It’s really important for people to understand how an SGLT2 inhibitor works. SGLT2 transporters pick up glucose from the urine and bring it back into the body. Unfortunately, when you live with diabetes there’s an up regulation and you store more glucose than you need.
What an SGLT2 inhibitor does is blocks that reabsorption in the urine, so in the distal tubule of the kidney, after it’s already cleared through the glomerulus and is filtered and ready to go out of the body, unfortunately the body doesn’t let it go. It sucks it back in.
So by blocking that reabsorption of glucose from the urine, we can actually lower glucose. We see that patients excrete glucose in the urine, which lowers blood sugar levels, that glucose equals calories, we know that somewhere between 70 and 120 grams of glucose is lost per day.
When they lose glucose and calories, there’s a potential for weight loss, and then, there’s also fluid that goes out with the glucose, somewhere between 250 to 400 cc a day. So that might mean that in fact there can be also blood pressure lowering.
We can only use SGLT2 glucose inhibitors for glucose lowering however, in individuals who have functioning kidneys. So we know that the indication is for people who have eGFRs over 60, and it isn’t so much that they’re harmful, it’s more so that they don’t really work when renal function declines.
So choosing the patient appropriately, you’ll look for someone in whom the benefit of glucose lowering, perhaps some weight loss, blood pressure lowering, would be essential. And then you look at their renal function, and then you also make sure that they’re not at risk for volume depletion, because those individuals may not be the best candidate.
When we think about this class of medication, it’s important to have a benefit-risk discussion with individuals, and we know that they lower glucose, they don’t cause hypoglycemia, and they have very minimum weight. We also know there’s an added benefit of blood pressure.
But more recently, what’s been really exciting around the SGLT2 inhibitors, is the new evidence that’s been created by cardiovascular outcome trials. Remembering that we do cardiovascular outcome trials in very high risk people with diabetes, typically those who have already had a previous cardiovascular event.
FDA, EMA and even Health Canada has mandated that we show all new drugs for diabetes to be safe, that they don’t cause harm. So we were very surprised when EMPA-REG in September 2015 came out and showed us benefit of 14% reduction in major adverse cardiovascular events and hospitalization for heart failure. Followed up June of this year, we saw the exact same MASE reduction with the CANVAS trial.
So suddenly we are now moving from talking about medications that are managing glucose to those that are managing cardiovascular risk. I think as health care professionals it’s really important for us to stay up to date on all of this evolving evidence.
So my challenge to you would be that you consider informing yourself about cardiovascular outcome trials, learning about real world evidence and also informing yourself of the advances that we’re learning about the class of SGLT2 inhibitors, beyond glucose lowering.
Presenter: Lori Berard, Nurse, Winnipeg, MB
Local Practitioners: Nurse
Lori Berard is Diabetes Educator with an expertise in diabetes education, management and clinical research. As a certified diabetes educator, she has over 30 years’ experience primarily as the Nurse Manager for the Health Sciences Centre Diabetes Research Program. More recently she was the Nurse Clinician/Educator at the Wellness Institute Seven Oaks General Hospital. She was a Faculty Member at the University of Manitoba Department of Medicine Section of Endocrinology from 2009 to 2017 and continues as a sessional instructor in the medical school.
Lori Berard is working as a consultant in diabetes management and clinical research operations. She continues to be actively involved in many continuing medical educational initiatives with numerous presentations and publications. Lori has been a professional member and major volunteer of Diabetes Canada for more than 25 years and has extensive experience with the Clinical Practice Guidelines. She has received many honors and awards related to her work in diabetes.
If you are looking for local services or treatment in the office or hospital from a Nurse, contact a provider such as ( Lori Berard ) with this phone number to inquire if they are accepting patients or you need a referral. . Now health Network