@AndrewJSauer @DrMichaelShapir @MichaelJBlaha @dramitkhera @pnatarajanmd @PamTaubMD @DrMarthaGulati @DrRaniKhatib @AAgarwalaMD @RpratleyMD @drricardocorrea @AliceYYCheng @SantosGallegoMD @SABOURETCardio @hvanspall @DLBHATTMD @cpcannon
— cardio-met (@cardiomet_CE) May 31, 2022
3) Hot on the heels of cardiology legend Eugene Braunwald’s @NEJM review, in this tweetorial we will discuss the role of Sodium-glucose co-transporter 2 inhibitors (#SGLT2i) in the treatment of type 2 diabetes (#T2D).
— cardio-met (@cardiomet_CE) May 31, 2022
See https://t.co/G2ebQXEO3c pic.twitter.com/FVlWWU1Nau
5) First, let’s discuss T2D and the burden of disease in the United States. #Diabetes continues to be a growing public health challenge in the US. See
— cardio-met (@cardiomet_CE) May 31, 2022
🔓https://t.co/kmeQSi0acD pic.twitter.com/b6HhNvewot
7) So what is T2D and how can SGLT2i help manage the hyperglycemia of this condition? A quick poll:
— cardio-met (@cardiomet_CE) May 31, 2022
Type 2 diabetes is a disease related to:
a. ⬇️ b-cell insulin
b. Dysregulated hepatic function
c. ⬆️ renal glucose reabsorption
d. All of the above and more
9) Another quick poll: while SGLT2i can affect multiple pathophysiologies involved in T2D, what organ is the primary target of its hypoglycemic effect?
— cardio-met (@cardiomet_CE) May 31, 2022
11) A healthy kidney filters ~180 g of glucose daily, nearly all of which is reabsorbed (normal urine should be dipstick negative for glucose!). Most of this reabsorption (about 90%) occurs in the first segment of the proximal convoluted tubule by SGLT2. https://t.co/tiBYERvcPP pic.twitter.com/MVMflpCWRb
— cardio-met (@cardiomet_CE) May 31, 2022
13) Typically, as long as plasma #glucose concentrations remain under about 180 mg/dL, essentially all filtered glucose undergoes reuptake. Only once this threshold is exceeded does a person experience #glucosuria. pic.twitter.com/zLUgWUtf29
— cardio-met (@cardiomet_CE) May 31, 2022
15) By blocking SGLT2, glucose remains in the tubular lumen, leading to vibrant glucosuria.
— cardio-met (@cardiomet_CE) May 31, 2022
See 🔓https://t.co/VGb858xzvk pic.twitter.com/GdBwVL44zx
17) There are 4 SGLT2i’s commercially available in the United States (in alpha order, #canagliflozin, #dapagliflozin, #empagliflozin, & #ertugliflozin). Other agents are beyond the scope of this tweetorial. They also come in combos with #metformin and/or #DPP4 inhibitors.
— cardio-met (@cardiomet_CE) May 31, 2022
19) Mark your best answer and return TOMORROW for the correct response and a link to your 🆓CE/#CME! 👍 @ChristosArgyrop @ShelleyZieroth @rajeshjain @DrMetabolism @SethShayMartin @didemturgut_ @GoggleDocs @MedTweetorials #FOAMed #CardioTwitter #endotwitter #NephTwitter
— cardio-met (@cardiomet_CE) May 31, 2022
21) So as to yesterday's quiz . . . you DID answer, right? If not, scroll back ⬆️to tweet 18 and tell me how much #A1c lowering can be expected from this #SGLT2i therapy in patients with #T2D?
— cardio-met (@cardiomet_CE) June 1, 2022
23) Over the years, however, we have seen a prioritization of this class due to pluripotent benefits outside of glycemic control. Compare the 2015 and 2022 @AmDiabetesAssn pharmacologic approach charts below.
— cardio-met (@cardiomet_CE) June 1, 2022
See https://t.co/cz2O2HaeQl pic.twitter.com/qmaudZF838
25) #SGLT2i have 2 critical benefits over some older med classes: they do not cause hypoglycemia & they do not cause weight gain (they typically promote mild weight loss, which helps w/the adiposity-driven pathophysiology of many patients with T2D).
— cardio-met (@cardiomet_CE) June 1, 2022
See 🔓https://t.co/cz2O2HaeQl pic.twitter.com/rSM7PfOcPU
27a) Some guidelines such as those of @TheAACE (🔓https://t.co/R1hmY5XbeL, left below) and joint @escardio/@EASDnews ( 🔓https://t.co/slp823ACqt, right below) even directly suggest #SGLT2i use . . . pic.twitter.com/xryUUZivJe
— cardio-met (@cardiomet_CE) June 1, 2022
28) The recently published AHA/ACC/HFSA heart failure guidelines also highlight this class with strong recommendations, as below (from 🔓https://t.co/aYf5PMRQ6Z): pic.twitter.com/FHflc7H4iC
— cardio-met (@cardiomet_CE) June 1, 2022
30) The impact of SGLT2i on each of these disease states has been discussed in other tweetorials (see tweet 4), and is summarized nicely in a recent NEJM article by cardiology legend Eugene Braunwald (tweet 3).
— cardio-met (@cardiomet_CE) June 1, 2022
32) A poll to drive home the point: a patient with T2D, heart failure and CKD presents to you. A1c is 6.5%. Should you consider SGLT2i therapy?
— cardio-met (@cardiomet_CE) June 1, 2022
34) Full warnings are included in package inserts, but a few practical considerations in the next tweets:
— cardio-met (@cardiomet_CE) June 1, 2022
35b) See https://t.co/mIoaeMh9K8
— cardio-met (@cardiomet_CE) June 1, 2022
🔓https://t.co/3wUD80f0Lf pic.twitter.com/8WbzV4YT56
37) 2. There is generally no risk of hypoglycemia unless pt is on insulin, sulfonylurea or meglitinide. Hypoglycemia is NOT from SGLT2i but from the other agent. Consider downtitration of those agents, particularly if pt has reasonable glycemic control before SGLT2i initiation.
— cardio-met (@cardiomet_CE) June 1, 2022
39) 4. By promoting glycosuria, SGLT2i can potentiate genitourinary infections, particularly genital yeast infections. Patients should be counseled regarding signs and symptoms. Reconsider therapy in patients experiencing recurrent episodes.https://t.co/bXppkaraDw
— cardio-met (@cardiomet_CE) June 1, 2022
41) 🤔Could SGLT2i move even earlier in the #cardiometabolic health journey and be used in #prediabetes or insulin-resistant non-diabetes to start impacting health earlier?
— cardio-met (@cardiomet_CE) June 1, 2022
43) Lastly, a plea: SGLT2i do not “belong” to anyone. Whether in endocrinology, primary care, cardiology, nephrology, etc, we are all responsible to our pts for using this class appropriately. SGLT2is may be the single most important and pluripotent medications of a generation.
— cardio-met (@cardiomet_CE) June 1, 2022
44) And that's it! You just earned 0.5hr CE/#CME! Go to https://t.co/fboHLoBYwr and claim your certificate! And follow @cardiomet_ce and @ckd_ce for the BEST continuing education on Twitter from expert authors! I am @tmodarressi. Thanks for joining!
— cardio-met (@cardiomet_CE) June 1, 2022