Association of British Clinical Diabetologists (ABCD) position statement on the risk of diabetic ketoacidosis associated with the use of sodium-glucose cotransporter-2 inhibitors

Defining the Role of SGLT2 Inhibitors in Primary Care: Time to Think Differently

Disease burden in people with diabetes is mainly driven by long-term complications such as cardiovascular disease, heart failure and chronic kidney disease. This is a consequence of the interconnection between the cardiovascular, renal and metabolic systems, through a continuous chain of events referred to as 'the cardiorenal metabolic continuum'. Increasing evidence suggests that sodium-glucose cotransporter 2 inhibitors (SGLT2is) have beneficial effects across all stages of the cardiorenal metabolic continuum, reducing morbidity and mortality in a wide range of individuals, from those with diabetes and multiple risk factors to those with established heart failure and chronic kidney disease, regardless of the presence of diabetes. Despite this robust evidence base, the complexity of label indications and misconceptions concerning potential side effects have resulted in a lack of clear understanding in primary care regarding the implementation of SGLT2is in clinical practice. With this in mind, we provide an overview of the clinical and economic benefits of SGLT2is across the cardiorenal metabolic continuum together with practical considerations in order to help address some of these concerns and clearly define the role of SGLT2is in primary care as a holistic outcomes-driven treatment with the potential to reduce disease burden across the cardiorenal metabolic spectrum.

Modification of physico-chemical surface properties and growth of Staphylococcus aureus under hyperglycemia and ketoacidosis conditions

Diabetes is a widely spread disease affecting the quality of life of millions of people around the world and is associated to a higher risk of developing infections in different parts of the body. The reasons why diabetes enhances infection episodes are not entirely clear; in this study our aim was to explore the changes that one of the most frequently pathogenic bacteria undergoes when exposed to hyperglycemia and ketoacidosis conditions. Physical surface properties such as hydrophobicity and surface electrical charge are related to bacterial growth behavior and the ability of Staphylococcus aureus to form biofilms. The addition of glucose made bacteria more negatively charged and with moderate-intermediate hydrophobicity. Ketone bodies increased hydrophobicity to approximately 75% and pathological concentrations hindered some of the bacterial surface charge by decreasing the negative zeta potential of cells. When both components were present, the bacterial physical surface changes were more similar to those observed in ketone bodies, suggesting a preferential adsorption of ketone bodies over glucose because of the more favorable solubility of glucose in water. Glucose diabetic concentrations gave the highest number of bacteria in the stationary phase of growth and provoked an increase in the biofilm slime index of around 400% in relation to the control state. Also, this situation is related with an increase of bacterial coverage. The combination of a high concentration of glucose and ketone bodies, which corresponds to a poorly controlled diabetic situation, appears associated with an early infection phase; increased hydrophobic attractive force and reduced electrostatic repulsion between cells results in better packing of cells within the biofilm and more efficient retention to the host surface. Knowledge of bacterial response in high amount of glucose and ketoacidosis environments can serve as a basis for designing strategies to prevent bacterial adhesion, biofilm formation and, consequently, the development of infections.

Association of British Clinical Diabetologists (ABCD) and Diabetes UK joint position statement and recommendations for non-diabetes specialists on the use of sodium glucose co-transporter 2 inhibitors in people with type 2 diabetes (January 2021)

Sodium glucose co-transporter 2 (SGLT2) inhibitors are now an established class of medications for the treatment of type 2 diabetes (T2D), no longer reserved for use by specialists in diabetes. They are being used increasingly for their cardiac and renal benefits by primary care, cardiology and renal teams for indications in parallel with diabetes care as part of holistic management. This guidance provides essential information on SGLT therapy, including the main advantages and the important risks of which healthcare professionals should be aware.

SGLT2 Inhibitor-Induced Euglycemic Diabetic Ketoacidosis: A Case Report

Euglycemic diabetic ketoacidosis is a rare but serious adverse effect of sodium-glucose cotransporter 2 (SGLT2) inhibitors. We present a case of a woman in her 40s with type 2 diabetes mellitus hospitalized for revascularization for moyamoya disease who developed empagliflozin-associated euglycemic diabetic ketoacidosis despite having stopped the medication before admission. Surgical stress, acute postoperative illness, and decreased carbohydrate intake are postulated to be contributing factors to the development of ketosis in this patient, while near-normal glucose levels initially suggested nondiabetic ketoacidosis physiology and led to delayed diagnosis and treatment. Patients with type 2 diabetes mellitus may develop diabetic ketoacidosis during states of relative insulinopenia, most frequently from inadequate medication or intercurrent illness. During periods of carbohydrate deficiency, volume depletion, and upregulation of counter-regulatory stress hormones, SGLT2 inhibitor therapy can promote lipolysis and ketogenesis while maintaining euglycemia. Clinical considerations to ensure safe SGLT2 inhibitor therapy include appropriate holding parameters, timely diagnosis of euglycemic diabetic ketoacidosis, and recognition that the pharmacologic effects of SGLT2 inhibitor treatment may persist beyond several half-lives of elimination.

Diabetes: the place of new therapies

Until the discovery of insulin in 1921 there were no effective treatments for diabetes mellitus. After the advent of long-acting insulin, the first oral agents, sulfonylureas became available in the mid-1950s, quickly followed (outside of the United States) by metformin. It was then another three decades before newer agents became available, with alpha glucosidase inhibitors, thiazolidinediones and meglitinides following in the 1990s. Since the turn of the century, several new classes have also been launched. But how do these agents fit into the management of type 2 diabetes? How does one choose which drug class to use after metformin? This review looks at the agents launched since 2000 and how and when they can be used. It also deals with some of the controversies that have arisen and how decisions have changed as a result, in particular moving away from the use of HbA1c as the driver for decision, but rather the cardiovascular safety of these agents and their use in the prevention of premature cardiovascular morbidity and mortality. Now that some of these agents have shown cardiovascular benefit, will this lead to a change in the treatment paradigm?