Advances in type 2 diabetes therapy: a focus on cardiovascular and renal outcomes

Cardiovascular outcomes in kidney transplant patients with pre-existing peripheral arterial disease and diabetes mellitus

Background: Kidney transplantation (KT) has been shown to enhance the quality of life, be more cost-effective, and reduce mortality in dialysis patients. We aimed to study the impact of pre-existing diabetes mellitus (DM) and peripheral arterial disease (PAD) on cardiovascular outcomes and mortality after kidney transplantation (KT). Materials and methods: A secondary USRDS (United States Renal Data System) analysis was performed from 2006 to 2017 in adult patients who underwent KT. The primary outcome was 3-year all-cause mortality, and secondary outcomes were myocardial infarction (MI), cerebrovascular accident, gangrene/limb ischemia, and graft failure. Adjusted hazard ratios were computed, and multivariate analysis was conducted. All p-values were 2-sided, and a value of <0.05 was deemed to be statistically significant. Statistical analyses were performed using the SAS 9.4 software. Results: A total of 51,009 patients with kidney transplants met the study inclusion/ exclusion criterion. Patients with both DM and PAD had the highest risk of mortality (15.3%, aHR 1.8, 1.6-2.0), followed by patients with PAD without DM (14.1%, aHR 1.6, 1.4-1.9), DM without PAD (9.9%, aHR 1.4, 1.3-2.6), and those without either DM or PAD (5.5%). MI was also higher in patients with DM and PAD (7.3%, aHR 1.8, 1.5-2.2), followed by DM alone (4.6%, aHR 1.58, 1.4-1.7), PAD alone (4.3%, aHR 1.14, 0.8-1.6), and no diabetes nor PAD (2.2%). Conclusions: In patients undergoing KT, those with pre-existing DM and/ or PAD have a significantly higher all-cause mortality and risk of MI.

A review of biopolymer-based hydrogels and IoT integration for enhanced diabetes diagnosis, management, and treatment

The prevalence of diabetes has been increasing globally, necessitating innovative approaches beyond conventional blood sugar monitoring and insulin control. Diabetes is associated with complex health complications, including cardiovascular diseases. Continuous Glucose Monitoring (CGM) devices, though automated, have limitations such as irreversibility and interference with bodily fluids. Hydrogel technologies provide non-invasive alternatives to traditional methods, addressing the limitations of current approaches. This review explores hydrogels as macromolecular biopolymeric materials capable of absorbing and retaining a substantial amount of water within their structure. Due to their high-water absorption properties, these macromolecules are utilized as coating materials for wound care and diabetes management. The study emphasizes the need for early diagnosis and monitoring, especially during the COVID-19 pandemic, where heightened attention to diabetic patients is crucial. Additionally, the article examines the role of the Internet of Things (IoT) and machine learning-based systems in enhancing diabetes management effectiveness. By leveraging these technologies, there is potential to revolutionize diabetes care, providing more personalized and proactive solutions. This review explores cutting-edge hydrogel-based systems as a promising avenue for diabetes diagnosis, management, and treatment, highlighting key biopolymers and technological integrations.

Global Prevalence of Nonalcoholic Fatty Liver Disease: An Updated Review Meta-Analysis comprising a Population of 78 million from 38 Countries

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is a global health challenge, with a rising rate in line with other metabolic diseases. We aimed to assess the global prevalence of NAFLD in adult and pediatric populations.

METHODS

PubMed, Scopus and Web of Science databases were systematically searched up to May 2023. Heterogeneity was assessed using Cochran's Q test and I2 statistics, and random-effects model was used for meta-analysis. Analyses were performed using STATA version 18.

RESULTS

A total of 479 studies with 78,001,755 participants from 38 countries were finally included. The global prevalence of NAFLD was estimated to be 30.2% (95% CI: 28.7-31.7%). Regionally, the prevalence of NAFLD was as follows: Asia 30.9% (95% CI: 29.2-32.6%), Australia 16.1% (95% CI: 9.0-24.8%), Europe 30.2% (95% CI: 25.6-35.0%), North America 29% (95% CI: 25.8-32.3%), and South America 34% (95% CI: 16.9-53.5%). Countries with a higher human development index (HDI) had significantly lower prevalence of NAFLD (coefficient = -0.523, p = 0.005). Globally, the prevalence of NAFLD in men and women was 36.6% (95% CI: 34.7-38.4%) and 25.5% (95% CI: 23.9-27.1%), respectively. The prevalence of NAFLD in adults, adults with obesity, children, and children with obesity was 30.2% (95% CI: 28.8-31.7%), 57.5% (95% CI: 43.6-70.9%), 14.3% (95% CI: 10.3-18.8%), and 38.0% (95% CI: 31.5-44.7%), respectively.

