoda
- Department of General Medicine, Saiseikai Fukuoka General Hospital, Tenjin 1-3-46, Fukuoka Chuo-ku, Fukuoka 810-0001, Japan
| | - D Yoshimura
- Department of General Medicine, Saiseikai Fukuoka General Hospital, Tenjin 1-3-46, Fukuoka Chuo-ku, Fukuoka 810-0001, Japan
| | - E Hayashida
- Department of Internal Medicine, Tenjin 1-3-38, Fukuoka Chuo-ku, Fukuoka 810-0001, Japan
| | - K Tanaka
- Department of General Medicine, Saiseikai Fukuoka General Hospital, Tenjin 1-3-46, Fukuoka Chuo-ku, Fukuoka 810-0001, Japan
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Dorcely B, Nitis J, Schwartzbard A, Newman JD, Goldberg IJ, Sum M. A Case Report: Euglycemic Diabetic Ketoacidosis Presenting as Chest Pain in a Patient on a Low Carbohydrate Diet. Curr Diabetes Rev 2021; 17:243-246. [PMID: 32178617 PMCID: PMC8020366 DOI: 10.2174/1573399816666200316112709] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 02/21/2020] [Accepted: 02/24/2020] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Sodium-glucose cotransporter-2 [SGLT2] inhibitors reduce cardiovascular events and mortality in patients with diabetes, particularly patients with established cardiovascular disease. Euglycemic diabetic ketoacidosis [euDKA], a complication of SGLT2 therapy, can be exacerbated by a low carbohydrate diet. CASE REPORT A 61-year-old man with a history of type 2 diabetes, taking an SGLT2 inhibitor empagliflozin 10 mg orally daily, presented to the emergency room with a 2-day history of nausea and chest pain. A week prior to presentation, he had started a ketogenic diet. He was initially admitted with a diagnosis of acute coronary syndrome. On initial assessment in the emergency room, his cardiac enzymes were normal and there were no ischemic changes in his ECG. As there was concern for unstable angina, he underwent cardiac catheterization, which showed a known total occlusion with collaterals and arteries with a non-obstructive disease without any evidence of acute plaque rupture. His baseline laboratory assessments revealed an elevated anion gap of 17, increased urinary and plasma ketones, and metabolic acidosis. His plasma glucose level was 84 mg/dL. The diagnosis of euDKA was made, and treatment with intravenous fluids and insulin was initiated. His chest pain and nausea subsequently resolved. CONCLUSION We present a case of euDKA triggered by a ketogenic diet while on SGLT2 inhibitor therapy presenting as chest pain. The recognition of euDKA is important in the context of increased SGLT2 use for the management of cardiovascular risk for patients with diabetes.
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Affiliation(s)
- Brenda Dorcely
- Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, NY 10016, USA
- Address correspondence to this author at the Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, NY 10016, USA; Tel: 212-263-8077l; Fax: 212-481-1355;
| | - Juliana Nitis
- Vagelos College of Physicians and Surgeons-Columbia University, New York, NY 10032, USA
| | - Arthur Schwartzbard
- Center for Prevention of Cardiovascular Disease, New York University School of Medicine, New York, NY, 10016, USA
| | - Jonathan D. Newman
- Center for Prevention of Cardiovascular Disease, New York University School of Medicine, New York, NY, 10016, USA
| | - Ira J. Goldberg
- Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, NY 10016, USA
| | - Melissa Sum
- Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, NY 10016, USA
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Ekanayake P, Hupfeld C, Mudaliar S. Sodium-Glucose Cotransporter Type 2 (SGLT-2) Inhibitors and Ketogenesis: the Good and the Bad. Curr Diab Rep 2020; 20:74. [PMID: 33230620 DOI: 10.1007/s11892-020-01359-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/28/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW The micro/macrovascular complications of diabetes cause considerable morbidity and premature mortality. The SGLT2 inhibitors are the first diabetes medications with significant benefits on microvascular disease (nephropathy) and macrovascular cardiovascular disease. In this review, we evaluate one of the potential mechanisms for these cardiorenal benefits-the production of ketones, their benefits, and risks. RECENT FINDINGS In recent cardiovascular outcome trials (CVOTs), the SGLT2 inhibitors demonstrated significant cardiorenal benefits and they are now approved to reduce CV events/death, heart failure hospitalization, and progression to end-stage renal disease. Glucosuria induced by the SGLT2 inhibitors leads to increased ketone production. Ketones are an efficient fuel source and can improve myocardial and renal function. Further, the ketone body beta-hydroxybutyrate exhibits anti-inflammatory/anti-oxidative actions, which favorably impact myocardial and renal remodeling/fibrosis. Uncontrolled ketogenesis leads to ketoacidosis, especially during conditions of acute illness and excessive insulin dose reductions. The SGLT2 inhibitors have demonstrated significant cardiorenal benefits in large CVOTs. Studies are in progress to elucidate whether SGLT2 inhibitor-induced low-grade hyperketonemia contributes to these benefits.
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Affiliation(s)
- Preethika Ekanayake
- Veterans Affairs Medical Center, San Diego, CA, USA
- Department of Medicine, University of California at San Diego, San Diego School of Medicine, San Diego, USA
| | - Christopher Hupfeld
- Veterans Affairs Medical Center, San Diego, CA, USA
- Department of Medicine, University of California at San Diego, San Diego School of Medicine, San Diego, USA
| | - Sunder Mudaliar
- Veterans Affairs Medical Center, San Diego, CA, USA.
- Department of Medicine, University of California at San Diego, San Diego School of Medicine, San Diego, USA.
- Diabetes/Metabolism Section, VA San Diego HealthCare System, 3350 La Jolla Village Drive (Mail Code: 111G), San Diego, CA, 92161, USA.
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16
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Nutrition Management in Older Adults with Diabetes: A Review on the Importance of Shifting Prevention Strategies from Metabolic Syndrome to Frailty. Nutrients 2020; 12:nu12113367. [PMID: 33139628 PMCID: PMC7693664 DOI: 10.3390/nu12113367] [Citation(s) in RCA: 121] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 02/07/2023] Open
Abstract
The increasing prevalence of older adults with diabetes has become a major social burden. Diabetes, frailty, and cognitive dysfunction are closely related to the mechanisms of aging. Insulin resistance, arteriosclerosis, chronic inflammation, oxidative stress, and mitochondrial dysfunction may be common mechanisms shared by frailty and cognitive impairment. Hyperglycemia, hypoglycemia, obesity, vascular factors, physical inactivity, and malnutrition are important risk factors for cognitive impairment and frailty in older adults with diabetes. The impact of nutrients on health outcomes varies with age; thus, shifting diet therapy strategies from the treatment of obesity/metabolic syndrome to frailty prevention may be necessary in patients with diabetes who are over 75 years of age, have frailty or sarcopenia, and experience malnutrition. For the prevention of frailty, optimal energy intake, sufficient protein and vitamin intake, and healthy dietary patterns should be recommended. The treatment of diabetes after middle age should include the awareness of proper glycemic control aimed at extending healthy life expectancy with proper nutrition, exercise, and social connectivity. Nutritional therapy in combination with exercise, optimal glycemic and metabolic control, and social participation/support for frailty prevention can extend healthy life expectancy and maintain quality of life in older adults with diabetes mellitus.
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Kusakabe T, Yokota S, Shimizu M, Inoue T, Tanaka M, Ohue-Kitano R, Muranaka K, Yamakage H, Wada H, Hasegawa K, Satoh-Asahara N. Differential effects of sodium-glucose cotransporter 2 inhibitor and low-carbohydrate diet on body composition and metabolic profile in obese diabetic db/db mice. BMJ Open Diabetes Res Care 2020; 8:8/1/e001303. [PMID: 32883687 PMCID: PMC7473664 DOI: 10.1136/bmjdrc-2020-001303] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 06/12/2020] [Accepted: 07/18/2020] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Treatment using sodium-glucose cotransporter (SGLT) 2 inhibitor and low-carbohydrate diet (LCD) for obesity and type 2 diabetes are similar in terms of carbohydrate limitation. However, their mechanisms of action differ, and the effects on the body remain unclear. We investigated the effects of SGLT2 inhibitor and LCD on body composition and metabolic profile using the db/db mouse model for obesity and type 2 diabetes. RESEARCH DESIGN AND METHODS Eight-week-old male db/db mice were divided into four groups: mice receiving normal diet and vehicle or canagliflozin (Cana) administration and mice receiving LCD and vehicle or Cana administration for 8 weeks. Consumed calories were adjusted to be equal among the groups. RESULTS Both Cana administration and LCD feeding resulted in significant weight gain. Cana administration significantly decreased plasma glucose levels and increased plasma insulin levels with preservation of pancreatic β cells. However, LCD feeding did not improve plasma glucose levels but deteriorated insulin sensitivity. LCD feeding significantly reduced liver weight and hepatic triglyceride content; these effects were not observed with Cana administration. Combined treatment with LCD did not lead to an additive increase in blood β-ketone levels. CONCLUSIONS SGLT2 inhibitors and LCD exert differential effects on the body. Their combined use may achieve better metabolic improvements in obesity and type 2 diabetes.
