are considerably higher than in individuals without T2DM (White, 2022). The transport maximum increasing further aggravates persistent hyperglycemia in patients with T2DM. Therefore, using SGLT2i provides a beneficial effect by preventing the reabsorption of between 30% and 50% of filtered glucose (White, 2022). Side effects SGLT2i cause diuresis, resulting in volume depletion and possible transient glomerular filtration reduction. Thus, a possible side effect with all four SGLT2i is an increased risk of hypotension, especially in the elderly, patients with renal impairment, or those treated with diuretics (White, 2022). Patients with low systolic blood pressure who are dehydrated need to have their volume status addressed and corrected prior to initiation of SGLT2i. SGLT2i increase the risk of genital mycotic infections because of glucosuria. Women present with mycotic infections more often than men. However, uncircumcised men with poor Dosing of sodium–glucose cotransporter 2 inhibitors The recommended dose for SGLT2i is shown in Table 6. SGLT2i are widely used noninsulin antihyperglycemic agents with intermediate to high glycemic efficacy, low rates of hypoglycemia, and positive cardiovascular and renal effects (White, 2022). According to 2023 guidelines for managing hyperglycemia in type 2 diabetes, study findings from several
There are currently five FDA-approved SGLT2 inhibitors in the U.S., including canagliflozin (Invokana), dapagliflozin (Farxiga), empagliflozin (Jardiance), ertugliflozin (Steglatro), and bexagliflozin (Brenzavvy). The efficacy of SGLT2i is dependent on the functional status of the kidney. Thus, SGLT2i are not indicated with an estimated glomerular filtration rate (eGFR) below specified values and are contraindicated in people with end-stage kidney disease and in those who are on dialysis. hygiene are more at risk. Most cases are easily treated with antifungal medications (ElSayed et al., 2023a; White, 2022). First, assess eGFR, polyuria, urinary frequency, and propensity for dehydration. Then cautiously prescribe SGLTS2i in patients with chronic urinary tract infections, urinary incontinence, and benign prostatic hypertrophy. Use of canagliflozin (Invokana) may lead to hyperkalemia. Patients at risk for hyperkalemia are those with moderate renal failure who are taking medications that interfere with potassium excretion or modulate the renin–angiotensin–aldosterone system (White, 2022). Thus, monitoring hyperkalemia is essential. RCTs have demonstrated the reduction of risk related to major adverse cardiovascular events, cardiovascular death, myocardial infarction, hospitalization for heart failure, and improvement in renal outcomes among patients with type 2 diabetes with an established high risk of CVD (Davies et al., 2022; ElSayed et al., 2023a).
Table 6: Noninsulin Antihyperglycemic Agents: Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitors Sodium-Glucose Cotransporter 2 (SGLT2) Starting Dose How to Titrate Dose
Available Strengths
Dosage Range
Generic Name (Trade Name) Canagliflozin (Invokana)
• 100 mg • 300 mg
• 100 mg/daily.
• Begin with lower dose; increase if greater glycemic management is needed, eGFR > 60 mL/min 1.73 m 2 , and patient tolerates lower dose. • Limit initial dose to 100 mg daily for patients with an eGFR <30 mL/min/1.73 m 2 . • Begin with lower dose; increase if greater glycemic management is needed and patient tolerates lower dose. • Do not prescribe for patients with an eGFR <25 mL/min/1.73 m 2 . • Begin with lower dose; increase if greater glycemic management is needed and patient tolerates lower dose. • Do not prescribe for patients with an eGFR <30 mL/min/1.73 m 2 . • Begin with lower dose; increase if greater glycemic management is needed and patient tolerates lower dose. • Do not prescribe for patients with an eGFR <45 mL/min/1.73 m 2 . • Do not prescribe if eGFR <30 mL/min 1.73 m 2 .
• 100–300 mg/daily.
Dapgliflozin (Farxiga)
• 2.5 mg • 5 mg • 10 mg
• 5 mg/daily.
• 5–10 mg/daily.
Empagloflozin (Jardiance)
• 10 mg • 25 mg
• 10 mg/daily.
• 10–25 mg/daily.
Ertugliflozin (Steglatro)
• 5 mg • 15 mg
• 5 mg/daily.
• 5–15 mg/daily.
Bexagliflozin (Brenzavvy)
• 20 mg
• 20 mg.
• 20 mg.
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Book Code: RPTTX2024
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