The overall profile of sodium-glucose cotransporter 2 inhibitors suggests they are a reliable, second-line therapy choice for adults with type 2 diabetes. However, the class is associated with possible side effects that should be carefully considered, according to a Dr. George L. Bakris, MD, director of the ASH Comprehensive Hypertension Center at the University of Chicago Medicine at a recent presentation at the Cardiometabolic Health Congress. Dr. Bakris stated that they definitely are preferred second-line agents, absolutely over sulfonylureas, and probably over thiazolidinediones and some other agents as well. “Both GLP-1 (receptor agonists) and SGLT2-s have shown a mortality benefit, more so than, really, any other class of diabetic glucose-lowering drugs in people with type 2 diabetes. There is no such thing as a perfect drug that has no side-effects and reactions with other drugs, where everyone can take these drugs without any issues. In addition, patients with kidney disease assigned empagliflozin experienced fewer renal events, and ongoing follow-up analyses suggest that the drug further slows nephropathy progression,” Bakris said. When prescribing an SGLT-2 inhibitor on a diuretic, Bakris said, there is a risk for hypotension — not from the SGLT-2 inhibitor alone, but from the interaction between the two drugs. “Older people, generally, either stop the diuretic or cut the diuretic dose in half, because then, you will be in trouble.” SGLT-2 inhibitors are also associated with certain genital infections, Bakris said. He recommended the drug not be prescribed to uncircumcised men due to the risk of balanitis; women using an SGLT-2 have an increased risk for vulvovaginitis. “If [patients] have frequent urinary tract infections, this drug is probably not so good, because it will increase that risk,” he said.
Bakris GL. SGLT2s: Should They Be Second-Line Therapy? Presented at: Cardiometabolic Health Congress; Oct. 5-8, 2016; Boston. Disclosure: Bakris reports receiving consultant fees from AbbVie, AstraZeneca, Bayer, Boehringer Ingelheim, Daiichi Sankyo, Eli Lilly, GlaxoSmithKline, Medtronic, Novartis and Takeda.