Risk of hypovolemia associated with sodium-glucose cotransporter-2 inhibitors treatment: A meta-analysis of randomized controlled trials

Renal and Safety Outcomes of SGLT2 Inhibitors in Patients with Type 2 Diabetes: A Nationwide Observational Cohort Study

Background/Objectives: Evidence on the renal benefits and safety of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in the Asia region is still lacking. This study aimed to evaluate the renal and safety outcomes of SGLT2is compared with dipeptidyl peptidase-4 inhibitors (DPP4i) using real-world data. Methods: A retrospective cohort study was conducted using the nationwide claims data in Republic of Korea. We evaluated kidney outcomes (any new-onset kidney events, acute kidney injury (AKI), chronic kidney disease (CKD), and kidney failure) as primary outcomes and safety outcomes (infection, hemodynamic adverse events, and fracture). Propensity score matching was used to adjust confounders, and the hazard ratios were calculated using the Cox proportional hazards model. Results: The study included 13,649 patients in the SGLT2i group and 35,043 in the DPP4i group after the matching. The SGLT2i group had a lower risk of kidney diseases, AKI, and CKD (HR 0.88 [0.61-0.74]) than the DPP4i group. For secondary outcomes, the risk of genital infection was higher (HR 2.38 [2.12-2.68]), and the risk of hyperkalemia was lower in the SGLT2i group than in the DPP4i group (HRs 0.49 [0.36-0.67]). Conclusions: The SGLT2 inhibitors had a lower risk of new-onset kidney outcomes and CKD than the DPP4 inhibitors. A high incidence of genital infection and a low incidence of hyperkalemia were shown in the SGLT2 inhibitor.

SGLT2 inhibitors as a novel senotherapeutic approach

Cellular senescence is the permanent cessation of cell proliferation and growth. Senescent cells accumulating in tissues and organs with aging contribute to many chronic diseases, mainly through the secretion of a pro-inflammatory senescence-associated secretory phenotype (SASP). Senotherapeutic (senolytic or senomorphic) strategies targeting senescent cells or/and their SASP are being developed to prolong healthy lifespan and treat age-related pathologies. Sodium-glucose co-transporter 2 (SGLT2) inhibitors are a new class of anti-diabetic drugs that promote the renal excretion of glucose, resulting in lower blood glucose levels. Beyond their glucose-lowering effects, SGLT2 inhibitors have demonstrated protective effects against cardiovascular and renal events. Moreover, SGLT2 inhibitors have recently been associated with the inhibition of cell senescence, making them a promising therapeutic approach for targeting senescence and aging. This review examines the latest research on the senotherapeutic potential of SGLT2 inhibitors.

Temporal risk patterns of severe hypovolemia associated with sodium-glucose cotransporter-2 inhibitors in patients with type 2 diabetes mellitus: A self-controlled case series study

AIMS

We aimed to investigate the temporal risk patterns of severe hypovolemia induced by sodium-glucose cotransporter-2 inhibitors (SGLT2i) in patients with type 2 diabetes mellitus.

MATERIALS AND METHODS

We conducted a self-controlled case series using claims data from Japan. Patients who were prescribed SGLT2i for treating type 2 diabetes mellitus and experienced severe hypovolemia were enrolled. The primary analysis evaluated the adjusted incidence rate ratios (IRRs) of exposure risk periods (Days 1 to 30, Days 31 to 90, Days 91 to 180 and Days ≥181) with their corresponding 95% confidence intervals (CIs), calculated using a multivariable conditional Poisson regression model, relative to that of the unexposed control period.

RESULTS

A total of 1200 new users of SGLT2i with 1334 severe hypovolemia events were included. The median follow-up and treatment periods were 3.66 and 2.53 years, respectively. The cohort was predominantly male (78.4%) with a median age of 54.1 years. A higher risk of severe hypovolemia associated with SGLT2i was observed particularly in the first 30 days (adjusted IRR 7.39, 95% CI 6.09-8.96) of treatment initiation. Secondary analyses highlighted the first 22 to 28 days (adjusted IRR 15.24, 95% CI 11.92-19.48) of treatment as the highest risk period for severe hypovolemia.

CONCLUSIONS

SGLT2i use in patients with type 2 diabetes mellitus was associated with a higher risk of severe hypovolemia, particularly within the first 30 days of treatment initiation, with the highest risk observed during 22 to 28 days.

