1b) Check out our other #ADA2022 recap #tweetorial by new @GoggleDocs family member @Ines_Vfonseca who focused on the cardiac data presented: https://t.co/osg2gwi4AI
— cardio-met (@cardiomet_CE) August 31, 2022
3) Faculty disclosures and statement of accreditation are provided at https://t.co/HgNk2ajJBC. Please FOLLOW @cardiomet_ce and @ckd_ce so you don’t miss any of our unique #accredited #serialized #tweetorials, always 🆓, always from expert authors!
— cardio-met (@cardiomet_CE) August 31, 2022
5) 🌟Highlight for us was the presentation of the New Joint Statement from ADA-KDIGO on the Management of #Diabetes & #CKD@ADA_DiabetesPro @goKDIGO
— cardio-met (@cardiomet_CE) August 31, 2022
Available in draft from
👉 🔓https://t.co/kkWJySuMh4 👈 pic.twitter.com/KpYuPieuVP
7) 👉Today we are going to focus purely on the utility and application of SGLT2i in the consensus statement.
— cardio-met (@cardiomet_CE) August 31, 2022
📍If you want to read more check out this 🧵: https://t.co/f2vVE8XXEs
8b) More detail at
— cardio-met (@cardiomet_CE) August 31, 2022
👉🔓https://t.co/kkWJySuMh4
and from @BakrisGeorge himself at https://t.co/Fm6mIvKpi7
10) 👉What’s more than this is that SGLT2i may delay the progression to dialysis by nearly 13 years❗️(based on data from the #CREDENCE trial)
— cardio-met (@cardiomet_CE) August 31, 2022
🔓https://t.co/xhUAh5btem pic.twitter.com/xX2g5FiKeJ
12) So ideal treatments should also ⤵️ adverse cardiovascular events as well as ⤵️ adverse kidney outcomes pic.twitter.com/EpWDthHBDV
— cardio-met (@cardiomet_CE) August 31, 2022
14) Perhaps the major change in the ADA-KDIGO joint statement is the inclusion of mineralocorticoid antagonists (#MRA)
— cardio-met (@cardiomet_CE) August 31, 2022
📍steroidal MRA (e.g. #spironolactone) for hypertension
or
📍non-steroidal MRA (e.g. #finerenone) for persistent albuminuria despite RAS blockade and #SGLT2i pic.twitter.com/zdFjOFBlGB
16) So we now do have three pillars of slowing #DKD progression & reducing adverse cardiovascular outcomes:
— cardio-met (@cardiomet_CE) August 31, 2022
1️⃣Renin-Angiotensin Blockade
2️⃣ SGLT2 Inhibition
3️⃣non-steroidal MRA@BakrisGeorge at #ADA2022: https://t.co/Fm6mIvKpi7 pic.twitter.com/Jixi1Mdt4G
17b) See 🔓https://t.co/ujtxboqghs
— cardio-met (@cardiomet_CE) August 31, 2022
&
🔓https://t.co/mT38Ee0aDV pic.twitter.com/ls6lmQ4ehE
19a) ⚠️Use of #RASi + #MRAs brings with it an ⤴️risk of #hyperkalaemia.
— cardio-met (@cardiomet_CE) August 31, 2022
📍Although ns-MRA, like #finerenone, have a much lower risk of hyperkalaemia than steroidal MRA’s
📍Finerenone was assoc. with ⤴️ discontinuation due to hyperkalaemia in the FIDELIO-DKD trial (2.3 vs 0.9%)
20a) Can #SGLT2i ⤵️ #hyperkalaemia risk❓
— cardio-met (@cardiomet_CE) August 31, 2022
📍SGLT2i ⤴️ distal 🧂 & water delivery, ⤴️ electronegative charge in the tubular lumen that regulates potassium excretion in the distal nephron
📍glycosuria may also ⤴️ potassium excretion
📍SGLT2i ⤴️ aldosterone so ⤵️ serum potassium
21) Discussed at #ADA2022:
— cardio-met (@cardiomet_CE) August 31, 2022
👉Results of ROTATE 3
📍randomized crossover clinical trial
📍#Dapagliflozin⬇️some ⤴️ serum K+ seen with #eplerenone (MRA) tx in pts with #CKD
📍The combination also ⤵️ urine #ACR more than either drug taken on its own
🔓https://t.co/vDI5t6qYW6 pic.twitter.com/ih54olNJ2U
23) More from the ADA-KDIGO session at #ADA2022:
— cardio-met (@cardiomet_CE) August 31, 2022
👉Baseline concomitant use of #SGLT2i with #finerenone associated with a ⤵️ in #hyperkalaemia events in the #FIDELIO_DKD trial, compared to non-use of SGLT2i at baseline
See 🔓https://t.co/UcUq5pcqEJ pic.twitter.com/Vlt8sisFrc
25) 👉SGLT2i treatment for heavy albuminuric CKD may even be cost-effective, meaning it may improve quality of life and reduce health care costs compared to placebo‼️
— cardio-met (@cardiomet_CE) August 31, 2022
New data from #ADA2022: pic.twitter.com/D9dVfjzaAJ
27) #SGLT2i have what effect on hyperkalaemia seen in people with CKD treated with RAS blockers and/or MRAs?
