Safety and effectiveness of the sodium-glucose cotransporter inhibitor bexagliflozin in cats newly diagnosed with diabetes mellitus

Clinical Management of Euglycemic Ketoacidosis in a Cat With Congenital Diabetes Mellitus Treated With Insulin and Dapagliflozin

OBJECTIVE

To describe the medical management of euglycemic diabetic ketoacidosis (EDKA) after two administrations of dapagliflozin in a cat with congenital diabetes mellitus undergoing insulin therapy.

CASE SUMMARY

A 2-year-old neutered female domestic shorthair cat with a prior presumptive diagnosis of congenital diabetes mellitus was followed for 20 months. After several adjustments to insulin therapy, the cat was relatively stable on high doses of insulin glargine (8.3 IU/kg, SC, q 12 h) with persistent hyperglycemia. Due to concerns regarding the impact of chronic hyperglycemia in a young cat, treatment was started with dapagliflozin (10 mg/cat, PO, q 24 h). A reduced dose of insulin glargine (1.3 IU/kg, SC, q 12 h) was administered concurrently to minimize the risk of ketoacidosis. Forty-eight hours after the second dapagliflozin administration, the cat was admitted for lethargy, hyporexia, and vomiting. Bloodwork was consistent with ketoacidosis and hypokalemia. During initial treatment for diabetic ketoacidosis, the cat developed hypophosphatemia, hyperbilirubinemia, and increased liver enzyme activities, with normal interstitial glucose values despite cessation of dapagliflozin. Management consisted of 7.5% glucose supplementation, a constant rate infusion of short-acting insulin, and correction of electrolyte and acid-base derangements. Improvement was seen within 12 h of starting this protocol. The cat was discharged after 9 days of hospitalization. Sixteen days after the discontinuation of dapagliflozin, the cat's interstitial glucose concentration, liver enzyme activities, and serum bilirubin concentration returned to pretreatment values.

NEW OR UNIQUE INFORMATION PROVIDED

With the introduction of sodium-glucose linked cotransporter 2 inhibitors, clinicians should be aware of EDKA and its management. This case report describes how the treatment of EDKA in cats, similar to treatment in people, may require proactive, aggressive glucose supplementation, treatment with short-acting soluble insulin, and vigilant electrolyte and acid-base monitoring. It also showcases the possibility of dapagliflozin having effect days beyond drug cessation.

Accuracy of the Freestyle Libre 3 Continuous Glucose Monitoring System in Hypo- and Euglycemic Cats

BACKGROUND

The FreeStyle Libre 3 (FSL3) has several improvements compared to previous FreeStyle Libre systems, but its accuracy has not yet been determined in cats. In diabetic people, FSL3 offers increased accuracy, and its smaller size could be advantageous for use in veterinary patients.

OBJECTIVES

Assess the accuracy of FSL3 in cats with experimentally induced hypoglycemia.

ANIMALS

Seven healthy, purpose-bred cats.

METHODS

Hyperinsulinemic-hypoglycemic clamps were performed. Interstitial glucose concentration (IG), measured by FSL3, was compared to blood glucose concentration (BG) measured by AlphaTrak2. Data were analyzed for all paired measurements (n = 474) and during stable BG (≤ 1 mg/dL/min change over 10 min). Pearson's r test, Bland-Altman test, and Parkes Error Grid analysis (EGA) respectively used to determine correlation, bias, and clinical accuracy.

RESULTS

Blood glucose concentration and IG correlated strongly (r = 0.86, p < 0.0001) in stable glycemia and moderately at all rates of change (r = 0.73, p < 0.0001). Analytical accuracy was not achieved, whereas clinical accuracy was demonstrated with 99%-100% of the results in zones A + B of the Parkes EGA. Interstitial glucose concentration underestimated BG in euglycemia and mild hypoglycemia (mean -11.7 ± 11.2, -5.5 ± 9.1, -1.5 ± 6.0 mg/dL in the ranges 91-120, 66-90, and 56-65 mg/dL, respectively), but overestimated BG in marked hypoglycemia (mean 6.3 ± 5.7, 15.7 ± 5.6 mg/dL in the ranges 46-55 and < 45 mg/dL, respectively).

