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What the Professionals Have to Say about the New SGLT2 Inhibitors

An abundance of excitement has surrounded the FDA approval of the sodium glucose cotransporter 2 inhibitor (SGLT2 –I), Invokana. So why did we need to introduce a 14th class of medication for treating diabetes? That answer was simple for Richard Aguilar, MD, Medical Director, Diabetes Nation, and Diabetes Care Foundation, who has 25 years of experience in treating diabetes, “Invokana does something no other diabetes drug does…This is the first time in diabetes that we are able to pharmacologically offload the body’s glucose.” While many other drugs work to shift the glucose from the blood into tissue, Invokana works in the kidney to prevent reabsorption of the glucose, and essentially flush the glucose out of the system….

Dr. Aguilar referred to Invokana as a glucosuretic, comparing its use to that of diuretics in congestive heart failure, saying, “Why would you not use this drug?” Data with Invokana showed weight loss, minor blood pressure improvements, and no risk of hypoglycemia. One of the greatest barriers in treating patients with diabetes is the risk for hypoglycemia, which is especially seen when using sulfonylureas. Dr. Aguilar stresses, “We need to eliminate the sulfonylureas in order to prevent hypoglycemia.… Invokana should push sulfs [sulfonylureas] out of the way.” Dr. Zachary Bloomgarden, Clinical Professor in the Department of Medicine, Division of Endocrinology at Mount Sinai School of Medicine, New York, affirms the excitement behind Invokana stating, “This drug could be the backbone of new treatments for type 2 diabetes.”

With all the positive hype, are there any negatives to Invokana? Due to the excess glucose being excreted, an increased risk for urinary tract infections and mycotic infections was anticipated. Data did confirm an increase in such infections. However, in the pooled analysis of four phase 3 studies the increase in UTI was 1.9% with Invokana 100mg and 0.3% increased with Invokana 300mg when compared to placebo. Dr. Aguilar comments, “This is striking how little the UTI’s were, I would have expected around 15%… so results showed much less than what I would have expected with a glucosuretic.”

So who should not take Invokana? According to the FDA, “Invokana should not be used to treat people with type 1 diabetes; in those who have increased ketones in their blood or urine (diabetic ketoacidosis); or in those with severe renal impairment, end stage renal disease, or in patients in dialysis.” Dr. Aguilar adds the need to be cautious and stress hygiene in men with uncircumcised penises as, “32 men experienced mycotic balanitis… of that 30 were uncircumcised.” Also, Dr. Anne Peters from the University of Southern California cautions the use of Invokana in patients who are already on diuretics or ACE inhibitors. “If you have a patient whose blood pressure is low, who already has orthostatic hypotension, and who at baseline is already a bit dehydrated, you might not need or want to give this drug.”

Invokana is already being manufactured and orders have been taken from doctors, according to company spokesperson, Christina Holden. It won’t be long until it will be seen regularly in practice.

References:
https://asweetlife.org/feature/how-invokana-works-new-type-2-diabetes-drug-hailed-as-a-major-treatment-advance/
Interview with Dr. Richard Aguilar, www.medscape.com/viewarticle/782119

 

David Joffe BSPharm, CDE, Clinical Assistant Professor of Pharmacotherapy and Translational Research

Lauren B. Self, Pharm D Candidate, University of Florida College of Pharmacy

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