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Affiliation(s)
- Toru Kusakabe
- Department of Endocrinology, Metabolism, and Hypertension Research, Clinical Research Institute, National Hospital Organisation Kyoto Medical Center, Kyoto, Japan
| | - Shigefumi Yokota
- Department of Endocrinology, Metabolism, and Hypertension Research, Clinical Research Institute, National Hospital Organisation Kyoto Medical Center, Kyoto, Japan
| | - Mika Shimizu
- Department of Endocrinology, Metabolism, and Hypertension Research, Clinical Research Institute, National Hospital Organisation Kyoto Medical Center, Kyoto, Japan
| | - Takayuki Inoue
- Department of Endocrinology, Metabolism, and Hypertension Research, Clinical Research Institute, National Hospital Organisation Kyoto Medical Center, Kyoto, Japan
| | - Masashi Tanaka
- Department of Endocrinology, Metabolism, and Hypertension Research, Clinical Research Institute, National Hospital Organisation Kyoto Medical Center, Kyoto, Japan
| | - Ryuji Ohue-Kitano
- Department of Endocrinology, Metabolism, and Hypertension Research, Clinical Research Institute, National Hospital Organisation Kyoto Medical Center, Kyoto, Japan
| | - Kazuya Muranaka
- Department of Endocrinology, Metabolism, and Hypertension Research, Clinical Research Institute, National Hospital Organisation Kyoto Medical Center, Kyoto, Japan
| | - Hajime Yamakage
- Department of Endocrinology, Metabolism, and Hypertension Research, Clinical Research Institute, National Hospital Organisation Kyoto Medical Center, Kyoto, Japan
| | - Hiromichi Wada
- Division of Translational Research, Clinical Research Institute, National Hospital Organisation Kyoto Medical Center, Kyoto, Japan
| | - Koji Hasegawa
- Division of Translational Research, Clinical Research Institute, National Hospital Organisation Kyoto Medical Center, Kyoto, Japan
| | - Noriko Satoh-Asahara
- Department of Endocrinology, Metabolism, and Hypertension Research, Clinical Research Institute, National Hospital Organisation Kyoto Medical Center, Kyoto, Japan
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Steinmetz-Wood S, Gilbert M, Menson K. A Case of Diabetic Ketoacidosis in a Patient on an SGLT2 Inhibitor and a Ketogenic Diet: A Critical Trio Not to Be Missed. Case Rep Endocrinol 2020; 2020:8832833. [PMID: 32855828 PMCID: PMC7443033 DOI: 10.1155/2020/8832833] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 07/24/2020] [Indexed: 01/24/2023] Open
Abstract
Results from major clinical trials have shown significant cardiorenal-protective benefits of SGLT2 inhibitors in patients with type 2 diabetes (T2DM), leading to increased popularity. A rare but serious side effect of SGLT2 inhibitors is euglycemic diabetic ketoacidosis (EDKA), which presents more covertly but has been described. Identification and report of modifiable risk factors would be an important step in helping clinicians appropriately counsel patients. In this case report, we present DKA in a patient on an SGLT2 inhibitor and ketogenic diet (KD). A 47-year-old male with a history of poorly controlled T2DM on metformin and empagliflozin presented to the emergency department (ED) with several days of pharyngitis, dyspnea, emesis, abdominal pain, and anorexia. Of note, one month prior to this event, he presented to the ED with malaise and was found to have an anion gap of 21, a bicarbonate level of 13 mmol/L, a pH level of 7.22, 3+ ketonuria, and a glucose level of 7 mmol/L (127 mg/dl). Additional workup was negative, and findings were attributed to his KD. His use of empagliflozin was not identified on his medication list. At second presentation, the patient was tachypneic and tachycardic and had mild abdominal tenderness. Labs revealed anion gap 28, bicarbonate 5 mmol/l, pH 6.94, 3+ ketonuria, glucose 14.9 mmol/L (269 mg/dl), and beta-hydroxybutyrate 8.9 mmol/L. The patient was diagnosed with DKA and was treated accordingly. With closure of anion gap, the patient was transitioned to insulin and metformin, and his empagliflozin was discontinued indefinitely. Before prescribing this medication class, physicians should inquire about low-carbohydrate diets given the higher risk for DKA, though knowledge of this risk is still not widespread.
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Affiliation(s)
- Samantha Steinmetz-Wood
- Department of Medicine, Larner College of Medicine at the University of Vermont, 111 Colchester Ave, Burlington, VT, USA
| | - Matthew Gilbert
- Department of Medicine, Larner College of Medicine at the University of Vermont, 111 Colchester Ave, Burlington, VT, USA
| | - Katherine Menson
- Department of Medicine, Larner College of Medicine at the University of Vermont, 111 Colchester Ave, Burlington, VT, USA
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Fleming N, Hamblin PS, Story D, Ekinci EI. Evolving Evidence of Diabetic Ketoacidosis in Patients Taking Sodium-Glucose Cotransporter 2 Inhibitors. J Clin Endocrinol Metab 2020; 105:5821255. [PMID: 32302001 DOI: 10.1210/clinem/dgaa200] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 04/15/2020] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Sodium glucose cotransporter 2 inhibitors (SGLT2i) have emerged as an important class of blood glucose-lowering medications, due to cardiovascular, metabolic, and renal benefits. However, there is a small but significant risk of diabetic ketoacidosis (DKA) associated with their use. METHODS A literature search was conducted in Ovid MEDLINE and Embase to July 2019 using variants on the key search terms sodium-glucose cotransporter 2, diabetic ketoacidosis, and type 2 diabetes. A broad spectrum of evidence was incorporated to facilitate a comprehensive narrative review. Further sources were identified through hand searching of reference lists. DISCUSSION Although cardiovascular outcome trials demonstrated mixed evidence of SGLT2i associated DKA, increasing evidence from case reports and cohort studies has identified an increased risk. SGLT2i use is associated with a ketotic state caused by an increased glucagon:insulin ratio and stimulated by factors including stress-induced hormonal changes, insufficient insulin, decreased glucose, increased ketone resorption, and hypovolemia. Atypical presentations of DKA with lower-than-expected blood glucose levels are possible with SGLT2i use, so clinical and biochemical monitoring is vital for early identification and management. DKA risk is particularly increased with precipitating factors, therefore optimization of risk factors is vital. Recommendations for perioperative and sick day management of patients taking SGLT2i have been suggested based on available evidence. CONCLUSION SGLT2i are an excellent class of drug in the physician's toolkit for managing type 2 diabetes. However, both clinicians and patients must be aware of the potential for DKA and the need for increased monitoring, both clinically and biochemically, when potential precipitating factors are present. In acutely unwell patients, these medications should be withheld to reduce the risk of DKA.
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Affiliation(s)
- Nicola Fleming
- Department of Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Peter Shane Hamblin
- Department of Endocrinology & Diabetes, Western Health, Melbourne, Victoria, Australia
- Department of Medicine - Western Precinct, University of Melbourne, St Albans, Victoria, Australia
| | - David Story
- Centre for Integrated Critical Care, University of Melbourne, Parkville, Victoria, Australia
- Department of Anaesthesia, Austin Health, Heidelberg, Australia
| | - Elif I Ekinci
- Department of Medicine, Austin Health, Heidelberg, Victoria, Australia
- Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia
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Sampani E, Sarafidis P, Papagianni A. Euglycaemic diabetic ketoacidosis as a complication of SGLT-2 inhibitors: epidemiology, pathophysiology, and treatment. Expert Opin Drug Saf 2020; 19:673-682. [PMID: 32521174 DOI: 10.1080/14740338.2020.1764532] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Sodium-glucose co-transporters 2 (SGLT-2) inhibitors are a relatively novel class of oral medications for the treatment of Type 2 Diabetes Mellitus, which lower plasma glucose by inhibiting glucose reabsorption in the proximal renal tubule. Apart from their hypoglycemic action, recent data suggest these agents have additional major cardioprotective and nephroprotective properties. AREAS COVERED This review summarizes the existing data on epidemiology, pathophysiology, and treatment of euglycaemic ketoacidosis (euDKA) as a complication of SGLT-2 inhibitor use. EXPERT OPINION Although SGLT-2 inhibitors have a relatively good adverse event profile, they have been associated with the serious and potentially life-threatening metabolic complication of euDKA. Data from major outcome trials suggest that the rate of DKA is quite low. However, the rate of DKA could be generally underestimated in clinical trials due to the atypical presentation of ketoacidosis, and even more so in real-life conditions. Management of this serious metabolic complication requires a proper understanding of its pathophysiology as well as increased awareness and early recognition of the potential risk factors involved. Following this, the institution of an array of simple supportive measures, could safely restore normal acid-base balance in most patients.
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Affiliation(s)
- Erasmia Sampani
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki , Thessaloniki, Greece
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki , Thessaloniki, Greece
| | - Aikaterini Papagianni
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki , Thessaloniki, Greece
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Diabetes Canada Position Statement on Low-Carbohydrate Diets for Adults With Diabetes: A Rapid Review. Can J Diabetes 2020; 44:295-299. [DOI: 10.1016/j.jcjd.2020.04.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Earle M, Ault B, Bonney C. Euglycemic Diabetic Ketoacidosis in Concurrent Very Low-carbohydrate Diet and Sodium-glucose Transporter-2 Inhibitor Use: A Case Report. Clin Pract Cases Emerg Med 2020; 4:185-188. [PMID: 32426668 PMCID: PMC7219989 DOI: 10.5811/cpcem.2020.2.45904] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 02/13/2020] [Accepted: 02/21/2020] [Indexed: 01/27/2023] Open
Abstract
Introduction With the incredibly high incidence of Type 2 Diabetes in the current population of emergency department patients, it is critical for clinicians to understand the possible complications of the treatment of this disease. Medication like canagliflozin are more common to encounter on patient's home medication lists and clinicians should be aware of how these medications, alone or combined with dietary modifications, can result in significant pathology and even mortality if not appropriately treated. Case Report We report a case of a patient with type II diabetes mellitus who presented with euglycemic diabetic ketoacidosis in the setting of concurrent use of canagliflozin, a sodium-glucose transporter-2 (SGLT-2) inhibitor, and strict adherence to a low-carbohydrate ketogenic diet for weight control. Discussion Euglycemic ketoacidosis has previously been observed in both diabetic and non-diabetic patients following strict ketogenic diets, as well as in diabetic patients being treated with SGLT-2 inhibitors. Conclusion As more patients choose ketogenic diets for weight control and diabetes management, clinicians should be aware of this potentially life-threatening complication in patients concurrently taking SGLT-2 inhibitors.