CONCLUSIONS

The FSL3 underestimates BG across most of the hypo-euglycemic range but overestimates BG in marked hypoglycemia (< 55 mg/dL). Recognizing the proportional, glycemic-dependent bias of FSL3 improves the safety of its clinical application in cats.

Sodium-glucose co-transporter 2 inhibitors: a pleiotropic drug in humans with promising results in cats

Diabetes mellitus is a common metabolic disease in humans and cats. Cats share several features of human type-2 diabetes and can be considered an animal model for this disease. In the last decade, sodium-glucose transporter 2 inhibitors (SGLT2i) have been used successfully as a class of hypoglycemic drug that inhibits the reabsorption of glucose from the renal proximal tubules, consequently managing hyperglycemia through glycosuria. Furthermore, SGLT2i have been shown to have cardiac, renal, and other protective effects in diabetic humans acting as a pleiotropic drug. Currently, at least six SGLT2i are approved by the Food and Drug Administration (FDA) for use in humans with type-2 diabetes, and recently, two drugs were approved for use in diabetic cats. This narrative review focuses on the use of SGLT2i to treat diabetes mellitus in humans and cats. We summarize the human data that support the use of SGLT2i in controlling type-2 diabetes and protecting against cardiovascular and renal damage. We also review the available literature regarding other benefits of these drugs in humans as well as the effects of SGLT2i in cats. Adverse effects related to the use of these hypoglycemic drugs are also discussed.

Sodium-glucose transport protein 2 inhibitor use in the management of insulin dysregulation in ponies and horses

Laminitis is a common and painful condition of the equine foot and approximately 90% of cases are associated with insulin dysregulation (ID) that is a central feature of the common endocrine disorder equine metabolic syndrome (EMS) and occurs in a subset of animals with pituitary pars intermedia dysfunction. Additional features of EMS include obesity, altered circulating concentrations of adipokines (particularly adiponectin and leptin) and hypertriglyceridaemia. Obesity, ID, hypoadiponectinaemia, hyperleptinaemia and an altered plasma lipid profile are also features of human metabolic syndrome (HMS) alongside hyperglycaemia. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are a novel class of oral hypoglycaemic agents used in combination with lifestyle changes in the management of HMS. SGLT2 receptors are responsible for 90% of the renal glucose reabsorption that occurs in the proximal convoluted tubule. Thus, these drugs increase urinary glucose excretion by suppressing glucose reabsorption from the glomerular filtrate resulting in urinary calorie loss with consequent weight loss and improvements in ID, hyperglycemia, hypoadiponectinaemia and hyperleptinaemia. There are no licenced veterinary drugs available for treating ID and preventing insulin-associated laminitis in horses. Thus, the use of SGLT2i for the control of equine hyperinsulinaemia with the goal of improving recovery from associated active laminitis or preventing future laminitis has recently been advocated. There are a small number of published studies reporting the use of the SGLT2i canagliflozin, ertugliflozin and velagliflozin to aid the management of equine ID. However, the doses used are largely extrapolated from human studies with limited consideration of species-specific variations. In addition, there is limited evaluation of the fundamental differences between ID in horses and humans, particularly the fact that most horses with ID remain hyperinsulinaemic but normoglycaemic such that increased urinary loss of glucose may not explain the beneficial effects of these drugs. Further study of the potential deleterious effects of treatment-associated hypertriglyceridaemia is required together with the effect of SGLT2i therapy on circulating concentrations of adipokines in horses.

SGLT2 inhibitor use in the management of feline diabetes mellitus

Sodium-glucose cotransporter-2 (SGLT2) inhibitors are routinely used in the management of human type 2 diabetes and have been shown to effectively mitigate hyperglycemia and reduce the risks of cardiovascular and renal compromise. Two SGLT2 inhibitors, namely bexagliflozin and velagliflozin, were recently FDA approved for the treatment of uncomplicated feline diabetes mellitus. These oral hypoglycemic agents are a suitable option for many newly diagnosed cats, with rapid improvements in glycemic control and clinical signs. Suitable candidates must have some residual β-cell function, as some endogenous insulin production is required to prevent ketosis. Appropriate patient selection and monitoring are necessary, and practitioners should be aware of serious complications such as euglycemic diabetic ketoacidosis.

