1/ #NYACP #Tweetorial
#MedTwitter, let’s start with a ❓
56 yo man with type 2 diabetes mellitus and CAD for 7 years has a A1C 8.0%, and albumin:creatinine ratio 300. Which add-on diabetes med will have a protective effect on his cardiac comorbidities?
@MedTweetorials
2/ That’s right- Canagliflozin!
In this tweetorial we address: Why are we optimistic about SGLT2 inhibitors?
♦️ The -flozins let glucose “flow out: of proximal convoluted tubules of nephrons
♦️ Half of filtered glucose is excreted- more than 💯g in T2DM patients
#flozinate
3/ Okay, they work for T2DM. But so do all7⃣of our first line agents! Why all the hype?
SGLTi also:
✅ ⬇️ risk of cardiovascular mortality in chronic and decompensated failure
✅ Slow progression of diabetic and non-diabetic kidney disease
✅ Induce weight loss ⚖️
4/
Let’s take a look at the evidence: 🫀events in those with T2DM
🔹 🥉major trials- EMPA-REG OUTCOME, CANVAS, and DECLARE-TIMI 58 established a ⬇️ in risk of major adverse cardiovascular events (MACE)
🔹 MPA-REG OUTCOME: empagliflozin showed a 38% relative risk ⬇️in CV death
5/ As of this January 2021, we know that this benefit extends even when GLT2i are started AFTER an episode of acute decompensated🫀 failure with reduced ejection fraction (HFrEF)
6/ Beyond 🫀 failure: SGLT2i slow diabetic kidney disease
CREDENCE (2019) showed that canagliflozin:
♦️ T2DM with eGFR 30-90
♦️ 34% ⬇️ risk of ESRD, doubling of creatinine, and death from renal cause
EMPA-KIDNEY is now investigating these effects in eGFR 20-45 and type 1 diabetes
7/ Last year, DAPA-CKD confirmed SGLTi work in those with non-diabetic kidney disease too
♦️ 14% patients had eGFR <30, and 33% had CKD without DMT2
♦️This is particularly impressive in the latter group, where ACE inhibitors are the ONLY medication that prevent kidney failure
8/ We need more clinical trials to study potential longterm adverse effects.
♦️ Most frequent: female mycotic infections, UTIs, ⬆️ urination
♦️ Hypoglycemia risk: low
♦️ Euglycemic ketoacidosis: low with adequate hydration and carb intake
Some SGLT2i carry specific warnings
9/ To recap, we know SGLT2i ⬇️
♦️ CKD progression, those with and without T2DM
♦️ MACE in T2DM, with history of CVD and after acute decompensated HFrEF
There’s still a lot to be discovered! The EMPEROR-preserved trial is investigating SGLT2i use in 🫀 failure with preserved EF
10/ Let’s end our SGLT2i discussion with some #histmed #historyofmedicine
SGLT2i have roots in the 1800s, when French chemists isolated Phlorizin from the bark of🍎🌳 and used it to treat🦠 🦟
It wasn't until the 1930s that🥼 discovered its effects on nephrons
11/ Want to learn more?
♦️Awesome podcasts by @thecurbsiders & @AmDiabetesAssn
🔸thecurbsiders.com/podcast/204
🔸diabetesjournals.org/content/sglt2i…
♦️ Great infographics by @cardionerds
cardionerds.com/cardsjc-solois…
@iMedEducation @COREIMpodcast @virenkaul @Gurleen_Kaur96 @PeterBhandariMD
12/
Thank you for this Tweetorial
@KShah0520!
Follow us for another #NYACP #Tweetorial in June!
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