Sodium-glucose cotransporter 2 inhibitors: a practical guide for the Dutch cardiologist based on real-world experience

Abstract

Sodium-glucose cotransporter 2 (SGLT2) inhibitors include a relatively new class of glucose-lowering drugs that reduce plasma glucose concentrations by inhibiting proximal tubular reabsorption of glucose in the kidney, while increasing its excretion in urine. Recent large randomised controlled trials have demonstrated that many of these agents reduce the occurrence of major adverse cardiovascular events, hospitalisation for heart failure, cardiovascular death and/or chronic kidney disease progression in patients with and without type 2 diabetes mellitus (DM2). Given their unique insulin-independent mode of action and favourable efficacy and adverse-event profile, SGLT2 inhibitors are promising and they offer an interesting therapeutic approach for the cardiologist to incorporate into routine practice. However, despite accumulating data supporting this class of therapy, cardiologists infrequently prescribe SGLT2 inhibitors, potentially due to a lack of familiarity with their use and the reticence to change DM medication. Here, we provide an up-to-date practical guide highlighting important elements of treatment initiation based on real-world evidence and expert opinion. We describe how to change DM medication, including insulin dosing when appropriate, and how to anticipate any adverse events based on real-world experience in patients with DM2 in the Meander Medical Centre in Amersfoort, the Netherlands. This includes a simple algorithm showing how to initiate SGLT2 inhibitor treatment safely, while considering the consequence of the glucosuric effects of these inhibitors for the individual patient.

Balancing Risks and Benefits: Sodium-Glucose Cotransporter 2 Inhibitors and the Risk of Diabetic Ketoacidosis

“…Consultation with an endocrinologist or diabetologist is warranted before initiating SGLT2i therapy in patients with type 1 diabetes. Practical algorithms are available that can aid in the safe prescription of SGLT2is as well as dose adjustments of glucose-lowering co-medication [ 17 ]. Furthermore, all patients using SGLT2is should be informed about the risks of DKA and carefully instructed about precipitating factors and management strategies.…”

A novel comprehensive program combining optimal medical treatment with lifestyle for type 2 diabetes

“…Theoretically, this iRT-ABCDEFG program is more plausible for better management and self-management of T2D due to truly individualized glycaemic goals. It is helpful to individuals with T2D for early detection of ischemic heart disease, unrecognized CHF, and early statins and SGLT2 inhibitors treatment safely for improvement of lipids and endothelial function and lowering MACCE [106]. In fact, a biomarker score is helpful to stratify T2D and pre-diabetes related CHF risks [107].…”

Practical aspects of initiation and use of SGLT2 inhibitors: inpatient and outpatient perspectives

“…Начало терапии иSGLT2 необходимо предварить исследованием HbA 1с . В случае если HbA 1с >8%, лечение иSGLT2 может быть инициировано без каких-либо модификаций общей схемы лечения [43].…”

“…Адаптировано из [43]. Бариатрические операции заслуживают особого внимания, поскольку за 1-2 нед до операции пациентов часто переводят на низкоуглеводную диету с высоким содержанием белка, чтобы улучшить визуализацию операционного поля во время лапароскопических процедур [48].…”