Feline acute patient physiologic and laboratory evaluation scores and other prognostic factors in cats with first-time diabetic ketoacidosis

BACKGROUND

Acute Patient Physiologic and Laboratory Evaluation (APPLE) scores have not been reported in cats with diabetic ketoacidosis (DKA).

HYPOTHESIS

In cats with DKA, APPLE scores will be significantly higher in non-survivors compared with survivors and these scores will predict mortality.

ANIMALS

Sixty-eight cats with DKA.

METHODS

Retrospective study. The APPLE scores, blood glucose concentration (BG), venous pH, and ketone concentrations were compared between survivors and non-survivors. Simple logistic regression was used to determine if these variables predict the binary variable of survival or non-survival, and if they did, an empirical optimal cut point for mortality prediction was calculated.

RESULTS

The APPLEfast and APPLEfull scores were significantly higher in non-survivors (30 cats; 24.6 ± 7.4 and 45.2 ± 7.3 , respectively) compared with survivors (38 cats; 20.9 ± 6.2 and 41.7 ± 6.5 ; P = .01 and P = .02, respectively). The APPLEfast (P = .03) but not the APPLEfull scores (P = .06) predicted mortality. For every 1 unit increase in the APPLEfast score, the odds of death increased by 1.08 (95% confidence interval [CI], 1.006-1.17; P = .03). Median BG was significantly higher in non-survivors (431 mg/dL; range, 260-832 mg/dL) compared with survivors (343 mg/dL; range, 256-738 mg/dL; P = .01) and BG predicted mortality (P = .02). For every 1 mg/dL increase in BG, the odds of death increased by 1.004 (95% CI, 1.0006-1.008). Empirical optimal cut points for APPLEfast and BG mortality prediction were 24.5 and 358 mg/dL, respectively.

CONCLUSIONS AND CLINICAL IMPORTANCE

The APPLEfast score and BG predict mortality in cats with DKA and can be used to stratify populations by risk of mortality in clinical trials of DKA in cats.

Efficacy and safety of once daily oral administration of sodium-glucose cotransporter-2 inhibitor velagliflozin compared with twice daily insulin injection in diabetic cats

BACKGROUND

Options for treatment of diabetes mellitus in cats are limited to insulin injections and monitoring for hypoglycemia.

HYPOTHESIS

Once daily sodium-glucose cotransporter-2 inhibitor velagliflozin PO is noninferior to insulin injections.

ANIMALS

Client-owned diabetic cats (127 safety; 116 efficacy assessment).

METHODS

Prospective, randomized (1 mg/kg velagliflozin), positive controlled (titrated Caninsulin), open label, noninferiority field trial, comparing number of cats with treatment success in ≥1 clinical variable and ≥1 glycemic variable (margin Δ: 15%) on Day 45; secondary endpoints included glycemic and clinical assessments during 91 days.

RESULTS

On Day 45, 29/54 (54%) velagliflozin-treated cats and 26/62 (42%) Caninsulin-treated cats showed treatment success, demonstrating noninferiority (difference -11.8%; upper 1-sided 97.5% confidence interval, -∞ to 6.3%). By Day 91, quality of life (QoL), polyuria, and polydipsia had improved in 81%, 54% and 61% (velagliflozin); on blood glucose (BG) curves, mean BG was <252 mg/dL in 42/54 (78%; velagliflozin) and 37/62 (60%; Caninsulin); minimum BG was <162 mg/dL in 41/54 (76%; velagliflozin) and 41/62 (66%; Caninsulin); serum fructosamine was <450 μmol/L in 41/54 (76%; velagliflozin) and 38/62 (61%; Caninsulin). Velagliflozin's most frequent adverse events were loose feces/diarrhea (n = 23/61, 38%), positive urine culture (n = 19/61, 31%), and nonclinical hypoglycemia (BG <63 mg/dL; n = 8/61, 13%); Caninsulin's: clinical and nonclinical hypoglycemia (n = 35/66, 53%), positive urine culture (n = 18/66, 27%), and loose feces/diarrhea (n = 10/66, 15%). Diabetic ketoacidosis occurred in 4/61 (7%; velagliflozin) and 0/66 (Caninsulin).

CONCLUSIONS AND CLINICAL IMPORTANCE

Once daily oral administration of velagliflozin was noninferior to insulin injections, showed good QoL and glycemia without clinical hypoglycemia.