— cardio-met (@cardiomet_CE) August 31, 2022
a. Slightly⤴️ risks
b. Have no impact on hyperkalaemia risks
c. Slightly⤵️ risks
Mark your response here too & RETURN TOMORROW for the correct answer & your 🆓CE/#CME!
29) Still from the #ADA2022 @ADA_DiabetesPro–@goKDIGO session: a word about screening & treatment gaps:
— cardio-met (@cardiomet_CE) September 1, 2022
📍90%+ of people with #T2DM have #eGFR testing
📍about 50% with #T2DM have #UACR tested within a year
📍Although these are🇺🇸 data, very similar data are found in the 🇬🇧 pic.twitter.com/m0tyCfs4gX
31) Thinking about #population_health two more questions spring to mind:
— cardio-met (@cardiomet_CE) September 1, 2022
1⃣Are the right people prescribing #SGLT2i?
2⃣Are the right people being treated with SGLT2i? pic.twitter.com/LiI2oSXh9j
33) Are the right people taking #SGLT2i’s?
— cardio-met (@cardiomet_CE) September 1, 2022
More concern for kidney doctors is that among pts with #CKD in 2019
📍 only 20.6% are on a RAS Blocker
⚠️ potentially reno-toxic drugs (NSAIDs & PPIs) are prescribed in 20.5 & 13.2% respectively
☹️ only 0.1% of people are on SGLT2i‼️ pic.twitter.com/HnYt9F38nI
35) Q. Does the out-of-pocket expense cost influence initiating #SGLT2i in patients #T2DM + established #ASCVD?
— cardio-met (@cardiomet_CE) September 1, 2022
A. Yes 😡
👉Analysis by Prof. Jing Luo presented #ADA2022:
👉Retrospective cohort study
👉Mainly in Medicare Advantage (🇺🇸 data)
🌟⤴️costs associated with⤵️initiation
37) The correct answer is c—being of white European descent is NOT a barrier to being initiated on #SGLT2i therapy.
— cardio-met (@cardiomet_CE) September 1, 2022
So . . . pic.twitter.com/JhVJ3GFW8i
39) More #ADA2022:
— cardio-met (@cardiomet_CE) September 1, 2022
Q. Does frailty impact on extended #MACE outcomes of #SGLT2i (i.e. including all-cause ☠️ &🏥💔)?
A. Relative risk ⤵️remains the same, although absolute benefits appear greater in frail patients‼️
⚠️Population based study – Medicare (🇺🇸)
✅ Propensity matching pic.twitter.com/NTKiDCQAIK
40b) I will try to summarise a great session at #ADA2022 by one of the friends of @GoggleDocs – @drshafikuchay pic.twitter.com/wYtFdlQM1B
— cardio-met (@cardiomet_CE) September 1, 2022
42) 👉#SGLT2i as a treatment for #NAFLD
— cardio-met (@cardiomet_CE) September 1, 2022
📍Data from #MRI studies#SGLT2i:
⤵️ Liver Fat
⤵️ Liver Enzymes
⤵️ Inflammatory and fibrotic markers pic.twitter.com/Gun0v7Cbbt
44) 👉SGLT2i as a treatment for NAFLD/NASH in #T2DM:
— cardio-met (@cardiomet_CE) September 1, 2022
📍Multi-centre RCT in 🇯🇵
📍n=55
📍Liver biopsy study😊#Ipragliflozin use assoc. with
⤵️ Liver Fibrosis
⤵️ Progression from NAFLD➡️ NASH
⤴️ remission from NASH
🔓https://t.co/68f2e5THIN pic.twitter.com/uaDe2GlfYu
46) In summary #SGLT2i
— cardio-met (@cardiomet_CE) September 1, 2022
📍⤵️ risk of developing #NAFLD
📍⤵️ Fibrosis
📍⤵️ portal hypertension
As well as
⤵️ #HbA1c
⤵️ Adverse #CV events
⤵️ Adverse kidney events pic.twitter.com/0YYujgsAxh
47) At #ADA2022 David Cherney presented interesting data from the now published BETWEEN Study, aimed at testing theory that #RAS blockade (#rampiril) & #SGLT2i (#empagliflozin) had complementary effects of in restoration of Tubuloglomerular feedback
— cardio-met (@cardiomet_CE) September 1, 2022
📍Only pts with #T1D recruited pic.twitter.com/7Jk9B2oTju
49) 👉Results:
— cardio-met (@cardiomet_CE) September 1, 2022
Expected GFR ⤵️
⬇️Oxidative stress markers
Additional ⤵️BP
⤵️ Total peripheral resistance.
full paper now published👇
🔓https://t.co/Qa4t6exTJk pic.twitter.com/DhyO282mvF
51) So, in parting . . . in people with #T1D and kidney #hyperfiltration the addition of a #SGLT2i in people taking ramipril causes?
— cardio-met (@cardiomet_CE) September 1, 2022
a) ⤵️ Intraglomerular pressure
b) ⤵️ Total peripheral resistance
c) ⤵️ Oxidative stress markers
d) All the above
53) So go to https://t.co/zqD0V8ItHy and claim what is yours! And FOLLOW @cardiomet_ce and @GoggleDocs for the latest in #cardiorenal and #cardiometabolic education! I am @drpatrickholmes, and I thank you for joining us! pic.twitter.com/YTpY3It3Ds
— cardio-met (@cardiomet_CE) September 1, 2022