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September 2016, Volume 38, No. 3
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Internet
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What’s on the web for family physicians – diabetes treatment updateAlfred KY Tang 鄧權恩，Man-wo Tsang 曾文和
Ambulatory insulin initiation The website provides a systematic overview on the introduction of insulin in type 2 diabetes mellitus in a primary care setting. It outlines the current Australian guidelines on insulin therapy both as once daily basal therapy and as premixed insulin. It would be ideal that family physicians are familiar with the process, as commencement and titration of insulin can in fact be conducted safely in an ambulatory care setting. The website also covers information on when and how to start insulin therapy, how titration of insulin can be done and when to stop other medications. There are also information on when to consider more complex insulin regimens, and how to choose the most appropriate insulin regimen. Clinical decisions based on patient factors and self-monitoring of blood glucose, together with a multidisciplinary approach, would ensure a successful transition to insulin.
Diabetes framework Hong Kong: drug treatment of hyperglycaemia The Hong Kong reference framework for diabetes care, developed by the Primary Care Office of Department of Health, aims to provide a common reference guide to all healthcare professionals in Hong Kong. Based on best evidence, the reference frameworks aims to provide a comprehensive reference for primary care practitioners, which is in line with the government policy of promoting primary care within Hong Kong. To ensure incorporation of the latest medical developments and evidence, the framework will undergo review and update by clinical advisory groups on a regular basis. Module 6 of the document covers drug treatment of diabetes. The whole document on diabetes framework can be found at http://www. pco.gov.hk/english/resource/professionals_diabetes_ pdf.html and a friendly one-page summary is available at http://www.pco.gov.hk/english/resource/files/DM_ A4.pdf
Food and Drug Administration (FDA) website:
Sodium-glucose cotransporter-2 (SGLT2) inhibitors SGLT2 inhibitors are a class of prescription medicines that are FDA-approved for use together with diet and exercise to lower blood sugar in adults with type 2 diabetes. Information on SGLT2 inhibitors are updated regularly at this section of the FDA website. Apart from lowering blood sugar levels, SGLT2 can reduce cardiovascular mortality and protect kidney health. They are available as single-ingredient products and also in combination with other diabetes medicines such as metformin. SGLT2 inhibitors act by remove sugar from the body through the urine and hence lower blood sugar level. At the same time, FDA has also issued information on Drug Safety Communications on SGLT2 inhibitors for diabetes at http://www.fda.gov/ Drugs/DrugSafety/ucm475463.htm
Practical considerations for the use of SGLT2
inhibitors in treating hyperglycemia in type 2 diabetes The article outlines the characteristics of SGLT2 inhibitors for physicians who are about to prescribe this new class of oral anti-diabetic agents to their patients. The mode of action of SGLT2 inhibitors is insulin-independent. For patients with diabetes with adequate renal function, SGLT2 reduce hyperglycemia by blocking renal glucose reabsorption and increasing urinary glucose excretion. They are indicated for the treatment of hyperglycemia in type 2 diabetes mellitus (T2DM), as an adjunct to diet and exercise. The risk of hypoglycemia is low, unless combined with sulfonylureas or insulin. They may be used in combination with metformin, sulfonylureas, or insulin. SGLT2 inhibitors are associated with modest weight loss and mild anti-hypertensive effects. The major side effects are increased risk of volume depletion and of genitourinary infections, which may need additional medical intervention.
SGLT2-Metformin combo can be used right away A recent study has shown that patients with type 2 diabetes did better if given the combination therapy at the outset than if given any one of the components as monotherapy. The combo drug, first approved in August 2014, is the first combination of an SGLT2 inhibitor and metformin available in the United States. Canagliflozin was the first of the class of SGLT2 inhibitors, which was approved by FDA in 2013. Metformin has long been the first-line therapy for type 2 diabetes. New treatment guidelines from the American Diabetes Association call for using combination therapy from the very beginning especially for patients with more elevated levels of glycated hemoglobin. After 6 months, a higher share of patients who were given the combination therapy achieved an A1C of less than 7% than those on monotherapy.
More evidence-based information relating to different SGLT2 inhibitors T2DM is associated with 2-4 times of cardiovascular risk. Published in 2015, the multicenter empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes trial (EMPA-REG OUTCOME) is the first type 2 diabetes trial to demonstrate improved cardiovascular outcomes in high-risk patients. The trial randomised 7,020 patients to daily empagliflozin 10 or 25mg or placebo. At 3.1 years of follow up, empagliflozin was associated with a reduction in cardiovascular mortality, nonfatal MI, or nonfatal stroke, as well as a reduction in all-cause mortality and CV mortality. It should be noted that type 2 diabetes is a major cause of end stage renal disease, with 35% of patients eventually developing it, and almost half (50%) of the renal-dialysis population at any current time is made up of those with diabetes, primarily type 2.
(ii) Empagliflozin and progression of kidney disease in
type 2 diabetes When added to standard care to patients with type 2 diabetes with high cardiovascular risk, empagliflozin was associated with slower progression of kidney disease and lower rates of renal events when compared to placebo.
(iii) Canagliflozin slows progression of renal function
decline independently of glycemic effects A study with the conclusion that canagliflozin 100 or 300mg/day, compared with glimepiride, slowed the progression of renal disease over two years in patients with type 2 diabetes, and that canagliflozin may confer renoprotective effects independently of its glycemic effects.
Alfred KY Tang, MBBS (HK), MFM (Monash)
Family Physician in Private Practice Man-wo Tsang, MBBS (HK), FHKCP, FHKAM (Medicine), FRCP (L.E.G.) Endocrinologist in Private Practice Correspondence to: Dr Alfred KY Tang, Shop 3A, 2/F, Hsin Kuang Shopping Centre, Wong Tai Sin, Kowloon, Hong Kong SAR, China. E-mail:alfredtang@hkma.org |
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