SGLT-2 Inhibitors Use

[TLAD123]

---

Members don't see this ad.

Similarly to another poster's question on esomeprazole strontium, have any of you seen the new SGLT-2 inhibitors in practice yet? What doses are you seeing and what patient characteristics? What have you noticed as its place in therapy for those patients (in addition to metformin, after a few others have been tried, etc.)?

For those who do not know, SGLT-2 inhibitors are a new class of meds treating DM-Type 2; SGLT stands for sodium glucose co-transporter, with a MOA of inhibiting glucose reuptake in the proximal tubules of the nephron.

Canagliflozin (Invokana) was first approved with dapagliflozin (Farxiga) following it most recently. Both have increased risk of UTIs and genital mycotic infections (up to 30% risk of these ADRs), and Farxiga has an increased risk of bladder cancer associated with it.

 

[sakigt]

I think Invokana is coming up at our P&T meeting for forumlary addition......

The rep said the docs love them, but I havent seen it come in as a home med yet. Apparently a 1% reduction in A1c....

 

[All4MyDaughter]

Our P & T was not crazy about them, mostly because our patient population is elderly and doesn't need additional risk for UTIs, etc. Also, our patients already have compromised renal function and for the most part, do not need the weight loss.

I think the ideal patient is a young, overweight/obese but otherwise healthy patient with diabetes.

 

[fauxden]

A drug rep talked to me about invokana a few months ago. I wanted to punch her in the face because she was so condescending....and we have yet to see an Rx for it.

 

[TLAD123]

I think Invokana is coming up at our P&T meeting for forumlary addition......
The rep said the docs love them, but I havent seen it come in as a home med yet. Apparently a 1% reduction in A1c....

Yeah, all literature shows ~0.7% reduction with 100mg daily canagliflozin, and ~0.9-1% reduction with 300mg daily.

Our P & T was not crazy about them, mostly because our patient population is elderly and doesn't need additional risk for UTIs, etc. Also, our patients already have compromised renal function and for the most part, do not need the weight loss.

I think the ideal patient is a young, overweight/obese but otherwise healthy patient with diabetes.

That's what we determined in our journal club discussion, as well. There was a baby trial (I say baby b/c it only had 20-30 patients) that showed it was still effective in patients on insulin. I didn't critically evaluate that article, rather glanced over it for background info.

 

[All4MyDaughter]

That's what we determined in our journal club discussion, as well. There was a baby trial (I say baby b/c it only had 20-30 patients) that showed it was still effective in patients on insulin. I didn't critically evaluate that article, rather glanced over it for background info.

I can see why that would be. Do you think it could have any utility in T1DM?

 

[TLAD123]

I can see why that would be. Do you think it could have any utility in T1DM?

Good question - I can't recall completely, but I thought there were some studies showing that lower insulin requirements resulted in better cardiovascular outcomes than higher ones - if this can be shown to do that, then I would hopefully optimistic about their use in Type 1.

 

[PharmdA07]

I've seen it only once, and it was given by an endocrinologist MD, PhD from a large academic clinic with several university affiliations. When I talked to the prescriber to verify the script, he said that they always give it out together with an abx rx (for this case it was bactrim DS, the pt is a DM2 guy in his late 50s) for UTI and instructed pt to fill it when they had an UTI. I asked about how the pt could go around diagnosing themselves with the UTI and he told me that the pt would be calling his staffs and would be instructed to fill that abx rx if necessary. Looking through the data I just don't like the UTI risk, especially in females--imagine your elderly Betty Janes already at risk for UTI, leaving alone and ended up with a urosepsis (just my imagination ....)

 

[All4MyDaughter]

Good question - I can't recall completely, but I thought there were some studies showing that lower insulin requirements resulted in better cardiovascular outcomes than higher ones - if this can be shown to do that, then I would hopefully optimistic about their use in Type 1.

Any other benefits you can think of for Type 1?

 

[zelman]

Any other benefits you can think of for Type 1?

Probably not.

I believe that it might provide less blood glucose variability since more glucose would be lost to urine when the blood glucose level is higher, but that's pure speculation.

 

[amox]

Great for patients as an add on to other medications. Keep in mind this drug also causes osmotic diuresis leading to statistically significant reductions in blood pressure. I recommend reading the studies, good stuff. I have seen many patients on this medication and are responding well.

Obviously it's not a good choice in patients who are consistently acquiring prior UTIs.

Every drug has it's niche, and we all are scarred of new medications. Give it time for more data 🙂

 

[PharMed2016]

Any other benefits you can think of for Type 1?

I do foresee potential benefits on microvascular complications simply by having better glucose control but only time will tell.

 

[Rouelle]

We actually fill a fair amount of Invokana, maybe 3-4 scripts per week. Most come from a couple of endocrine practices...I guess the rep has them sold. I have not seen the "just-in-case-you-get-a-UTI" scripts to go along with them yet. Also have yet to see Farxiga written...