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Affiliation(s)
- Matthew Earle
- University of Nevada Las Vegas, Department of Emergency Medicine, Las Vegas, Nevada
| | - Brian Ault
- University of Nevada Las Vegas, Department of Emergency Medicine, Las Vegas, Nevada
| | - Caitlin Bonney
- University of Nevada Las Vegas, Department of Emergency Medicine, Las Vegas, Nevada
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Yamamoto M, Ide N, Kitajima S, Obayashi M, Asada K, Matsushima S, Ito M. [Risk of Euglycemic Diabetic Ketoacidosis Due to Low-carbohydrate Diet While Taking Empagliflozin: a Case Report]. YAKUGAKU ZASSHI 2020; 139:1479-1483. [PMID: 31685745 DOI: 10.1248/yakushi.19-00120] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Empagliflozin reduces blood glucose levels independently of insulin secretion by reducing glucose reabsorption in the proximal renal tubules through inhibition of sodium-glucose cotransporter 2 (SGLT2). Because SGLT2 inhibitors have a different mechanism of action to conventional antidiabetic drugs, recommendations have been issued about the management of specific side effect such as ketoacidosis, urinary tract infection, and genital infection. There have been some reports of SGLT2 inhibitor-associated euglycemic diabetic ketoacidosis (euDKA), but there have been few reports about euDKA in patients with type 2 diabetes using SGLT2 inhibitors while on a low-carbohydrate diet. Here we report a patient who developed euDKA after starting a very low-carbohydrate diet while taking empagliflozin. A 51-year-old man was hospitalized with nausea and vomiting, and investigations revealed metabolic acidosis. euDKA was diagnosed from the information about medications in his drug notebook and a history of eating a low-carbohydrate diet (1900 kcal, consisting of 5.7% carbohydrate, 21.1% protein, 47.3% fat and 25.9% alcohol) for 4 d. The patient improved after infusion of acetated Ringer's solution with 5% glucose and administration of regular insulin. It is necessary for physicians and pharmacists to thoroughly inform patients about the side effects of SGLT2 inhibitors such as ketoacidosis, urinary tract infection, and genital infection. Patients should also be advised about the higher risk of euDKA associated with a low-carbohydrate diet while taking SGLT2 inhibitors.
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Affiliation(s)
| | - Naohito Ide
- Department of Pharmacy, Chutoen General Medical Center
| | | | - Masakazu Obayashi
- Department of Emergency and Critical Care Medicine, Chutoen General Medical Center
| | - Kei Asada
- Department of Emergency and Critical Care Medicine, Chutoen General Medical Center
| | - Satoru Matsushima
- Department of Emergency and Critical Care Medicine, Chutoen General Medical Center
| | - Masaharu Ito
- Department of Pharmacy, Chutoen General Medical Center
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Kwak SH, Hwang YC, Won JC, Bae JC, Kim HJ, Suh S, Lee EY, Lee S, Kim SY, Kim JH. Comparison of the effects of gemigliptin and dapagliflozin on glycaemic variability in type 2 diabetes: A randomized, open-label, active-controlled, 12-week study (STABLE II study). Diabetes Obes Metab 2020; 22:173-181. [PMID: 31502749 DOI: 10.1111/dom.13882] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 09/03/2019] [Accepted: 09/05/2019] [Indexed: 01/07/2023]
Abstract
AIMS The aim of this study was to compare the effect of gemigliptin, a dipeptidyl peptidase-4 inhibitor, and dapagliflozin, a sodium glucose co-transporter-2 inhibitor, on glycaemic variability in type 2 diabetes patients. MATERIALS AND METHODS In this randomized, blinded end point, multicentre clinical trial, we enrolled 71 patients with type 2 diabetes who were inadequately controlled with metformin alone or were drug naïve. The participants were randomized to receive gemigliptin 50 mg (n = 35) or dapagliflozin 10 mg (n = 36) daily for 12 weeks. Glycaemic variability was estimated by mean amplitude of glycaemic excursions (MAGE), standard deviation (SD) and coefficient of variation (CV) using a 6-day continuous glucose monitoring system. The primary efficacy endpoint was change in MAGE after 12 weeks compared to baseline. RESULTS Intergroup differences in baseline characteristics were not significant. The adjusted mean change (± standard error) in MAGE after 12 weeks in the gemigliptin and dapagliflozin groups was -27.2 ± 4.4 mg/dL and -7.9 ± 4.9 mg/dL, respectively. Between-group comparisons showed a significantly larger reduction in MAGE in the gemigliptin group (-19.2 mg/dL; 95% CI, -31.3 to -7.2; P = .002). Measures of SD and CV also showed a significantly larger reduction in the gemigliptin group. Average glycaemic control, estimated by HbA1c, fasting glucose and safety profiles, was comparable between the two groups. CONCLUSIONS Compared to dapagliflozin, gemigliptin significantly improved glycaemic variability, with similar glucose-lowering efficacy and safety profiles in patients with type 2 diabetes who were inadequately controlled with metformin alone or were drug naïve.
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Affiliation(s)
- Soo Heon Kwak
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - You-Cheol Hwang
- Division of Endocrinology and Metabolism, Department of Medicine, Kyung Hee University School of Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea
| | - Jong Chul Won
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Sanggye Paik Hospital, Cardiovascular and Metabolic Disease Center, Inje University School of Medicine, Seoul, Republic of Korea
| | - Ji Cheol Bae
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Hyun Jin Kim
- Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Sunghwan Suh
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Dong-A University Medical Center, Dong-A University College of Medicine, Busan, Republic of Korea
| | - Eun Young Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Subin Lee
- Clinical Development Team, LG Chem, Seoul, Republic of Korea
| | - Sang-Yong Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, School of Medicine, Chosun University, Gwangju, Republic of Korea
| | - Jae Hyeon Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Sato Y, Nunoi K, Kaku K, Yoshida A, Suganami H. Basal insulin secretion capacity predicts the initial response and maximum levels of beta-hydroxybutyrate during therapy with the sodium-glucose co-transporter-2 inhibitor tofogliflozin, in relation to weight loss. Diabetes Obes Metab 2020; 22:222-230. [PMID: 31608549 PMCID: PMC6973158 DOI: 10.1111/dom.13890] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 09/11/2019] [Accepted: 09/27/2019] [Indexed: 01/14/2023]
Abstract
AIMS To investigate predictors of the initial response of beta-hydroxybutyrate (BHB) and maximum BHB (max-BHB) values during long-term therapy with the sodium-glucose co-transporter-2 inhibitor tofogliflozin (TOFO), and to explore the association of the initial elevation of BHB with subsequent clinical effects in people with type 2 diabetes mellitus. METHODS We analysed 774 people receiving TOFO in phase 3 trials in two groups based on measurable BHB change at week 4 (initial response): the top quartile [n = 194] and the three lower quartiles [n = 579]. Multivariate analysis was used to determine baseline predictors of inclusion in the top quartile and the max-BHB values. To investigate the association of the initial response with subsequent clinical effects, adjusted changes in variables in the two groups were compared using an analysis of covariance model. RESULTS Of the participants, 66% were men, and the mean age, glycated haemoglobin, body mass index and estimated glomerular filtration rate were 58.5 years, 8.1%, 25.6 kg/m2 and 83.9 mL/min/1.73 m2 , respectively. Median changes in BHB at week 4 in the top quartile and lower three quartiles were +246.4* and +30.8* μmol/L, respectively (*P < .001 vs baseline). Lower baseline insulin secretion capacity predicted the inclusion in the top quartile and greater max-BHB levels. The top quartile was associated with greater weight loss following greater increases in free fatty acids and greater reductions in fasting C-peptide levels compared with the lower three quartiles. CONCLUSIONS Lower basal insulin secretion capacity might predict greater initial BHB elevations and max-BHB levels during long-term TOFO therapy. Greater weight loss through lipid use might be related to high initial BHB elevations.
