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SGLT-2 Inhibitors in diabetes and heart failure

What is this Webinar about?

OneWelbeck present a series of webinars hosted by our OneWelbeck Consultants across various specialities.

Dr Iqbal Malik, Medical Director of OneWelbeck Heart Health outlines a summary of what the webinar; SGLT-2 Inhibitors in diabetes and heart failure, entails. The webinars are initially targeted at doctors but feel free to watch if you are a patient who would like to know more.

SGLT-2 Inhibitors in diabetes and heart failure: Hosted by Dr Iqbal Malik at OneWelbeck Hearth Health and Dr Shivani Misra at OneWelbeck Endocrinology.

Some basics about diabetes mellitus

Diabetes mellitus essentially causes high blood glucose levels and glucose eventually spills into the urine. Your pancreas beta-cells (that produce insulin) are lost, to lead to you losing the ability to control your sugar. In Type 2 Diabetes, you may be insulin resistant, and your cells can’t keep up.

If the sugar is too high, you can get very sick due to dehydration, and are at risk of heart attacks and strokes. A young type 2 diabetic patient with cardiovascular disease may well be losing 10 years of life compared to a non-diabetic patient.

It is worth noting, early onset Type 2 diabetes is worse than type 1 coming on at the same age. Additionally, a diabetic patient will see the GP, the cardiologist as well as the diabetes specialist. We all need to pay attention to you!

Even if you have no symptoms of heart disease, you may be brewing major risk factors for heart attack and stroke.

What is good sugar control?

Hba1c is a 3 month average measure of your sugar. A target Hba1c of 48 mmol/mol or 6.5% is used to show good control, as above this the risk starts to rise exponentially- so you need to try to get this level. However, as you get older and more frail, we may want to reduce treatment, so you don’t get too low a sugar- as that can also be a risk.

What drugs should you have?

This can sometimes be tricky to determine, but some options are:

a) Metformin. This is preferred as it is inexpensive and has some heart benefits as well as controlling sugar, unless you arrived in a mess in hospital, very dry, in which case, insulin might be needed first off

b) Other factors. Your weight, age, other conditions you have, lifestyle, HBa1c, and any side effects all help decide what your next options would be. These include:

  • GLP-1 receptor agonists
  • SGLT-2 inhibitors
  • DPP-4 inhibitors
  • Sulphonylureas
  • Insulin

In addition, you will be on blood pressure lowering agents and statins. Control of all your risk factors is vital and it is strongly advised not to smoke.

What’s so special about SGLT2-Inhibitors?

These newer agents appear to help additional factors- preserve the kidney, reduce heart failure, reduce cardiovascular events, reduce blood pressure.

They can cause genital infections as they work to pass sugar in the urine and there is no large risk involved in urine infections. However, they can  increase the risk of hypoglycaemia, and if you are sick then it is recommended to pause this type of drug to avoid keto-acidosis.

When you would avoid use

We avoid the use of SGLT2-Inhibitors in frail people with poor kidney function and we would also stop use if you have contracted COVID-19.

Heart Failure- what are the new treatments?

We give many different medications as treatment such as Beta-blockers, ACE-inhibitors and Angiotensin- receptor blockers, Spironolactone and Eprelonone, and Entresto.

What is new is that SGLT-2 inhibitors appear to give ADDITIONAL benefit to all these drugs. So we have started giving these on top. Why? Because you will feel better and live longer!

How do they do this magic? It is not clear. It is not just about lowering the BP, or passing water out, but perhaps it is acting directly on the heart? The weight loss of fat around your body may be important.

We discussed 3 cases

Perhaps the most interesting part was that a BMI of >28 makes you “obese” if you are Asian, and >35 if you are Caucasian.

Dr Misra and I went through the cases to help resolve how we make medication choices.

You can watch the full webinar here on our YouTube Channel. 

Written By Dr Iqbal Malik

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