CONCLUSION

The prevalence of NAFLD is remarkably high, particularly in countries with lower HDI. This substantial prevalence in both adults and children underscores the need for disease management protocols to reduce the burden.

SGLT-2 inhibitors and high-dose acarbose as potential high-risk combinations for ketosis and ketoacidosis in Asian patients with T2DM: A case series

Key Clinical Message

High-dose acarbose may increase the risk of diabetic ketosis/diabetic ketoacidosis in Asian patients on sodium-glucose cotransporter-2 inhibitors. Healthcare providers and patients should be cautious to avoid this combination.

Abstract

Low-calorie diets should be avoided in patients receiving sodium-glucose cotransporter-2 (SGLT-2) inhibitors to decrease the risk of diabetic ketoacidosis (DKA). High-dose acarbose can decelerate carbohydrate absorption. We detail three cases of diabetic ketosis (DK) following concurrent SGLT-2 inhibitor and high-dose acarbose therapy (acarbose 300 mg/day and dapagliflozin 10 mg/day). Patients, aged 38-63 years with 3-10 years of type 2 diabetes mellitus (T2DM), developed DK, indicated by moderate urinary ketones and high glucose (urine ketone 2+ to 3+ and glucose 3+ to 4+) without acidosis, within 4 days to 1 month post-therapy initiation. Serum glucose was 172.8-253.8 mg/dL; HbA1c was 9.97%-10.80%. The combination therapy was halted, and DK was managed with low-dose intravenous insulin and fluids, followed by intensive insulin therapy. High-dose acarbose with SGLT-2 inhibitors may increase the risk of DK/DKA in Asian patients.

Multiple nanotechnological approaches using natural compounds for diabetes management

Objectives

Diabetes mellitus (DM) is a long-standing and non-transmissible endocrine disease that generates significant clinical issues and currently affects approximately 400 million people worldwide. The aim of the present review was to analyze the most relevant and recent studies that focused on the potential application of plant extracts and phytocompounds in nanotechnology for the treatment of T2DM.

Methods

Various databases were examined, including Springer Link, Google Scholar, PubMed, Wiley Online Library, and Science Direct. The search focused on discovering the potential application of nanoparticulate technologies in enhancing drug delivery of phytocompounds for the mentioned condition.

Results

Several drug delivery systems have been considered, that aimed to reduce adverse effects, while enhancing the efficiency of oral antidiabetic medications. Plant-based nanoformulations have been highlighted as an innovative approach for DM treatment due to their eco-friendly and cost-effective synthesis methods. Their benefits include targeted action, enhanced availability, stability, and reduced dosage frequency.

Conclusions

Nanomedicine has opened new opportunities for the diagnosis, treatment, and prevention of DM. The use of nanomaterials has demonstrated improved outcomes for both T1DM and T2DM. Notably, flavonoids, including substances such as quercetin, naringenin and myricitrin, have been recognized for their enhanced efficacy when delivered through novel nanotechnologies in preventing T2DM onset and associated complications. The perspectives on the addressed subject point to the development of more nanostructured phytocompounds with improved bioavailability and therapeutic efficacy.

Revealing the improvement of diabetes by Si Wei Jiang Huang Tang San through ERK/HIF1α signaling pathway via network pharmacology

ETHNOPHARMACOLOGICAL RELEVANCE

Si Wei Jiang Huang Tang San (SWJHTS) is a traditional Tibetan medicine prescription for the treatment of urethritis, frequent urination, and urgency, composed of four traditional Chinese medicines: Curcumae longae rhizoma, Berberidis cortex, Tribuli fructus, and Phyllanthi fructus. However, whether SWJHTS exhibits hypoglycemic efficacy and its specific mechanism remain unclear.

AIM OF THE STUDY

In this study, we aimed to investigate the anti-diabetic effects of SWJHTS and elucidate the underlying mechanism.