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Affiliation(s)
- Yuichi Sato
- Department of Diabetes and EndocrinologySt Mary's HospitalFukuokaJapan
| | - Kiyohide Nunoi
- Department of Diabetes and EndocrinologySt Mary's HospitalFukuokaJapan
| | - Kohei Kaku
- Department of Internal MedicineKawasaki Medical SchoolOkayamaJapan
| | - Akihiro Yoshida
- Cardiovascular and Diabetes Product Marketing DepartmentKowa Company, LtdTokyoJapan
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Fukuda M, Nabeta M, Muta T, Fukami K, Takasu O. Euglycemic diabetic ketoacidosis caused by canagliflozin: a case report. Int J Emerg Med 2020; 13:2. [PMID: 31969112 PMCID: PMC6977311 DOI: 10.1186/s12245-020-0261-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 01/03/2020] [Indexed: 02/06/2023] Open
Abstract
Background Diabetic ketoacidosis (DKA) is seen relatively frequently in the emergency department (ED). DKA is characterized by hyperglycemia, acidosis, and ketonemia, and sodium glucose transporter 2 inhibitors (SGLT2i) represent a new diabetes medication that has been associated with euglycemic DKA (eu-DKA). Case presentation A 71-year-old female who was being treated for type 2 diabetes with canagliflozin, metformin, and saxagliptin orally presented to the ED for evaluation of reduced oral intake, malaise, nausea, and abdominal pain. Although her blood glucose was not severely elevated (259 mg/dL), there was notable ketoacidosis (pH 6.89; CO2, 11.4 mmHg; HCO3, 1.9 mEq/L; base excess, − 31.3 mmol/L; 3-hydroxybutyric acid > 10,000 μmol/L) was observed. The uncontrolled acidosis improved following 3 days of continuous renal replacement therapy, but elevated urinary glucose continued for more than 10 days. Ringer’s lactated fluid supplementation was continued for management of polyurea and glucosuria. Urinary glucose turned negative on day 16, and there was improvement in the patient’s overall state; hence, she was discharged on day 18. Conclusion Although it is difficult to diagnose eu-DKA because of the absence of substantial blood glucose abnormalities in the ED, there is a need to consider eu-DKA when evaluating acidosis in a patient treated with SGLT2i. Moreover, even after discontinuing the SGLT2i, attention should be given to the possibility of continuing glucosuria. Regular measurements of urinary glucose should be obtained, and the patient should be monitored for dehydration.
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Affiliation(s)
- Masafumi Fukuda
- Division of Nephrology, Department of Medicine, Kurume University School of Medicine, 67 Asahi Kurume, Fukuoka, 830-0011, Japan. .,Advanced Emergency Medical Service Center, Kurume University Hospital, Department of Emergency and Acute Intensive Care Medicine, Kurume University School of Medicine, 67 Asahi, Kurume, Fukuoka, 830-0011, Japan.
| | - Masakazu Nabeta
- Advanced Emergency Medical Service Center, Kurume University Hospital, Department of Emergency and Acute Intensive Care Medicine, Kurume University School of Medicine, 67 Asahi, Kurume, Fukuoka, 830-0011, Japan
| | - Takanori Muta
- Advanced Emergency Medical Service Center, Kurume University Hospital, Department of Emergency and Acute Intensive Care Medicine, Kurume University School of Medicine, 67 Asahi, Kurume, Fukuoka, 830-0011, Japan
| | - Kei Fukami
- Division of Nephrology, Department of Medicine, Kurume University School of Medicine, 67 Asahi Kurume, Fukuoka, 830-0011, Japan
| | - Osamu Takasu
- Advanced Emergency Medical Service Center, Kurume University Hospital, Department of Emergency and Acute Intensive Care Medicine, Kurume University School of Medicine, 67 Asahi, Kurume, Fukuoka, 830-0011, Japan
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Ferrannini E, Baldi S, Frías JP, Guja C, Hardy E, Repetto E, Jabbour SA, DeFronzo RA. Hormone-substrate changes with exenatide plus dapagliflozin versus each drug alone: The randomized, active-controlled DURATION-8 study. Diabetes Obes Metab 2020; 22:99-106. [PMID: 31469220 DOI: 10.1111/dom.13870] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 08/16/2019] [Accepted: 08/28/2019] [Indexed: 01/17/2023]
Abstract
AIM To determine the effects of individual and combined therapies on plasma insulin, glucagon, β-hydroxybutyrate (β-OH) and associated metabolites. MATERIALS AND METHODS In DURATION-8, the combination of once-weekly exenatide (EQW) + 10 mg dapagliflozin (Dapa) in patients with type 2 diabetes poorly controlled with metformin-reduced HbA1c levels and body weight (at weeks 28 and 52) was compared with EQW + placebo (Plb) or Dapa + Plb. The study included 678 patients randomized 1:1:1 to EQW + Dapa, EQW + Plb, or Dapa + Plb. Plasma insulin and glucagon were measured at fasting and 2 hours after a mixed meal. Fasting plasma free fatty acids (FFA) and β-OH concentrations were measured. RESULTS The fasting insulin-to-glucagon molar ratio (I/Glg) increased with EQW + Plb only; postprandial I/Glg increased in all groups but significantly more with EQW + Plb. β-OH, FFA, and glycerol concentrations showed a parallel response: larger increments with Dapa + Plb, larger decrements with EQW + Plb, and intermediate changes with EQW + Dapa. β-OH levels and I/Glg were inversely related to one another. Patients in the top quartile of β-OH changes from baseline [median (interquartile range): +207 (305) vs. -65 (-154) μmol/L; P < .0001] were more frequently treated with Dapa + Plb, had higher urine glucose-to-creatinine ratios, and lower fasting insulin [52 (51) vs. 68 (53) pmol/L; P = .0013) and I/Glg [1.76 (1.49) vs. 2.23 (1.70) mol/mol; P = .0020]. Haematocrit increased only in the Dapa group. CONCLUSIONS The EQW + Dapa combination abolished the Dapa-induced rise in β-OH, reduced the EQW-induced increase in I/Glg, maintained glycosuria, and increased haematocrit in patients with poorly controlled type 2 diabetes. The drug combination may preserve any putative benefits while mitigating the risk of ketoacidosis.
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Affiliation(s)
| | - Simona Baldi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Juan P Frías
- National Research Institute, Los Angeles, California
| | - Cristian Guja
- Department of Diabetes, Nutrition and Metabolic Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | | | | | - Serge A Jabbour
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Ralph A DeFronzo
- Diabetes Division, University of Texas Health Science Center, San Antonio, Texas
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Nubiola A, Ternianov A, Remolins I. Dieta cetogénica como factor desencadenante de cetoacidosis diabética euglucémica en un paciente en tratamiento con iSGLT2. HIPERTENSION Y RIESGO VASCULAR 2020; 37:39-41. [DOI: 10.1016/j.hipert.2019.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 09/15/2019] [Accepted: 09/16/2019] [Indexed: 01/24/2023]
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Pleus S, Ulbrich S, Zschornack E, Kamann S, Haug C, Freckmann G. Documentation of Skin-Related Issues Associated with Continuous Glucose Monitoring Use in the Scientific Literature. Diabetes Technol Ther 2019; 21:538-545. [PMID: 31335203 DOI: 10.1089/dia.2019.0171] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background: The average wear time of continuous glucose monitoring (CGM) systems steadily increased over the last years. Increased wear times are likely achieved by using adhesives with a longer adherence time, which may have a more pronounced effect on the skin than adhesives with shorter adherence time. Methods: In this project, a structured literature search was performed to assess how potential skin-related issues with CGM usage have been reported in scientific literature in the last 5 years. The literature search was performed with four search terms in the PubMed database. Results: In sum, 279 articles were analyzed. Skin-related issues were mentioned in 19.0% of articles (53 out of 279). With respect to articles mentioning skin-related issues, CGM performance or efficacy was the study's main topic of most of these studies, whereas the minority used CGM as "add-on" to assess other objectives. There was a varying degree in how detailed skin-related issues were described and no uniform structured documentation was given. While some articles only described findings, other articles already documented final diagnoses, such as contact dermatitis. Furthermore, inconsistent wordings for comparable issues were used. The most frequent issues were pain, itching, erythema, bleeding, bruising, and allergic reactions. Conclusion: To draw possible conclusions about the occurrence of skin-related issues during CGM use, more reports about skin-related issues in scientific literature are needed. A more detailed and uniformly structured documentation, possibly facilitated by a generally accepted guideline for structured descriptions, of skin-related issues could be helpful to enable clear differentiations between the described skin reactions.
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Affiliation(s)
- Stefan Pleus
- Institut für Diabetes-Technologie, Forschungs- und Entwicklungsgesellschaft mbH an der Universität Ulm, Ulm, Germany
| | - Sina Ulbrich
- Institut für Diabetes-Technologie, Forschungs- und Entwicklungsgesellschaft mbH an der Universität Ulm, Ulm, Germany
| | - Eva Zschornack
- Institut für Diabetes-Technologie, Forschungs- und Entwicklungsgesellschaft mbH an der Universität Ulm, Ulm, Germany
| | | | - Cornelia Haug
- Institut für Diabetes-Technologie, Forschungs- und Entwicklungsgesellschaft mbH an der Universität Ulm, Ulm, Germany
| | - Guido Freckmann
- Institut für Diabetes-Technologie, Forschungs- und Entwicklungsgesellschaft mbH an der Universität Ulm, Ulm, Germany
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30
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Yoshida A, Matsubayashi Y, Nojima T, Suganami H, Abe T, Ishizawa M, Fujihara K, Tanaka S, Kaku K, Sone H. Attenuation of Weight Loss Through Improved Antilipolytic Effect in Adipose Tissue Via the SGLT2 Inhibitor Tofogliflozin. J Clin Endocrinol Metab 2019; 104:3647-3660. [PMID: 30811541 DOI: 10.1210/jc.2018-02254] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 02/22/2019] [Indexed: 02/06/2023]
Abstract
CONTEXT Although calorie loss from increased urinary glucose excretion continues after long-term treatment with sodium-glucose cotransporter 2 inhibitors (SGLT2is), the mechanisms of the attenuated weight loss due to SGLT2is are not well known. OBJECTIVE To examine the mechanism of the attenuated weight loss during long-term treatment with an SGLT2i, tofogliflozin, focusing on the antilipolytic effect of insulin on adipose tissue. DESIGN AND PARTICIPANTS An integrated analysis was performed using data from two phase 3 studies of 52 weeks of tofogliflozin administration. The antilipolytic effect was evaluated using adipose tissue insulin resistance (Adipo-IR) calculated from the product of the levels of fasting insulin (f-IRI) and fasting free fatty acids (f-FFAs). RESULTS Data from 774 patients with type 2 diabetes (mean age, 58.5 years; glycosylated hemoglobin, 8.1%; body mass index, 25.6 kg/m2; estimated glomerular filtration rate, 83.9 mL/min/1.73m2; 66% men) were analyzed. Weight loss plateaued between weeks 24 and 52 after decreasing significantly. f-IRI levels decreased significantly from baseline to week 24, and the decrease was maintained until Week 52. f-FFA levels significantly increased, peaked at week 24, then declined from weeks 24 to 52. Adipo-IR levels declined progressively throughout the 52 weeks (-3.6 mmol/L·pmol/L and -6.2 mmol/L·pmol/L at weeks 24 and 52, respectively; P < 0.001 baseline vs weeks 24 and 52 and week 24 vs week 52). Higher baseline Adipo-IR levels were independently associated with greater weight loss at week 52. CONCLUSION The improved antilipolytic effect in adipose tissue may attenuate progressive lipolysis, leading to attenuating future weight loss induced by an SGLT2i in patients with type 2 diabetes.