Effect of sodium-glucose cotransporter 2 inhibitor canagliflozin on interstitial glucose concentration in insulin-treated diabetic dogs

BACKGROUND

The utility of sodium-glucose cotransporter 2 inhibitors (SGLT2i) has not been reported in insulin-treated diabetic dogs.

HYPOTHESIS

Canagliflozin, a PO-administered SGLT2i, decreases interstitial glucose concentration (IG) in insulin-treated diabetic dogs.

ANIMALS

Five insulin-treated diabetic dogs.

METHODS

Uncontrolled open label longitudinal study. Canagliflozin (2-4 mg/kg/day PO) was added to an unchanged insulin dose for 7 days. Fractional excretion of glucose was calculated by dividing the product of urine glucose and serum creatinine concentrations by the product of serum glucose and urine creatinine concentrations. Hypoglycemia was defined as IG <60 mg/dL.

RESULTS

Median IG in 2869 measurements obtained while dogs were treated with insulin and canagliflozin was 87 mg/dL (range, 40-500 mg/dL) and was significantly lower than median IG in 1426 measurements obtained while dogs were treated with insulin alone (212 mg/dL; range, 41-500 mg/dL; P < .001). Median fractional excretion of glucose when dogs were treated with insulin and canagliflozin was 1.1% (range, 0.9%-2.0%), significantly higher than when dogs were treated with insulin alone (0.3%; range, 0.01%-1.0%; P = .04). The frequency of hypoglycemia was higher in dogs treated with insulin and canagliflozin (544 of 2869 IG measurements, 19%) compared with the frequency of hypoglycemia in dogs treated with insulin alone (52 of 1426 IG measurements, 4%; P < .001).

CONCLUSIONS AND CLINICAL IMPORTANCE

Canagliflozin may have a role in improving glycemic control in insulin-treated diabetic dogs, but the dose of insulin should be decreased when adding canagliflozin to insulin treatment.

Risks and Benefits of SGLT-2 Inhibitors for Type 1 Diabetes Patients Using Automated Insulin Delivery Systems-A Literature Review

The primary treatment for autoimmune Diabetes Mellitus (Type 1 Diabetes Mellitus-T1DM) is insulin therapy. Unfortunately, a multitude of clinical cases has demonstrated that the use of insulin as a sole therapeutic intervention fails to address all issues comprehensively. Therefore, non-insulin adjunct treatment has been investigated and shown successful results in clinical trials. Various hypoglycemia-inducing drugs such as Metformin, glucagon-like peptide 1 (GLP-1) receptor agonists, dipeptidyl peptidase-4 (DPP-4) inhibitors, amylin analogs, and Sodium-Glucose Cotransporters 2 (SGLT-2) inhibitors, developed good outcomes in patients with T1DM. Currently, SGLT-2 inhibitors have remarkably improved the treatment of patients with diabetes by preventing cardiovascular events, heart failure hospitalization, and progression of renal disease. However, their pharmacological potential has not been explored enough. Thus, the substantial interest in SGLT-2 inhibitors (SGLT-2is) underlines the present review. It begins with an overview of carrier-mediated cellular glucose uptake, evidencing the insulin-independent transport system contribution to glucose homeostasis and the essential roles of Sodium-Glucose Cotransporters 1 and 2. Then, the pharmacological properties of SGLT-2is are detailed, leading to potential applications in treating T1DM patients with automated insulin delivery (AID) systems. Results from several studies demonstrated improvements in glycemic control, an increase in Time in Range (TIR), a decrease in glycemic variability, reduced daily insulin requirements without increasing hyperglycemic events, and benefits in weight management. However, these advantages are counterbalanced by increased risks, particularly concerning Diabetic Ketoacidosis (DKA). Several clinical trials reported a higher incidence of DKA when patients with T1DM received SGLT-2 inhibitors such as Sotagliflozin and Empagliflozin. On the other hand, patients with T1DM and a body mass index (BMI) of ≥27 kg/m2 treated with Dapagliflozin showed similar reduction in hyperglycemia and body weight and insignificantly increased DKA incidence compared to the overall trial population. Additional multicenter and randomized studies are required to establish safer and more effective long-term strategies based on patient selection, education, and continuous ketone body monitoring for optimal integration of SGLT-2 inhibitors into T1DM therapeutic protocol.