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When and When Not to Use An SGLT-2

Sep 1, 2018
 

After reviewing evidence, a tool to evaluate benefit and risk has been developed showing when and when not to use an SGLT-2 inhibitor.

The management of type 2 diabetes has significantly diversified over recent years, producing a data-rich environment. SGLT2 inhibitors are a more recent agent that work by reabsorbing glucose in the kidney and cause an increase in glucose excretion in the urine. There have been misconceptions concerning the efficacy, safety and appropriate use of SGLT2 inhibitors in diabetes management. In order to address these concerns, the UK created The Improving Diabetes Steering Committee, consisting of diabetes specialists.

The Improving Diabetes Steering Committee used multiple trials to developed a quick reference guide that aims to clarify common areas in type 2 diabetes management, with a focus on SGLT2 inhibitors. Some major topics discussed include medications associated with amputation and bone fracture risks, early and late use of SGLT2 inhibitors, risk of diabetic ketoacidosis, obesity, diabetic ketoacidosis, sick days in people with T2DM, and prescribing of SGLT2 inhibitors in patients receiving diuretics.

They were able to use this information to create a traffic light system, in terms of risk, for the use of SGLT2 inhibitors:

  • Green (low risk): Strong evidence that supports prescribing in certain situations. eGFR >60 mL/min/1.73m2, first line (metformin intolerant), combination of basal insulin or multiple daily injections, established CVD, no history of lower leg amputation (LLA) or peripheral arterial disease (PAD)
  • Yellow (moderate risk): Prescribe with caution (benefit outweighs risk). History of PAD, osteoporosis, frail/elderly, ketogenic diet, steroid therapy, cognitive impairment, BMI <25
  • Red (high risk): Do not prescribe due to lack of evidence, risk of adverse events, or license restrictions. Previous LLA, diabetic foot ulcers, DKA, eating disorders, excessive alcohol intake, receiving loop diuretics, type 1 diabetes, acute illness, pregnancy, recent major surgery.

Download Chart: When and When Not to Use An SGLT-2 Inhibitor

John Wilding, a professor at the University of Liverpool, explained that the committee focused on research that was accurate by using evidence-based guidance to help clinicians determine certain patients who would benefit most with SGLT2 inhibitors. He concluded that increased education in diabetes management is key to optimal therapy for patients who have type 2 diabetes.

Dr. Kevin Fernando, a co-author of the paper added: “Managing patients with type 2 diabetes is complex and can be challenging, particularly for clinicians working in primary care who are faced with many competing clinical priorities. We felt it was important to help provide every day, usable tools that will help healthcare professionals ensure their patients receive optimal care for their type 2 diabetes.”

Practice Pearls:

  • The Improving Diabetes Steering Committee in the UK created a risk vs benefits reference guide for SGLT2i treatment in T2D that aims to clarify amputation and bone fracture risks, early and late use of SGLT2 inhibitors, and risk of diabetic ketoacidosis.
  • The reference guide is an easy-to-use red traffic light system organized by risk levels.
  • The committee also addressed current issues by summarizing evidenced-based guidance to help busy providers have a better understand and more confidence when prescribing SGLT2 inhibitors.

Reference:

Wilding, J., Fernando, K., Milne, N. et al. “SGLT2 Inhibitors in Type 2 Diabetes Management: Key Evidence and Implications for Clinical Practice.” Diabetes Ther. July 2018. doi: https://doi-org.ezproxy.hsc.usf.edu/10.1007/s13300-018-0471-8.

Melissa Bailey, Pharm.D. Candidate, USF College of Pharmacy