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Affiliation(s)
- Akihiro Yoshida
- Department of Hematology, Endocrinology and Metabolism, Niigata University Faculty of Medicine, Niigata, Japan
- Medical Information and Product Advancement Department, Kowa Pharmaceutical Co., Ltd., Tokyo, Japan
| | - Yasuhiro Matsubayashi
- Department of Hematology, Endocrinology and Metabolism, Niigata University Faculty of Medicine, Niigata, Japan
| | - Toshiaki Nojima
- Department of Hematology, Endocrinology and Metabolism, Niigata University Faculty of Medicine, Niigata, Japan
- Clinical Data Science Department, Kowa Co., Ltd., Tokyo, Japan
| | - Hideki Suganami
- Clinical Data Science Department, Kowa Co., Ltd., Tokyo, Japan
| | - Takahiro Abe
- Department of Hematology, Endocrinology and Metabolism, Niigata University Faculty of Medicine, Niigata, Japan
| | - Masahiro Ishizawa
- Department of Hematology, Endocrinology and Metabolism, Niigata University Faculty of Medicine, Niigata, Japan
| | - Kazuya Fujihara
- Department of Hematology, Endocrinology and Metabolism, Niigata University Faculty of Medicine, Niigata, Japan
| | - Shiro Tanaka
- Department of Clinical Biostatistics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kohei Kaku
- Department of General Internal Medicine, Kawasaki Medical School, Okayama, Japan
| | - Hirohito Sone
- Department of Hematology, Endocrinology and Metabolism, Niigata University Faculty of Medicine, Niigata, Japan
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31
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Seino Y, Ueno S, Yabe D, Suzuki A. Dietary recommendations for type 2 diabetes patients: Lessons from recent clinical and basic research in Asia. J Diabetes Investig 2019; 10:1405-1407. [PMID: 31472101 PMCID: PMC6825937 DOI: 10.1111/jdi.13135] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 08/27/2019] [Accepted: 08/28/2019] [Indexed: 12/21/2022] Open
Abstract
Dishes containing dietary fibers are eaten first, and the protein and fat courses are then followed by the carbohydrate dishes.
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Affiliation(s)
- Yusuke Seino
- Department of Endocrinology and Metabolism, Fujita Health University, Toyoake, Japan
| | - Shinji Ueno
- Department of Endocrinology and Metabolism, Fujita Health University, Toyoake, Japan
| | - Daisuke Yabe
- Department of Diabetes and Endocrinology, Gifu University Graduate School of Medicine, Gifu, Japan.,Yutaka Seino Distinguished Center for Diabetes Research, Kansai Electric Power Medical Research Institute, Kobe, Japan.,Division of Molecular and Metabolic Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Atsushi Suzuki
- Department of Endocrinology and Metabolism, Fujita Health University, Toyoake, Japan
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32
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Kimura Y, Kuno A, Tanno M, Sato T, Ohno K, Shibata S, Nakata K, Sugawara H, Abe K, Igaki Y, Yano T, Miki T, Miura T. Canagliflozin, a sodium-glucose cotransporter 2 inhibitor, normalizes renal susceptibility to type 1 cardiorenal syndrome through reduction of renal oxidative stress in diabetic rats. J Diabetes Investig 2019; 10:933-946. [PMID: 30663266 PMCID: PMC6626958 DOI: 10.1111/jdi.13009] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 01/12/2019] [Accepted: 01/17/2019] [Indexed: 12/18/2022] Open
Abstract
AIMS/INTRODUCTION Type 2 diabetes mellitus is a risk factor of acute kidney injury after myocardial infarction (MI), a form of cardiorenal syndrome. Recent clinical trials have shown that a sodium-glucose cotransporter 2 (SGLT2) inhibitor improved both cardiac and renal outcomes in patients with type 2 diabetes mellitus, but effects of an SGLT2 inhibitor on cardiorenal syndrome remain unclear. MATERIALS AND METHODS Type 2 diabetes mellitus (Otsuka Long-Evans Tokushima Fatty rats [OLETF]) and control (Long-Evans Tokushima Otsuka rats [LETO]) were treated with canagliflozin, an SGLT2 inhibitor, for 2 weeks. Renal tissues were analyzed at 12 h after MI with or without preoperative fasting. RESULTS Canagliflozin reduced blood glucose levels in OLETF, and blood β-hydroxybutyrate levels were increased by canagliflozin only with fasting. MI increased neutrophil gelatinase-associated lipocalin and kidney injury molecule-1 protein levels in the kidney by 3.2- and 1.6-fold, respectively, in OLETF, but not in LETO. The renal messenger ribonucleic acid level of Toll-like receptor 4 was higher in OLETF than in LETO after MI, whereas messenger ribonucleic acid levels of cytokines/chemokines were not significantly different. Levels of lipid peroxides, nicotinamide adenine dinucleotide phosphate oxidase (NOX)2 and NOX4 proteins after MI were significantly higher in OLETF than in LETO. Canagliflozin with pre-MI fasting suppressed MI-induced renal expression of neutrophil gelatinase-associated lipocalin and kidney injury molecule-1 in OLETF, together with reductions in lipid peroxides and NOX proteins in the kidney. Blood β-hydroxybutyrate levels before MI were inversely correlated with neutrophil gelatinase-associated lipocalin protein levels in OLETF. Pre-incubation with β-hydroxybutyrate attenuated angiotensin II-induced upregulation of NOX4 in NRK-52E cells. CONCLUSIONS The findings suggest that SGLT2 inhibitor treatment with a fasting period protects kidneys from MI-induced cardiorenal syndrome, possibly by β-hydroxybutyrate-mediated reduction of NOXs and oxidative stress, in type 2 diabetic rats.
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Affiliation(s)
- Yukishige Kimura
- Department of Cardiovascular, Renal and Metabolic MedicineSapporo Medical University School of MedicineSapporoJapan
| | - Atsushi Kuno
- Department of Cardiovascular, Renal and Metabolic MedicineSapporo Medical University School of MedicineSapporoJapan
- Department of PharmacologySapporo Medical University School of MedicineSapporoJapan
| | - Masaya Tanno
- Department of Cardiovascular, Renal and Metabolic MedicineSapporo Medical University School of MedicineSapporoJapan
| | - Tatsuya Sato
- Department of Cardiovascular, Renal and Metabolic MedicineSapporo Medical University School of MedicineSapporoJapan
- Department of Cellular Physiology and Signal TransductionSapporo Medical University School of MedicineSapporoJapan
| | - Kouhei Ohno
- Department of Cardiovascular, Renal and Metabolic MedicineSapporo Medical University School of MedicineSapporoJapan
| | - Satoru Shibata
- Department of Cardiovascular, Renal and Metabolic MedicineSapporo Medical University School of MedicineSapporoJapan
| | - Kei Nakata
- Department of Cardiovascular, Renal and Metabolic MedicineSapporo Medical University School of MedicineSapporoJapan
| | - Hirohito Sugawara
- Department of Cardiovascular, Renal and Metabolic MedicineSapporo Medical University School of MedicineSapporoJapan
| | - Koki Abe
- Department of Cardiovascular, Renal and Metabolic MedicineSapporo Medical University School of MedicineSapporoJapan
| | - Yusuke Igaki
- Department of Cardiovascular, Renal and Metabolic MedicineSapporo Medical University School of MedicineSapporoJapan
| | - Toshiyuki Yano
- Department of Cardiovascular, Renal and Metabolic MedicineSapporo Medical University School of MedicineSapporoJapan
| | - Takayuki Miki
- Department of Cardiovascular, Renal and Metabolic MedicineSapporo Medical University School of MedicineSapporoJapan
| | - Tetsuji Miura
- Department of Cardiovascular, Renal and Metabolic MedicineSapporo Medical University School of MedicineSapporoJapan
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Tougaard NH, Faber J, Eldrup E. Very low carbohydrate diet and SGLT-2-inhibitor: double jeopardy in relation to ketoacidosis. BMJ Case Rep 2019; 12:12/4/e227516. [PMID: 30954957 DOI: 10.1136/bcr-2018-227516] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Diabetic euglycaemic ketoacidosis is a possible adverse effect of sodium-glucose co-transporter-2 inhibitors (SGLT2i). We report a case in which the combination of SGLT2i and a strict very low-carbohydrate diet led to severe diabetic ketoacidosis in a young Caucasian man with type 2 diabetes.
