empagliflozin

Great Goodfellow webinar tonight. Endocrinologist Dr Ryan Paul and RNZCGP Medical Director Dr Bryan Betty discussed the role of these medications.

Key Messages 

Empagliflozin is a preferred 2nd line agent in cardiovascular disease, especially heart failure, and renal disease.

It reduces mortality from cardiovascular events and renal disease progression independent of its effects on glycaemic control.

It leads to weight loss, blood pressure reduction and will not cause hypoglycaemia in or of itself.

Therefore, SGLT2 inhibitors (SGLT2i) should be strongly considered in all patients with type 2 diabetes with diabetic renal disease OR heart failure OR known cardiovascular disease OR 5 year CVD risk > 15% regardless of their glycaemic control or other glucose lowering therapies.

Available in 10 mg and 25 mg tablets or in various empagliflozin/metformin combinations (5 mg/500 mg; 5 mg/1000 mg; 12.5 mg/500 mg; 12.5 mg/1000 mg)

Typically start at 10 mg daily and can increase to maximum of 25 mg daily after several weeks if no adverse effects AND as required for glycaemic control

Special Authority Criteria

Patient has type 2 diabetes with an HbA1c > 53 mmol/mol despite at least 3 months of regular use of metformin and/or an alternative glucose lowering therapy, not on a funded GLP1RA (i.e. dulaglutide) AND any of the following:

  • Diabetic renal disease  (urinary albumin:creatinine ratio > 3 mg/mmol and/or eGFR < 60 mL/min) OR
  • Known cardiovascular disease (any ischaemic heart disease, cerebrovascular event, peripheral vascular disease, congestive heart failure or familial hypercholesterolaemia) OR
  • 5 year cardiovascular disease risk > 15% OR
  • A high lifetime cardiovascular risk due to onset of diabetes in childhood or as a young adult OR
  • Māori or Pacific ethnicity

Adverse effects of SGLT2 inhibitors

  • Polyuria – consider reducing diuretics before commencing if applicable
  • Genitourinary infections e.g. UTIs, vaginal thrush, balantitis
  • Patients should be educated on correct hygiene and warned of the rare risk of Fournier’s gangrene  that is a medical emergency
  • Hypotension – consider reducing antihypertensive agents before commencing/increasing dose
  • Increases risk of diabetic ketoacidosis (DKA) including normoglycaemic DKA but still rare (1 in 3000)

https://www.t2dm.nzssd.org.nz/Subject-21-Non-insulin-medications

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