MATERIALS AND METHODS

HPLC-MS method was used to identify the key components of four kinds of traditional Chinese medicine (Curcumae longae rhizoma, Berberidis cortex., Tribuli fructus, and Phyllanthi fructus) which composed SWJHTS and determine their structure. Normal mice and 145 mg/kg STZ-induced type 1 diabetic mice were treated with three doses of SWJTHS by oral gavage. Body weight, 24h food and water intake, fasting blood glucose, glucose tolerance and other indicators were measured to evaluate the hypoglycemic effect of SWJHTS. OMIM, Genecards and other databases were used to collect targets of diabetes, and HPLC-MS results and TCMSP database information were used to collect drug component targets. Bioinformatics methods such as pathway enrichment analysis and molecular docking were used to predict the key targets of SWJHTS. The gene and protein expressions of HIF1α and ERK signaling pathways in HepG2 cells treated with SWJHTS were detected by RT-PCR and Western blot.

RESULTS

A total of 181 components were identified, including curcumin, palmatine, and berberine, etc. The in vivo studies showed that SWJHTS could significantly lower fasting blood glucose levels and improve the symptoms of polydipsia, polyphagia, and polyuria in diabetic mice. Furthermore, we identified HIF1α as the potential key target of SWJHTS against diabetes utilizing network pharmacology approach and in silico molecular docking. Subsequently, we experimentally confirmed that SWJHTS could suppress the high glucose-induced upregulation of HIF1α expression, which mediated the glucose consumption in HepG2 cells. The ERK signaling pathway was further found to be activated by the SWJHTS as the upstream of HIF1α.

CONCLUSIONS

SWJHTS can improve glucose metabolism by targeting the ERK/HIF1α signaling pathway; hence might be a prospective anti-diabetic drug for diabetic patients as traditional Tibetan medicine.

Glycyrrhizic Acid Protects Glomerular Podocytes Induced by High Glucose by Modulating SNARK/AMPK Signaling Pathway

OBJECTIVE

Diabetic nephropathy is one of the most important microvascular complications of diabetes, which mainly refers to glomerular capillary sclerosis. Podocytes are an important part of glomerular capillaries. Previous clinical and basic studies have shown that fibrosis is the main factor of diabetic nephropathy. This study aimed to assess the protective mechanism of glycyrrhizic acid (GA) on glomerular podocytes induced by high glucose as we hypothesized that GA may have antifibrotic and anti-inflammatory effects on podocytes through regulation of the adenosine 5'-monophosphate-activated protein kinase (AMPK)/sucrose nonfermenting AMPK-related kinase (SNARK) signaling pathway.

METHODS

SNARK siRNA was used to transfect podocytes. Real-time quantitative polymerase chain reaction and immunofluorescence staining assays were used for molecular and pathological analysis. The expression levels of key pathway proteins (including TGF-β1, α-SMA, SITR1, AMPKα, LKB1, PGC-1α, NF-κB, IL-6, and TNF-α) were verified by Western blotting. The expression of inflammatory factors in podocytes was detected by ELISA.

RESULTS

We demonstrated that GA decreased the expression of podocyte fibrosis signaling pathway-related factors by upregulating the AMPK pathway and its related factors. However, after transfection of podocytes with SNARK siRNA, there was an increased expression of fibrosis-related factors and inflammation-related factors.

CONCLUSION

GA can protect podocytes and alleviate fibrosis and inflammation induced by high glucose, which is related to the AMPK signaling pathway. Meanwhile, knockdown of SNARK protein can inhibit the AMPK signaling pathway, aggravate fibrosis, and increase inflammation.

The epidemiology of ketosis and low bicarbonate concentration in inpatients treated with sodium-glucose linked cotransporter inhibitors or dipeptidyl peptidase-4 inhibitors

AIMS

To compare the level of ketones and bicarbonate in inpatients treated with sodium-glucose linked cotransporter 2 inhibitors (SGLT2i) and those treated with dipeptidyl peptidase-4 inhibitors (DPP4i).

METHODS

We conducted an electronic medical records-based cohort study. We identified patients with type 2 diabetes, with ketone measurements available, who received SGLT2i (n = 82) or DPP4i (n = 308) during admission. We compared ketone levels between those who received SGLT2i or DPP4i using mixed ordinal logistic regression. The primary outcome was level of ketosis (<0.6, 0.6-1.5, 1.6-3.0, >3 mmol/L). Secondary outcomes included bicarbonate levels, hospital complications, ICU admission, and death.

RESULTS

SGLT2i use was not associated with greater ketosis than DPP4i use, after adjusting for age, weight, Charlson Comorbidity Index, HbA1c, estimated glomerular filtration rate, principal diagnosis category, admission type and insulin administration (OR 4.52 95 % CI (0.33, 61.82)). After adjustment, there was no difference in complications (p = 0.14), ICU admissions (p = 0.64), mortality (p = 0.30), or bicarbonate levels (p = 0.97).