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Affiliation(s)
| | - Jens Faber
- Department of Endocrinology, Herlev Hospital, Herlev, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ebbe Eldrup
- Department of Endocrinology, Herlev Hospital, Herlev, Denmark
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34
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Aharon-Hananel G, Raz I. An evaluation of the efficacy and safety of Tofogliflozin for the treatment of type II diabetes. Expert Opin Pharmacother 2019; 20:781-790. [PMID: 30835599 DOI: 10.1080/14656566.2019.1583210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Genya Aharon-Hananel
- Diabetes Medical Center, Tel Aviv, Israel
- Endocrine Institute, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Itamar Raz
- Diabetes Medical Center, Tel Aviv, Israel
- Hadassah Hebrew University Hospital, Jerusalem, Israel
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35
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Dietary Approaches for Japanese Patients with Diabetes: A Systematic Review. Nutrients 2018; 10:nu10081080. [PMID: 30104491 PMCID: PMC6116111 DOI: 10.3390/nu10081080] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/01/2018] [Accepted: 08/08/2018] [Indexed: 12/31/2022] Open
Abstract
This study aimed to elucidate the effect of an energy restricted and carbohydrate restricted diet on the management of Japanese diabetes patients. Several databases including MEDLINE, EMBASE, and the Japan Medical Abstracts Society were searched for relevant articles published prior to June 2017. The articles identified were systematically reviewed. We identified 286 articles on an energy restricted diet, assessed seven and included two studies in our review. On a carbohydrate restricted diet, 75 articles were extracted, seven articles assessed and three included in the review, of which two were the studies that were selected for the energy restricted diet group, since they compared energy restricted diets with carbohydrate restricted diets. All selected studies were on Japanese patients with type 2 diabetes. No studies for type 1 diabetes were found in our search. Two randomized controlled trials on an energy restricted diet were also included in the three studies for a carbohydrate restricted diet. All the three randomized controlled trials showed better glucose management with the carbohydrate restricted diet. Our study revealed that there is very little evidence on diets, particularly in Japanese patients with diabetes, and that the energy restricted diet, which has been recommended by the Japan Diabetes Society in the sole dietary management approach, is not supported by any scientific evidence. Our findings suggest that the carbohydrate restricted diet, but not the energy restricted diet, might have short term benefits for the management of diabetes in Japanese patients. However, since our analysis was based on a limited number of small randomized controlled trials, large scale and/or long term trials examining the dietary approaches in these patients are needed to confirm our findings.
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Dapagliflozin-Associated Euglycemic Diabetic Ketoacidosis in a Patient Presenting with Acute Pancreatitis. Case Rep Endocrinol 2018; 2018:6450563. [PMID: 30159178 PMCID: PMC6106964 DOI: 10.1155/2018/6450563] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 07/11/2018] [Indexed: 12/20/2022] Open
Abstract
Sodium-glucose cotransporter 2 (SGLT-2) inhibitors are a class of medications used for glycemic control in type II diabetes mellitus. Their mechanism of action involves preventing resorption of glucose at the proximal kidney, thereby promoting glucosuria and weight loss. However, they have also been found to be associated with euglycemic diabetic ketoacidosis (euDKA). This case describes a 25-year-old male with a history of type II diabetes on metformin, sitagliptin, and dapagliflozin who was admitted with his third episode of pancreatitis secondary to hypertriglyceridemia. His home oral glycemic agents were continued as inpatient. Despite tight euglycemic control, the patient developed profound metabolic acidosis and was found to have an elevated beta-hydroxybutyrate level and normal lactic acid level. He was admitted into the intensive care unit and started on an insulin drip, and after resolution of his acidosis he was transitioned to basal insulin successfully. He was discharged with an insulin regimen while his oral glycemic agents were discontinued indefinitely. SGLT-2 inhibitors are associated with euDKA, most likely as a result of their non-insulin-dependent glucose clearance, hyperglucagonemia, and decreased ketone clearance. The aim of this case report is to inform the physician about the possibility of euDKA in a patient with type II diabetes on a SGLT-2 inhibitor presenting with an acute illness.
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Blunck JR, Newman JW, Fields RK, Croom JE. Therapeutic augmentation of ketogenic diet with a sodium-glucose cotransporter 2 inhibitor in a super-refractory status epilepticus patient. EPILEPSY & BEHAVIOR CASE REPORTS 2018; 10:61-64. [PMID: 30073144 PMCID: PMC6068319 DOI: 10.1016/j.ebcr.2018.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 05/18/2018] [Accepted: 05/29/2018] [Indexed: 01/01/2023]
Abstract
Background A ketogenic diet (KD) may have a role in treating patients in super-refractory status epilepticus (SRSE). Sodium-glucose cotransporter 2 (SGLT2) inhibitors have a risk of ketoacidosis that could facilitate induction of KD. Case summary A 42-year-old with a history of drug resistant epilepsy developed SRSE requiring several pharmacological interventions during her hospital course including the initiation of KD that failed. SGLT2 inhibitor therapy was initiated in a successful attempt to augment ketone production. Conclusion SGLT2 inhibitors may have a therapeutic value in SRSE patients who cannot achieve ketosis with KD alone. Super-refractory status epilepticus (SRSE) carries a high risk of morbidity and mortality despite both pharmacologic and non-pharmacologic interventions. The ketogenic diet can play an important role as an adjunct treatment for these patients, but delaying ketosis could negate those benefits. Sodium-glucose cotransporter 2 inhibitors can carry an increased risk of ketoacidosis that may benefit patients in SRSE who do not achieve ketosis on the ketogenic diet alone.
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Affiliation(s)
- Joseph R Blunck
- Saint Luke's Hospital, 4401 Wornall Rd., 64111 Kansas City, MO, United States of America
| | - Joseph W Newman
- Saint Luke's Hospital, 4401 Wornall Rd., 64111 Kansas City, MO, United States of America
| | - Ronald K Fields
- Saint Luke's Hospital, 4401 Wornall Rd., 64111 Kansas City, MO, United States of America
| | - John E Croom
- Saint Luke's Hospital, 4401 Wornall Rd., 64111 Kansas City, MO, United States of America
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Seino Y, Sasaki T, Fukatsu A, Imazeki H, Ochiai H, Sakai S. Efficacy and safety of luseogliflozin added to insulin therapy in Japanese patients with type 2 diabetes: a multicenter, 52-week, clinical study with a 16-week, double-blind period and a 36-week, open-label period. Curr Med Res Opin 2018; 34:981-994. [PMID: 29448833 DOI: 10.1080/03007995.2018.1441816] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of luseogliflozin in Japanese patients with type 2 diabetes (T2D) inadequately controlled with insulin monotherapy. METHODS This 52-week multicenter study entailed a 16-week, double-blind period followed by a 36-week, open-label period. Patients were randomized to receive either luseogliflozin 2.5 mg (n = 159) or placebo (n = 74) during the double-blind period. All patients who entered the open-label period received luseogliflozin. Major efficacy endpoints included the changes from baseline in HbA1c, fasting plasma glucose (FPG), postprandial plasma glucose (PPG) and bodyweight. Safety assessments included adverse events, laboratory tests and vital signs. RESULTS In the double-blind period, luseogliflozin significantly decreased HbA1c (-1.18%), FPG (-42.4 mg/dL), 2 hour PPG (-68.7 mg/dL) and bodyweight (-1.27 kg) compared with placebo (all p < .001); these reductions were maintained over 52 weeks. The changes from baseline at Week 52 were -1.00%, -35.1 mg/dL, -68.8 mg/dL and -1.81 kg, respectively (all p < .001). In the placebo group, favorable glycemic control and bodyweight reduction were also observed after switching to luseogliflozin. Most adverse events were mild in severity. During the double-blind period, the incidences of hypoglycemia were 20.8% and 13.5% in the luseogliflozin and placebo groups, respectively. During the 52 weeks of luseogliflozin treatment, the frequency of hypoglycemia was 33.3%, but no serious hypoglycemia occurred. The safety profile other than hypoglycemia was also acceptable. There were no new safety concerns about luseogliflozin added to insulin. CONCLUSION Luseogliflozin added to insulin therapy significantly improved glycemic control with bodyweight reduction and was well tolerated in Japanese patients with T2D. CLINICAL TRIAL REGISTRATION Japan Pharmaceutical Information Center (JapicCTI-142582).
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Affiliation(s)
- Yutaka Seino
- a Kansai Electric Power Hospital , Osaka , Japan
- b Kansai Electric Power Medical Research Institute , Kobe , Japan
| | - Takashi Sasaki
- c Institute of Clinical Medicine and Research, The Jikei University School of Medicine , Chiba , Japan
| | | | | | | | - Soichi Sakai
- e Taisho Pharmaceutical Co. Ltd. , Tokyo , Japan
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Sainsbury E, Kizirian NV, Partridge SR, Gill T, Colagiuri S, Gibson AA. Effect of dietary carbohydrate restriction on glycemic control in adults with diabetes: A systematic review and meta-analysis. Diabetes Res Clin Pract 2018. [PMID: 29522789 DOI: 10.1016/j.diabres.2018.02.026] [Citation(s) in RCA: 173] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Nutrition therapy is considered a key component of diabetes management, yet evidence around the ideal macronutrient composition of the diet remains inconclusive. A systematic review and meta-analysis was performed to assess the effects of carbohydrate-restricted diets (≤45% of total energy) compared to high carbohydrate diets (>45% of total energy) on glycemic control in adults with diabetes mellitus. Six databases were searched for articles published between January 1980 and August 2016. Primary outcome was between-group difference in HbA1c change. Individual effect sizes were standardized, and a meta-analysis performed to calculate pooled effect size using random effects. 25 RCTs involving 2412 participants were included. Carbohydrate-restricted diets, in particular those that restrict carbohydrate to <26% of total energy, produced greater reductions in HbA1c at 3 months (WMD -0.47%, 95% CI: -0.71, -0.23) and 6 months (WMD -0.36%, 95% CI: -0.62, -0.09), with no significant difference at 12 or 24 months. There was no difference between moderately restricted (26-45% of total energy) and high carbohydrate diets at any time point. Although there are issues with the quality of the evidence, this review suggests that carbohydrate-restricted diets could be offered to people living with diabetes as part of an individualised management plan.