Pros and Cons of Inpatient SGLT2i Use for Hyperglycemia and Heart Failure

Sodium-glucose cotransporter 2 inhibitors (SGLT2is), originally approved by the US Food and Drug Administration for glycemic control in type 2 diabetes mellitus (DM2), have shown substantial cardiovascular and renal benefits, leading to their expanded use in managing heart failure (HF) and chronic kidney disease in the outpatient setting. Despite these benefits, their use for inpatient hyperglycemia management is not universally endorsed due to safety concerns and inadequate data. However, emerging evidence suggests potential advantages of initiating SGLT2i treatment for patients during hospitalization in the setting of HF. While SGLT2is are not recommended for managing inpatient hyperglycemia, initiation during hospitalization for HF provides significant benefits. We review the current literature on the pros and cons of using SGLT2is in hospitalized DM2 and HF patients and provide guidance on careful patient selection and risk mitigation for inpatient use.

Inpatient diabetes management

Diabetes mellitus is currently approaching epidemic proportions and disproportionately affects patients in the hospital setting. In the United States, individuals living with diabetes represent over 17 million emergency department visits and 8 million admissions annually. The management of these patients in the hospital setting is complex and differs considerably from the outpatient setting. All patients with hyperglycemia should be screened for diabetes, as in-hospital hyperglycemia portends a greater risk for morbidity, mortality, admission to an intensive care unit, and increased hospital length of stay. However, the definition of hyperglycemia, glycemic targets, and strategies to manage hyperglycemia in the inpatient setting can vary greatly depending on the population considered. Moreover, the presenting illness, changing nutritional status, and concurrent hospital medications often necessitate thoughtful consideration to adjustments of home diabetes regimens and/or the initiation of new insulin doses. This review article will examine core concepts and emerging new literature surrounding inpatient diabetes management, including glycemic targets, insulin dosing strategies, noninsulin medications, new diabetes technologies, inpatient diabetes management teams, and discharge planning strategies, to optimize patient safety and satisfaction, clinical outcomes, and even hospital financial health.

SGLT2 Inhibitors in Kidney Diseases-A Narrative Review

Some of the most common conditions affecting people are kidney diseases. Among them, we distinguish chronic kidney disease and acute kidney injury. Both entities pose serious health risks, so new drugs are still being sought to treat and prevent them. In recent years, such a role has begun to be assigned to sodium-glucose cotransporter-2 (SGLT2) inhibitors. They increase the amount of glucose excreted in the urine. For this reason, they are currently used as a first-line drug in type 2 diabetes mellitus. Due to their demonstrated cardioprotective effect, they are also used in heart failure treatment. As for the renal effects of SGLT2 inhibitors, they reduce intraglomerular pressure and decrease albuminuria. This results in a slower decline in glomelular filtration rate (GFR) in patients with kidney disease. In addition, these drugs have anti-inflammatory and antifibrotic effects. In the following article, we review the evidence for the effectiveness of this group of drugs in kidney disease and their nephroprotective effect. Further research is still needed, but meta-analyses indicate SGLT2 inhibitors' efficacy in kidney disease, especially the one caused by diabetes. Development of new drugs and clinical trials on specific patient subgroups will further refine their nephroprotective effects.

Sodium-Glucose Cotransporter 2 Inhibitors Should Be Avoided for the Inpatient Management of Hyperglycemia

OBJECTIVE

Hyperglycemia in patients with type 2 diabetes mellitus is frequently encountered in the hospital setting. The recent guidelines for the management of inpatient hyperglycemia have included the use of dipeptidyl peptidase 4 inhibitors as an alternative to standard insulin therapy in select patients. This raises the question of the inpatient use of sodium-glucose cotransporter 2 inhibitors (SGLT2i), which have gained increasing popularity in the outpatient setting because of beneficial cardiovascular and renal outcomes. This article describes the risks associated with the use of SGLT2i for the management of inpatient hyperglycemia.

METHODS

A literature review was performed using PubMed and Google Scholar for studies assessing the inpatient use of SGLT2i. Search terms included "SGLT2 inhibitors," "euglycemic DKA," "inpatient hyperglycemia," "DPP4 inhibitors," "hypovolemia," and "urinary tract infections." Studies not written in English were excluded. Forty-eight articles were included.

RESULTS

Review of the literature showed significant safety concerns with the use of SGLT2i for the inpatient management of hyperglycemia. Hospitalized patients treated with SGLT2i were at increased risk of diabetic ketoacidosis, euglycemic diabetic ketoacidosis, hypovolemia, and urinary tract infections. When compared head-to-head, SGLT2i were not more effective for inpatient glycemic control than dipeptidyl peptidase 4 inhibitors and did not reduce insulin requirements when used in combination with insulin. Although SGLT2i can be considered for the treatment of congestive heart failure, they should be started close to or at the time of discharge.

CONCLUSION

Although SGLT2i are a preferred pharmacotherapy class for the outpatient management of type 2 diabetes mellitus, there are considerable safety concerns when using them in a hospital setting, and avoidance is recommended.