CONCLUSION

Ketone levels were not greater in patients who received SGLT2i than those who received DPP4i. There were no differences in bicarbonate levels, complications, ICU admissions, or mortality, implying that, in inpatients, SGLT2i use is neither associated with ketosis nor adverse clinical outcomes.

Temporal trends in, and associations of, early-career general practitioner prescriptions of second-line Type 2 Diabetes medications, 2010-2018

INTRODUCTION

Second-line pharmacotherapy for Type 2 Diabetes Mellitus ('diabetes') is necessary for optimal glycaemic control and preventing longer-term complications. We aimed to describe temporal trends in, and associations of, Australian general practitioner (GP) registrars' prescription, and initiation, of 'new' second-line oral agents (dipeptidyl peptidase 4 inhibitors, sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide 1 agonists) compared to sulphonylureas.

MATERIALS AND METHODS

A longitudinal analysis (2010-2018) of data from the Registrar Clinical Encounters in Training project. Analysis included any diabetes problem/diagnosis that involved prescription of sulphonylureas or 'new' oral agents. Simple and multiple logistic regression models were fitted within the generalised estimating equations framework.

RESULTS

2333 registrars recorded 6064 diabetes problems/diagnoses (1.4%). 835 problems/diagnoses involved sulphonylurea or 'new' medication prescription. Of these, 61.0% [95% CI:57.4-64.4] involved 'new' medication prescription. 230 problems/diagnoses involved sulphonylurea or 'new' medication initiation, with 77% [95%CI:70.8-82.1] involving a 'new' medication. There was a significant 52% per year increase in prescribing (OR = 1.52[95% CI:1.38-1.68],p<0.001), and a 77% per (two-to-three-year) time-interval increase in initiation (OR = 1.77,[95% CI:1.30-2.43],p = <0.001) of 'new' medications compared to sulphonylureas. 'New' medications were prescribed less for non-English-speaking patients. There was some regional variation in prescribing.

CONCLUSION

Registrar uptake of 'new' oral agents compared to sulphonylureas has increased rapidly.

Insulin-loaded liposomes packaged in alginate hydrogels promote the oral bioavailability of insulin

Compared to subcutaneous injections, oral administration of insulin would be a preferred route of drug administration for diabetic patients. For oral delivery, both liposomes and alginate hydrogels face many challenges, including early burst release of the encapsulated drug and poor intestinal drug absorption. Also, adhesion to the intestinal mucosa remains weak, which all result in a low bioavailability of the payload. This study reports on an alginate hydrogel loaded with liposomes for oral insulin administration. Liposomes (Lip) loaded with arginine-insulin complexes (AINS) were incorporated into a hydrogel prepared from cysteine modified alginate (Cys-Alg) to form liposome-in-alginate hydrogels (AINS-Lip-Gel). An ex vivo study proves that intestinal permeation of AINS and AINS-Lip is approximately 2.0 and 6.0-fold, respectively, higher than that of free insulin. The hydrogel retarded early release of insulin (∼30%) from the liposomes and enhanced the intestinal mucosal retention. In vivo experiments revealed that the AINS-Lip-Gel released insulin in a controlled manner and possessed strong hypoglycemic effects. We conclude that liposome-in-alginate hydrogels loaded with AINS represent an attractive strategy for the oral delivery of insulin.

Effect of different antidiabetic medications on atherosclerotic cardiovascular disease (ASCVD) risk score among patients with type-2 diabetes mellitus: A multicenter non-interventional observational study

Objective

The aim of this study was to compare the clinical outcomes associated with different combinations of oral diabetic drugs among patients with type 2 diabetes mellitus.

Method

A prospective multicenter longitudinal, noninterventional observation study design was applied. At baseline (0 month), clinical parameters including glucose profile, renal function, lipid profile and risk assessment for cardiovascular risks were calculated. Mean Weighted difference (MWD) with heterogeneity and effect z was calculated to determine the risk reduction at the end of the study.