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Affiliation(s)
- Emma Sainsbury
- The University of Sydney, The Boden Institute of Obesity, Nutrition, Exercise & Eating Disorders, Charles Perkins Centre, NSW 2006, Australia.
| | - Nathalie V Kizirian
- The University of Sydney, The Boden Institute of Obesity, Nutrition, Exercise & Eating Disorders, Charles Perkins Centre, NSW 2006, Australia.
| | - Stephanie R Partridge
- The University of Sydney, The Boden Institute of Obesity, Nutrition, Exercise & Eating Disorders, Charles Perkins Centre, NSW 2006, Australia.
| | - Timothy Gill
- The University of Sydney, The Boden Institute of Obesity, Nutrition, Exercise & Eating Disorders, Charles Perkins Centre, NSW 2006, Australia.
| | - Stephen Colagiuri
- The University of Sydney, The Boden Institute of Obesity, Nutrition, Exercise & Eating Disorders, Charles Perkins Centre, NSW 2006, Australia.
| | - Alice A Gibson
- The University of Sydney, The Boden Institute of Obesity, Nutrition, Exercise & Eating Disorders, Charles Perkins Centre, NSW 2006, Australia.
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Polidori D, Iijima H, Goda M, Maruyama N, Inagaki N, Crawford PA. Intra- and inter-subject variability for increases in serum ketone bodies in patients with type 2 diabetes treated with the sodium glucose co-transporter 2 inhibitor canagliflozin. Diabetes Obes Metab 2018; 20:1321-1326. [PMID: 29341404 PMCID: PMC5947648 DOI: 10.1111/dom.13224] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 01/02/2018] [Accepted: 01/11/2018] [Indexed: 01/08/2023]
Abstract
Sodium glucose co-transporter 2 (SGLT2) inhibitors have been associated with increased serum ketone body levels in patients with type 2 diabetes mellitus (T2DM). In the present analysis we evaluated serum ketone body levels and variability in 1278 Japanese patients with T2DM treated with canagliflozin 100 or 200 mg. Similar mean increases in ketone body concentrations of ~2-fold were seen with both canagliflozin doses. The median (interquartile range) percent change from baseline was 62% (0;180) for acetoacetate and 78% (2;236) for β-hydroxybutyrate. Approximately two-thirds of the variability in each ketone measure was attributed to intra-subject variability. Intra-subject variability was higher for serum ketones than other metabolites. Patients in the lowest response tertile exhibited no increase in ketones. Those in the highest response tertile tended to be male and have higher fasting plasma glucose levels, lower insulin levels, and longer T2DM duration at baseline. Moreover, changes in serum ketones were not fully explained by changes in plasma fatty acids, suggesting downstream effects of SGLT2 inhibition on hepatic metabolism that favour ketogenesis. In summary, increases in serum ketone bodies with canagliflozin were greater and more variable than changes in other metabolic measures in Japanese patients with T2DM.
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Affiliation(s)
| | - Hiroaki Iijima
- Ikuyaku. Integrated Value Development Division, Mitsubishi Tanabe Pharma CorporationTokyoJapan
| | - Maki Goda
- Ikuyaku. Integrated Value Development Division, Mitsubishi Tanabe Pharma CorporationTokyoJapan
| | - Nobuko Maruyama
- Ikuyaku. Integrated Value Development Division, Mitsubishi Tanabe Pharma CorporationTokyoJapan
| | - Nobuya Inagaki
- Department of Diabetes, Endocrinology and NutritionGraduate School of Medicine, Kyoto UniversityKyotoJapan
| | - Peter A. Crawford
- Departments of Medicine, and Biochemistry, Molecular Biology, and BiophysicsUniversity of MinnesotaMinneapolisMinnesota
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Sievenpiper JL, Chan CB, Dworatzek PD, Freeze C, Williams SL. Nutrition Therapy. Can J Diabetes 2018; 42 Suppl 1:S64-S79. [DOI: 10.1016/j.jcjd.2017.10.009] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Indexed: 02/07/2023]
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42
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Tahara A, Takasu T. Antidiabetic effects of SGLT2 inhibitor ipragliflozin in type 2 diabetic mice fed diets containing different carbohydrate contents. Life Sci 2018; 197:80-90. [DOI: 10.1016/j.lfs.2018.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 01/26/2018] [Accepted: 02/05/2018] [Indexed: 01/14/2023]
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43
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Bonora BM, Avogaro A, Fadini GP. Sodium-glucose co-transporter-2 inhibitors and diabetic ketoacidosis: An updated review of the literature. Diabetes Obes Metab 2018; 20:25-33. [PMID: 28517913 DOI: 10.1111/dom.13012] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 05/12/2017] [Accepted: 05/13/2017] [Indexed: 12/15/2022]
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT2is) are increasingly used for the treatment of type 2 diabetes (T2D) and can improve glucose control also in type 1 diabetes (T1D). In May 2015, regulatory agencies issued a warning that SGLT2is may cause diabetic ketoacidosis (DKA). We report details on 2 new cases of SGLT2i-associated DKA and review the literature for similar cases within randomized controlled trials (RCTs), cohort studies and single reports. We searched the medical literature for reports of SGLT2i-associated DKA cases. A quantitative analysis of frequency and clinical characteristics is reported. The 2 narrative cases illustrate that SGLT2i-associated DKA can occur in patients with T1D incorrectly diagnosed as T2D, perhaps without the presence of obvious DKA precipitating factors. The incidence of SGLT2i-associated DKA was less than 1/1000 in randomized controlled trials and 1.6/1000 person-years in cohort studies. We retrieved detailed data on 105 SGLT2i-associated DKA case reports, wherein 35% showed glucose levels of less than 200 mg/dL and 22% were not associated with typical triggers. In case reports and in pharmacovigilance databases, duration of SGLT2i treatment before DKA onset was extremely variable. Fatal SGLT2i-associated DKA episodes were found only in pharmacovigilance databases and represented 1.6% of all reported cases. DKA is a rare adverse event during SGLT2i therapy. Predisposing and precipitating factors are still incompletely understood, although a minority of cases lacked typical DKA triggers. More narrative case series and cohort studies are needed to better understand the true risk and the spectrum of this adverse event.
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Affiliation(s)
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Padova, Italy
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Nakamura I, Maegawa H, Tobe K, Tabuchi H, Uno S. Safety and efficacy of ipragliflozin in Japanese patients with type 2 diabetes in real-world clinical practice: interim results of the STELLA-LONG TERM post-marketing surveillance study. Expert Opin Pharmacother 2017; 19:189-201. [DOI: 10.1080/14656566.2017.1408792] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
| | - Hiroshi Maegawa
- Department of Medicine, Shiga University of Medical Science, Shiga, Japan
| | - Kazuyuki Tobe
- First Department of Internal Medicine, University of Toyama, Toyama, Japan
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Xia M, Ye Z, Shi Y, Zhou L, Hua Y. Curcumin improves diabetes mellitus‑associated cerebral infarction by increasing the expression of GLUT1 and GLUT3. Mol Med Rep 2017; 17:1963-1969. [PMID: 29257220 DOI: 10.3892/mmr.2017.8085] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 10/03/2017] [Indexed: 11/05/2022] Open
Abstract
Curcumin is characterized by anti‑inflammatory, anti‑oxidative, antiviral, antifibrotic, anticoagulation and glucose regulatory functions. However, whether it is protective in diabetes mellitus‑associated cerebral infarction remains to be fully elucidated. In the present study, it was demonstrated for the first time, to the best of our knowledge, that curcumin markedly improved neurological deficits, cerebral infarct volume and brain edema rate following middle cerebral artery occlusion (MCAO) surgery. It was also shown that the expression levels of glucose transporter (GLUT)1 and GLUT3 were reduced in the MCAO group. However, following curcumin treatment, the levels of GLUT1 and GLUT3 were markedly increased. In addition, curcumin markedly decreased cell apoptosis, indicating an anti‑apoptotic role of curcumin in the brain. To further evaluate whether curcumin prevented cell apoptosis by modulating the expression of GLUT1 and GLUT3, small interfering RNAs targeting GLUT1 and GLUT3 were selected. It was found that the knockdown of GLUT1 and GLUT3 inhibited the abundance of GLUT1, GLUT3 and B‑cell lymphoma 2, even following incubation with curcumin. These data showed that curcumin protected brain cells from apoptosis and cerebral infarction, predominantly by upregulating GLUT1 and GLUT3.
