SGL2 Inhibitors in 2020

Dr KK Aggarwal

President CMAAO and HCFI

In 2020, the American Diabetes Association is making two paradigm-shifting recommendations in the treatment of type 2 diabetes.

1.      Prescribe Sodium glucose co-transporter 2 (SGLT2) inhibitors or glucagon-like peptide 1 (GLP-1) receptor agonists to patients at high risk for atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease, in addition to patients with already established disease, as previously recommended.

2.      Consideration for use of those drugs be independent of the patient's baseline A1c or individualized A1c target. Previously, additional pharmacologic agents were recommended only when A1c was above target despite using first-line metformin and lifestyle interventions.

Atherosclerotic CV Disease: Add Empagliflozin

Heart Failure: Empagliflozin, canagliflozin or dapagliflozin. For patients with heart failure with reduced ejection fraction (HFrEF) who have persistent symptoms and an elevated serum natriuretic peptide level on optimal pharmacologic and device therapy, add dapagliflozin.

CKD:  Canagliflozin in patients with diabetes and proteinuria: In patients with type 2 diabetes who have nephropathy (urine albumin excretion >300 mg per day) and eGFR >30 mL/min per 1.73 m², add Canagliflozin (CREDENCE trial).

In addition, SGLT2 inhibitors in general may have a role as a third agent in those who cannot or will not take insulin, when full doses of metformin and a sulfonylurea have not produced satisfactory metabolic control, or in patients in whom risk of hypoglycaemia is high (frail, older adults) or in whom avoidance of weight gain is a priority. 

The four keys to prevent cardiovascular disease

An estimated 80% of all CVD cases — heart disease, heart attack, heart failure, and stroke — can be prevented. The key is to control high blood pressure and high cholesterol and to maintain healthy habits, such as exercising regularly, eating a plant-based diet, getting enough sleep, and not smoking.

Exercise: Guidelines recommend 30 minutes of moderate-intensity exercise five times a week. "Doing more is better.

·         Walk for 5 minutes every 2 hours. Do a set or two of push-ups either on the floor or against the kitchen counter.

·         Perform up to 10 repetitions of stand-and-sit exercises, where you rise from a chair not using your arms and then sit down again.

·         Find opportunities to do extra movements. For example, park farther away from the grocery store, take the stairs, and do simple yard work like weeding, planting, and raking. Every bit of everyday movement can count toward your overall exercise requirements.

Diet: Focus on plant foods; minimize intake of red meat, especially processed meat.

Sleep: Guidelines from the American Academy of Sleep Medicine and the Sleep Research Society recommend adults get at least 7 hours of sleep per night on a regular basis. Studies have found that getting less than this amount is associated with heart disease risk factors like higher stress, increased inflammation, high blood pressure, and weight gain. Sleep apnea can also increase the risk. According to a study published online Feb. 12, 2018 in the Journal of Sleep Disorders & Therapy, people with sleep apnea are more likely to also have heart failure, an irregular heartbeat and diabetes

Numbers: Keep the lower BP, LDL cholesterol, abdominal circumference and fasting sugar < 80

(Source: Harvard Health Watch)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Warning signs of worsening heart failure

If you have heart failure, call your doctor if you notice any of these signs:

• Sudden weight gain (2–3 pounds in one day or 5 or more pounds in one week)
• Extra swelling in the feet or ankles
• Swelling or pain in the abdomen
• Shortness of breath not related to exercise
• Discomfort or trouble breathing when lying flat
• Waking up feeling short of breath
• Coughing or wheezing
• Increased fatigue
• Mental confusion
• Loss of appetite

Dr KK Answers: Dr. KK’s tip of heart failure

Any patient with acute left heart failure presenting as pulmonary edema, check the blood pressure if the blood pressure is normal or high unless proved otherwise, it is a case of diastolic heart failure (abnormality of the relaxation function of the heart) and carries good prognosis. If the blood pressure is low, it indicates low systolic or pumping function of heart and carries bad prognosis.