Results

A total of 1,657 were enrolled to different cohorts with response rate of 75.5%. The distribution of patients was based on prescribed drug. A total of 513 (30.9%) in G1 (metformin alone), 217 (13.09%) in G2 (metformin with Glimepiride), 231 (12.85%) in G3 (Metformin with Gliclazide), 384 (23.17%) in G4 (metformin with Sitagliptin) and 312 (18.89%) in G5 (Metformin with Saxagliptin). There was no significant different in all clinical and social variables at baseline. The Intergroup analysis showed significant differences with all the primary outcome variables except BMI (p = 0.217) and eGFR (p = 0.782) among patients using sulphonylurea (SU) combination (G2 & G3). Findings also showed significant high frequency of emergency visit and hospitalization in G1 (78.16% & 30.8%) as compared to SU (70.1% & 28.3%, p = 0.001) and DPP-4 (56.6% & 20.4%, p = 0.001). The overall reported effect was z = 2.58, p = 0.001 for ASCVD risk reduction assessment.

Conclusion

The study concluded that significant effect of Dipeptidyl peptidase-4 inhibitor on reduction of hospitalization, lipid profile and also ASCVD risk score of type-II diabetes mellitus patients regardless of clinical comorbidities. Also, sulfonylurea combinations have showed significant reduction in LDL and triglycerides values.

The comparative epidemiology and outcomes of hospitalized patients treated with SGLT2 or DPP4 inhibitors

OBJECTIVE

To compare the outcomes of sodium glucose linked cotransporter 2 inhibitors (SGLT2i) and dipeptidyl peptidase 4 inhibitors (DPP4i) in hospitalized patients.

RESEARCH DESIGN AND METHODS

Electronic medical records-based cohort study. Identification of patients with type 2 diabetes and treatment with SGLT2i (n = 466) or DPP4i (n = 1541). Outcomes compared between those who received SGLT2i and those who received DPP4i. The primary outcome: adjusted percentage of blood glycemia within 4-10 mmol/L.

RESULTS

After adjustment, SGLT2i use had a statistically equivalent percentage of glycemia within range (coefficient: 4.55, 95% CI -3.23 to 12.32, p = 0.25) or <4 mmol/L (coefficient -0.17, 95% CI -0.71 to 3.72, p = 0.54). There were no significant differences in hospital length of stay (p = 0.22), complications, (p = 0.11) or mortality (p = 0.57). When measured, ketone levels were higher in the SGLT2i group on admission, but lower on days 3, 4 and 5 (p < 0.001 for interaction). Bicarbonate levels were not statistically different between groups. Finally, 54% of patients whose SGLT2i was ceased during admission, were discharged home without it.

CONCLUSION

Among inpatients with type 2 diabetes, SGLT2i use was associated with equivalent within-target glycaemia and no significant increase in hypoglycemia, ketonemia, or lower bicarbonate levels. These hypothesis-generating findings support further investigation of SGLT2i therapy in inpatients.

Cardio-renal outcomes and the direct medical cost of type 2 diabetes patients treated with sodium glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists: A population-based cohort study

AIMS

To compare cardio-renal outcomes and incurred direct medical costs of patients initiating sodium glucose cotransporter-2 inhibitors (SGLT2i) versus glucagon-like peptide-1 receptor agonists (GLP-1RA).

METHODS

A population-based cohort of patients with type 2 diabetes was identified from Hong Kong Hospital Authority. Patients who were free from cardiovascular and end-stage renal diseases at baseline, and newly treated with SGLT2i (n = 2,541) or GLP-1RA (n = 303), were included. Risks of developing cardio-renal complications, incurred direct medical costs, and changes in clinical parameters were assessed between groups.

RESULTS

Over a median follow-up of 12.5 months in SGLT2i group and 25.5 months in GLP-1RA group, SGLT2i users were associated with significantly lower risk of heart failure compared with those on GLP-1RA [hazard ratio = 0.183, 95 %CI = (0.045, 0.745)]. 1-year change in clinical parameters also favored use of SGLT2i over GLP-1RA, where the former was associated with a larger reduction in fasting glucose level [difference-in-difference = -0.87 mmol/L, 95 %CI = (-1.42, -0.33), p = 0.002]. The two groups had comparable direct medical costs after 1-year of follow-up.

CONCLUSION

Patients initiating SGLT2i experienced a significantly lower risk of heart failure than those on GLP-1RA, alongside better glycemic control through a larger reduction in fasting glucose level over one-year follow-up, while direct medical cost incurred was comparable to that of GLP-1RA.

A Practical Review of Diabetes Mellitus Type 2 Treatment in Primary Care

The treatment of diabetes mellitus type 2 (DM2) is becoming more complex as new medications are approved. Primary care providers must maintain their medical knowledge on emerging medications for best patient care. This review simplifies the non-insulin treatments of diabetes with an emphasis on the cardio-renal protectants, sodium-glucose cotransporter 2 (SGLT-2) inhibitors and glucagon-like peptide 1 receptor agonists (GLP-1).

