,
15 tweets,
11 min read
Read on Twitter
1/15
For my first #Tweetorial, I will start with a question:
Which of the following medications from the SGLT2 inhibitor class have been shown to decrease cardiovascular morbidity and mortality?
#Diabetes #EndoTwitter #MedEd #MedTwitter #DM2 #T2D #CardioTwitter
For my first #Tweetorial, I will start with a question:
Which of the following medications from the SGLT2 inhibitor class have been shown to decrease cardiovascular morbidity and mortality?
#Diabetes #EndoTwitter #MedEd #MedTwitter #DM2 #T2D #CardioTwitter
2/15
Sodium glucose transporters (SGLT) in proximal tubules mediate glucose reabsorption.
How?
Na/K ATPase moves Na out & K into the cell ➡️gradient for Na to flow intracellular
SGLT uses this potential to move glucose against its gradient from the tubular fluid into the cell.
Sodium glucose transporters (SGLT) in proximal tubules mediate glucose reabsorption.
How?
Na/K ATPase moves Na out & K into the cell ➡️gradient for Na to flow intracellular
SGLT uses this potential to move glucose against its gradient from the tubular fluid into the cell.
3/15
SGLT2 inhibitors block glucose reabsorption
➡️renal glucose excretion
➡️glucose levels⬇️
Because this has nothing to do with insulin, they usually don’t cause hypoglycemia or weight gain.
Actually, because of the osmotic diuresis, they decrease blood pressure & weight.
SGLT2 inhibitors block glucose reabsorption
➡️renal glucose excretion
➡️glucose levels⬇️
Because this has nothing to do with insulin, they usually don’t cause hypoglycemia or weight gain.
Actually, because of the osmotic diuresis, they decrease blood pressure & weight.
4/15
Remember they arent 1st line therapy for most w/ type 2 DM.
Initial therapy usually starts w/ diet, weight reduction, exercise, & metformin.
Consider adding if:
✅not at goal on metformin + lifestyle
✅cardiovascular disease (see later tweets)
✅obesity or hypertension
Remember they arent 1st line therapy for most w/ type 2 DM.
Initial therapy usually starts w/ diet, weight reduction, exercise, & metformin.
Consider adding if:
✅not at goal on metformin + lifestyle
✅cardiovascular disease (see later tweets)
✅obesity or hypertension
5/15
Because they cause mild volume depletion, use carefully with NSAIDs, ACE inhibitors, ARBs, diuretics, hypovolemia, heart failure, & liver injury.
Also, because the warm, dark, & sugar-filled urine is a breeding ground, careful in patients w/ UTIs or GU yeast infections.
Because they cause mild volume depletion, use carefully with NSAIDs, ACE inhibitors, ARBs, diuretics, hypovolemia, heart failure, & liver injury.
Also, because the warm, dark, & sugar-filled urine is a breeding ground, careful in patients w/ UTIs or GU yeast infections.
7/15
The EMPA-REG from @Boehringer & @LillyPad looked at 7K patients with DM2 and CVD, randomized to EMPAGLIFLOZIN or placebo. No surprise, these patients were also on many other meds for HTN, lipids, & DM (incl. metformin & insulin).
The EMPA-REG from @Boehringer & @LillyPad looked at 7K patients with DM2 and CVD, randomized to EMPAGLIFLOZIN or placebo. No surprise, these patients were also on many other meds for HTN, lipids, & DM (incl. metformin & insulin).
8/15
The CANVAS trials (2 of them) from @JannsenUS also looked at high-risk patients with DM2 with established CVD or CVD risk factors. Patients were randomized to CANAGLIFLOZIN or placebo. These patients were similarly taking many other meds for HTN, lipids, & DM.
The CANVAS trials (2 of them) from @JannsenUS also looked at high-risk patients with DM2 with established CVD or CVD risk factors. Patients were randomized to CANAGLIFLOZIN or placebo. These patients were similarly taking many other meds for HTN, lipids, & DM.
9/15
DECLARE-TIMI trial from @AstraZeneca & @BMSNews also looked at high-risk patients w/ DM2 & with CVD or at risk for CVD. Patients were randomized to DAPAGLIFLOZIN or placebo.
Important to note that fewer patients here had established CVD compared with the other 2 trials.
DECLARE-TIMI trial from @AstraZeneca & @BMSNews also looked at high-risk patients w/ DM2 & with CVD or at risk for CVD. Patients were randomized to DAPAGLIFLOZIN or placebo.
Important to note that fewer patients here had established CVD compared with the other 2 trials.
10/15
All of the studies lead to reductions in weight, systolic & diastolic BP (without a change in HR), and uric acid. All lead to an increase in LDL and HDL, as well as in genital infections.
The differences among them are depicted in the table here:
All of the studies lead to reductions in weight, systolic & diastolic BP (without a change in HR), and uric acid. All lead to an increase in LDL and HDL, as well as in genital infections.
The differences among them are depicted in the table here:
11/15
What's fascinating is the minimal A1c reduction, suggesting CV benefit is not from glycemic control.
So why the benefit? Some proposed mechanisms are
⬇️ BP without ⬆️ HR
⬇️ plasma volume
⬇️ arterial stiffness
⬇️ SNS activity
⬆️ ketones (more readily utilizable ATP source)
What's fascinating is the minimal A1c reduction, suggesting CV benefit is not from glycemic control.
So why the benefit? Some proposed mechanisms are
⬇️ BP without ⬆️ HR
⬇️ plasma volume
⬇️ arterial stiffness
⬇️ SNS activity
⬆️ ketones (more readily utilizable ATP source)
12/15
So, back to original question:
Which of the following #diabetes medications have been shown to decrease cardiovascular morbidity & mortality?
#EndoTwitter #MedTwitter #MedEd #CardioTwitter #DM2 #T2D
So, back to original question:
Which of the following #diabetes medications have been shown to decrease cardiovascular morbidity & mortality?
#EndoTwitter #MedTwitter #MedEd #CardioTwitter #DM2 #T2D
13/15
While Dapagliflozin has shown improvement in heart failure hospitalization, only Canagliflozin & Empagliflozin have been shown to decrease cardiovascular morbidity and mortality.
While Dapagliflozin has shown improvement in heart failure hospitalization, only Canagliflozin & Empagliflozin have been shown to decrease cardiovascular morbidity and mortality.