SGLT2 Inhibitors' Cardiovascular Benefits in Individuals Without Diabetes, Heart Failure, and/or Chronic Kidney Disease: A Systematic Review

Despite the growing body of evidence regarding the beneficial cardiovascular effects of sodium-glucose cotransporter-2 (SGLT2) inhibitors, clinical data in individuals without diabetes, heart failure (HF), and/or chronic kidney disease (CKD) is limited. A systematic review of the literature was conducted in PubMed, Scopus, Web of Science, Cochrane Library, and Google Scholar, from database inception until May 4, 2023, to explore new evidence of SGLT2 inhibitors' cardiovascular benefits in individuals without diabetes, HF, and/or CKD. A total of 1156 individuals from 14 studies (13 randomized controlled trials and 1 nonrandomized study) were included. The results showed the benefits of SGLT2 inhibitors on blood pressure, weight, and body mass index in this population with an acceptable safety profile. The current evidence supports the potential role of SGLT2 inhibitors as primary prevention in individuals without diabetes, HF, and/or CKD. This review may shed light on the use of SGLT2 inhibitors in conditions such as stage A HF and metabolic syndrome. The literature trend is going toward uncovering SGLT2 inhibitors' role in stage B HF, different types of myocardial infarction, and cardiac arrhythmias.

The Effects of Sodium-Glucose Cotransporter 2-Inhibitors on Steatosis and Fibrosis in Patients with Non-Alcoholic Fatty Liver Disease or Steatohepatitis and Type 2 Diabetes: A Systematic Review of Randomized Controlled Trials

Type 2 Diabetes Mellitus (T2DM) and non-alcoholic fatty liver disease (NAFLD) are part of metabolic syndrome and share multiple causal associations. Both conditions have an alarmingly increasing incidence and lead to multiple complications, which have an impact on a variety of organs and systems, such as the kidneys, eyes, and nervous and cardiovascular systems, or may cause metabolic disruptions. Sodium-glucose cotransporter 2-inhibitors (SGLT2-i), as an antidiabetic class with well-established cardiovascular benefits, and its class members have also been studied for their presumed effects on steatosis and fibrosis improvement in patients with NAFLD or non-alcoholic steatohepatitis (NASH). The MEDLINE and Cochrane databases were searched for randomized controlled trials examining the efficacy of SGLT2-i on the treatment of NAFLD/NASH in patients with T2DM. Of the originally identified 179 articles, 21 articles were included for final data analysis. Dapagliflozin, empagliflozin, and canagliflozin are some of the most used and studied SGLT2-i agents which have proven efficacy in treating patients with NAFLD/NASH by addressing/targeting different pathophysiological targets/mechanisms: insulin sensitivity improvement, weight loss, especially visceral fat loss, glucotoxicity, and lipotoxicity improvement or even improvement of chronic inflammation. Despite the considerable variability in study duration, sample size, and diagnostic method, the SGLT2-i agents used resulted in improvements in non-invasive markers of steatosis or even fibrosis in patients with T2DM. This systematic review offers encouraging results that place the SGLT2-i class at the top of the therapeutic arsenal for patients diagnosed with T2DM and NAFLD/NASH.

Predictors and Outcomes of SGLT2 Inhibitor Discontinuation in a Real-World Population after Hospitalization for Heart Failure

Background: Sodium–glucose cotransporter 2 inhibitors (SGLT2i) reduce mortality and morbidity in patients with heart failure (HF), but are discontinued in some patients. Such patients may not enjoy favorable benefits of SGLT2i therapy. We evaluated the risk factors for SGLT2i discontinuation in a real-world population with HF. Methods: We retrospectively included consecutive patients who were hospitalized for HF and administered SGLT2i during the index hospitalization between February 2016 and September 2021. We assessed the baseline clinical factors associated with post-discharge discontinuation of SGLT2i. Results: This study included a total of 159 patients (median age = 73 years, 57 women). Among baseline characteristics, a lower serum albumin level (odds ratio = 0.23, 95% confidence interval = 0.07–0.76, p = 0.016) and a higher dose of furosemide (odds ratio = 1.02, 95% confidence interval = 1.00–1.05, p = 0.046) were independently associated with the future discontinuation of SGLT2i following index discharge. Patients who terminated SGLT2i (n = 19) had a higher incidence of HF recurrence or cardiovascular death during the 1-year therapeutic period (32% versus 11%, p = 0.020). Conclusions: Among patients who initiated SGLT2i during hospitalization for HF, lower serum albumin levels and higher doses of loop diuretic at index discharge were associated with the discontinuation of SGLT2i following index discharge. We should pay special attention to patients with such characteristics during the initiation of SGLT2i and during SGLT2i therapy.