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Affiliation(s)
- Mingyu Xia
- Vascular Ultrasonography Department, Xuanwu Hospital, Capital Medical University, Beijing 100053, P.R. China
| | - Zankai Ye
- Structural Heart Disease Department, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing 100037, P.R. China
| | - Yanfeng Shi
- Radiology Department, Daqing Longnan Hospital, Daqing, Heilongjiang 163453, P.R. China
| | - Libo Zhou
- Traditional Chinese Medicine Department, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing 100053, P.R. China
| | - Yang Hua
- Vascular Ultrasonography Department, Xuanwu Hospital, Capital Medical University, Beijing 100053, P.R. China
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46
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Blau JE, Tella SH, Taylor SI, Rother KI. Ketoacidosis associated with SGLT2 inhibitor treatment: Analysis of FAERS data. Diabetes Metab Res Rev 2017; 33:10.1002/dmrr.2924. [PMID: 28736981 PMCID: PMC5950709 DOI: 10.1002/dmrr.2924] [Citation(s) in RCA: 161] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 07/05/2017] [Accepted: 07/05/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Regulatory agencies have concluded that sodium glucose cotransporter 2 (SGLT2) inhibitors lead to ketoacidosis, but published literature on this point remains controversial. METHODS We searched the FDA Adverse Event Reporting System (FAERS) for reports of acidosis in patients treated with canagliflozin, dapagliflozin, or empagliflozin (from the date of each drug's FDA approval until May 15, 2015). We compared the number of SGLT2 inhibitor-related reports to reports of acidosis in patients treated with the 2 most commonly used DPP4 inhibitors: sitagliptin and saxagliptin. We estimated relative risks of acidosis by relating the number of reports to cumulative drug sales (a surrogate for patient exposure). RESULTS FAERS contained 259 reports of acidosis (including 192 reports of ketoacidosis) for SGLT2 inhibitors compared with 477 reports of acidosis for DPP4 inhibitors (including 71 reports of ketoacidosis). Based on estimated patient exposure, the overall risk of developing acidosis was ~14-fold higher for SGLT2 inhibitors. Among 51 SGLT2 inhibitor-related reports with quantifiable metabolic information, 20 cases occurred in patients with type 1 diabetes (T1D), 25 in type 2 diabetes (T2D), and 6 in patients with unspecified type of diabetes. After excluding patients with T1D and focusing on patients identified as having T2D, we estimate that SGLT2 inhibitors were associated with ~7-fold increase in developing acidosis. Seventy-one percent had euglycemic ketoacidosis. CONCLUSIONS Our results support the FDA's warning that SGLT2 inhibitors lead to ketoacidosis, as evidenced by an increased reporting rate for acidosis above that in a comparator population treated with DPP4 inhibitors.
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Affiliation(s)
- Jenny E. Blau
- Diabetes, Endocrinology, and Obesity Branch, NIDDK, Bethesda, MD, USA
| | - Sri Harsha Tella
- Diabetes, Endocrinology, and Obesity Branch, NIDDK, Bethesda, MD, USA
| | - Simeon I. Taylor
- Diabetes, Endocrinology, and Obesity Branch, NIDDK, Bethesda, MD, USA
- Division of Endocrinology, Diabetes, and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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Alsahli M, Gerich JE. Renal glucose metabolism in normal physiological conditions and in diabetes. Diabetes Res Clin Pract 2017; 133:1-9. [PMID: 28866383 DOI: 10.1016/j.diabres.2017.07.033] [Citation(s) in RCA: 115] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 07/16/2017] [Accepted: 07/26/2017] [Indexed: 01/25/2023]
Abstract
The kidney plays an important role in glucose homeostasis via gluconeogenesis, glucose utilization, and glucose reabsorption from the renal glomerular filtrate. After an overnight fast, 20-25% of glucose released into the circulation originates from the kidneys through gluconeogenesis. In this post-absorptive state, the kidneys utilize about 10% of all glucose utilized by the body. After glucose ingestion, renal gluconeogenesis increases and accounts for approximately 60% of endogenous glucose release in the postprandial period. Each day, the kidneys filter approximately 180g of glucose and virtually all of this is reabsorbed into the circulation. Hormones (most importantly insulin and catecholamines), substrates, enzymes, and glucose transporters are some of the various factors influencing the kidney's role. Patients with type 2 diabetes have an increased renal glucose uptake and release in the fasting and the post-prandial states. Additionally, glucosuria in these patients does not occur at plasma glucose levels that would normally produce glucosuria in healthy individuals. The major abnormality of renal glucose metabolism in type 1 diabetes appears to be impaired renal glucose release during hypoglycemia.
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Affiliation(s)
- Mazen Alsahli
- Southlake Regional Health Center, Newmarket, Ontario, Canada; University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - John E Gerich
- University of Rochester School of Medicine, Rochester, NY, USA.
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Iuchi H, Sakamoto M, Matsutani D, Suzuki H, Kayama Y, Takeda N, Minamisawa S, Utsunomiya K. Time-dependent effects of ipragliflozin on behaviour and energy homeostasis in normal and type 2 diabetic rats: continuous glucose telemetry analysis. Sci Rep 2017; 7:11906. [PMID: 28928461 PMCID: PMC5605532 DOI: 10.1038/s41598-017-12106-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 09/04/2017] [Indexed: 01/03/2023] Open
Abstract
Sodium–glucose cotransporter 2 (SGLT2) inhibitors are oral antidiabetic drugs that promote urinary glucose excretion. Conversely, they cause behavioural changes, such as hyperphagia, that result in a positive energy balance. The relationship between energy homeostasis and SGLT2 inhibitors-induced behavioural changes remains unclear. Here we show that ipragliflozin, a SGLT2 inhibitor, time-dependently affects behaviour and enhances energy expenditure in normal and type 2 diabetic Goto–Kakizaki (GK) rats, using continuous glucose telemetry. Alongside increased urinary glucose excretion, ipragliflozin increased total food and water intakes in normal and GK rats. In normal rats, ipragliflozin treatment acutely disturbed the circadian rhythms of food and water intakes, activity, and body temperature. Subsequently, these rhythms gradually returned towards a normal state. However, activity and body temperature remained suppressed. In GK rats, ipragliflozin did not affect circadian rhythms. Blood glucose values assessed by glucose telemetry were significantly reduced in both ipragliflozin-treated groups. Despite these behavioural and glycaemic changes, ipragliflozin significantly increased oxygen consumption during dark and light periods in both groups. Ipragliflozin reduced body weight in normal rats only. Thus, ipragliflozin decreases blood glucose beyond compensatory hyperphagia in normal and GK rats, resulting in enhanced basal energy expenditure, despite acutely altering circadian rhythms in normoglycaemic individuals.
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Affiliation(s)
- Hiroyuki Iuchi
- Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Masaya Sakamoto
- Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan.
| | - Daisuke Matsutani
- Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Hirofumi Suzuki
- Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Yosuke Kayama
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Norihiko Takeda
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Susumu Minamisawa
- Department of Cell Physiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Kazunori Utsunomiya
- Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
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49
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Yabe D, Hamamoto Y, Seino Y, Kuwata H, Kurose T, Seino Y. Sodium glucose co-transporter 2 inhibitor luseogliflozin in the management of type 2 diabetes: a drug safety evaluation. Expert Opin Drug Saf 2017; 16:1211-1218. [DOI: 10.1080/14740338.2017.1359252] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Daisuke Yabe
- Yutaka Seino Distinguished Center for Diabetes Research, Kansai Electric Power Medical Research Institute, Kobe, Japan
| | - Yoshiyuki Hamamoto
- Yutaka Seino Distinguished Center for Diabetes Research, Kansai Electric Power Medical Research Institute, Kobe, Japan
- Center for Diabetes, Endocrinology and Metabolism, Kansai Electric Power Hospital, Osaka, Japan
- Center for Metabolism and Clinical Nutrition, Kansai Electric Power Hospital, Osaka, Japan
| | - Yusuke Seino
- Departments of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hitoshi Kuwata
- Yutaka Seino Distinguished Center for Diabetes Research, Kansai Electric Power Medical Research Institute, Kobe, Japan
- Center for Diabetes, Endocrinology and Metabolism, Kansai Electric Power Hospital, Osaka, Japan
| | - Takeshi Kurose
- Yutaka Seino Distinguished Center for Diabetes Research, Kansai Electric Power Medical Research Institute, Kobe, Japan
- Center for Diabetes, Endocrinology and Metabolism, Kansai Electric Power Hospital, Osaka, Japan
| | - Yutaka Seino
- Yutaka Seino Distinguished Center for Diabetes Research, Kansai Electric Power Medical Research Institute, Kobe, Japan
- Center for Diabetes, Endocrinology and Metabolism, Kansai Electric Power Hospital, Osaka, Japan
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Ferrannini E. Sodium-Glucose Co-transporters and Their Inhibition: Clinical Physiology. Cell Metab 2017; 26:27-38. [PMID: 28506519 DOI: 10.1016/j.cmet.2017.04.011] [Citation(s) in RCA: 231] [Impact Index Per Article: 28.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 03/07/2017] [Accepted: 04/13/2017] [Indexed: 12/25/2022]
Abstract
Sodium-glucose cotransporter-2 (SGLT2) is selectively expressed in the human kidney, where it executes reabsorption of filtered glucose with a high capacity; it may be overactive in patients with diabetes, especially in the early, hyperfiltering stage of the disease. As a therapeutic target, SGLT2 has been successfully engaged by orally active, selective agents. Initially developed as antihyperglycemic drugs, SGLT2 inhibitors have deployed a range of in vivo actions. Consequences of their primary effect, i.e., profuse glycosuria and natriuresis, involve hemodynamic (plasma volume and blood pressure reduction) and metabolic pathways (increase in lipid oxidation and ketogenesis at the expense of carbohydrate utilization); the hormonal mediation extends to insulin, glucagon, and gastrointestinal peptides. Their initial trial in high-risk patients with diabetes has provided evidence for marked reduction of cardiovascular risk. This review focuses on the quantitative pharmacology of SGLT2 inhibitors, which can be exploited to discover new physiology, in the heart, kidney, and brain.
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Affiliation(s)
- Ele Ferrannini
- CNR (Consiglio Nazionale delle Ricerche) Institute of Clinical Physiology, Via Roma, 67, 56126 Pisa, Italy.
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