Feasibility of once weekly exenatide-LAR and enhanced diabetes care in Indigenous Australians with type 2 diabetes. (Long-acting-Once-Weekly-Exenatide laR-SUGAR, "Lower SUGAR" study)

AIMS

To assess the feasibility and metabolic effects of once weekly supervised injection of exenatide-LAR in addition to standard care in Indigenous Australians with type 2 diabetes.

METHODS

Two communities in Central Australia with longstanding specialist clinical outreach services were allocated by random coin toss to receive once-weekly exenatide-LAR injection with weekly nurse review and adjustment of medication for 20 weeks (community with exenatide-LAR) or to weekly nurse review in addition to standard care over 20 weeks (community without exenatide-LAR). The primary outcome was the feasibility of the intensive diabetes management model of care with and without weekly supervised exenatide-LAR. Secondary outcomes included change in HbA1c.

RESULTS

13 participants from community with exenatide-LAR and 9 participants from the community without exenatide-LAR were analysed. 85% of individuals in the community with exenatide-LAR and 67% in the community without exenatide-LAR attended more than half of clinic visits. Median difference in the change in HbA1c from baseline to final visit, adjusted for baseline HbA1c, between the community with exenatide-LAR and the community without exenatide-LAR was -3.1%, 95% CI (-5.80%, -0.38%; p = 0.03).

CONCLUSIONS

Weekly exenatide-LAR combined with weekly nurse review demonstrated greater improvements in HbA1c, highlighting its potential for use in remote communities. This article is protected by copyright. All rights reserved.

Decrease of coronary heart disease risk with GLP1-receptor agonists or SGLT2 inhibitors therapy in patients with type 2 diabetes in primary cardiovascular prevention: A 24 months follow-up study

AIMS

The aim of this real-world study is to evaluate the effect of glucagon-like peptide1 receptor-agonist (GLP1 RA) and sodium-glucose co-transporter2 inhibitor (SGLT2i) on coronary heart disease (CHD) risk, in patients with type 2 diabetes (T2D) in primary cardiovascular prevention.

METHODS

Data from 312 patients with T2D, without CHD history, starting treatment with GLP1 RA (n = 174) or SGLT2i (n = 138), were retrospectively collected. UKPDS-RE score was used to estimate 10-years risk for CHD before and 6, 12 and 24 months after prescription.

RESULTS

The 10-year CHD risk significantly decreased over 24 months in both GLP1 RA and SGLT2i groups (p = 0.037 and p < 0.001, respectively), with 3% and 7% CHD risk reduction already obtained after the first 6 months of GLP1 RA and SGLT2i therapy respectively (p < 0.001 in both groups. Analyses by categories of baseline CHD risk showed significant reductions of CHD risk in the severe risk categories of both groups (p < 0.001). CHD risk reduction obtained with SGLT2i was higher than with GLP1 RA at 6 and 12 months but not at 24 months.

CONCLUSION

This real-world study shows that both GLP1 RA and SGLT2i reduce the 10-year risk for cardiovascular disease in patients with T2D in primary cardiovascular prevention.

Evolving Evidence of Diabetic Ketoacidosis in Patients Taking Sodium-Glucose Cotransporter 2 Inhibitors

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.

ANGPTL8 enhances insulin sensitivity by directly activating insulin-mediated AKT phosphorylation

ANGPTL8 is a 22-KDa protein in the angiopoietin-like family. It is a liver-derived hormone that dynamically regulates glucose metabolism after refeeding. The mechanism of its regulation of glucose metabolism is unclear. We analyzed the effect of ANGPTL8 overexpression on glucose tolerance in the mouse liver by tail vein hydrodynamic transfection. The mechanism of ANGPTL8 improving insulin sensitivity was analyzed by the overexpression or knockdown of ANGPTL8 in mouse primary hepatocytes through in vitro synthetic mRNA and siRNA technology. The key site of ANGPTL8 protein regulating this signal pathway was screened by DNA point mutation and fragment truncation. The results showed that ANGPTL8 may directly regulate AKT protein phosphorylation in the insulin-mediated PI3K/AKT signaling pathway to improve insulin sensitivity. Ser94 and Thr98 are the key sites of ANGPTL8 protein in activating AKT protein phosphorylation. Present results indicate that ANGPTL8 may be a potential new agent to reduce postprandial blood glucose.