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October/November Blog: SGLT-2 Inhibitors as Treatment Option for Type 2 Diabetes

Contributors: Alexandrea Coleman and Dion Blocker, PharmD Candidates Class of 2023, PCOM Georgia School of Pharmacy

What is diabetes? People commonly make the mistake of thinking that diabetes is only about having high blood sugar levels. Having consistently high blood sugar levels isn’t that big of a deal right? Wrong! Diabetes is a highly complicated condition. Diabetes can cause many different kinds of disturbances that affect many different organs – including the heart and kidneys. Uncontrolled diabetes is notorious for being the culprit of changes that can result in life-threatening kidney dysfunction. As you can see, protecting the kidneys should be a priority for patients with diabetes. This priority is especially important for patients who already have kidney disease. 

Don’t you wish there was a drug class that could slow down the progression of kidney disease for people with diabetes? I am way ahead of you! A class of drugs that does this already exists!

The sodium-glucose cotransporter-2 is a transporter that reabsorbs glucose and sodium in the kidneys. If this transporter is blocked, sodium and glucose are allowed to leave the kidneys in hordes; which leads to the body urinating out tons of glucose and extra water. A class of drugs was designed to target this exact action. The drugs are named the “sodium-glucose cotransporter-2 inhibitors”, or SGLT2 for short. When it comes to certain disease states, healthcare providers are always looking at a patient’s medication list to see if something they are taking is contributing to their current condition. SGLT2 is a special drug class where they actually add benefits across disease states. They are not only able to aid in the treatment of type 2 diabetes, but they have also been able to show that they can slow the progression of kidney disease in patients. They have even been shown to benefit patients that have a higher risk of having fatal heart events. 

This class of medication can provide a multitude of benefits for patients, across disease states. Prior to the release of this drug class, most diabetes therapies were targeted specifically to treat diabetes and did not add any additional benefits to other conditions the patient may currently have. In the most recent update to the ADA guidelines, you will see that patient treatment no longer goes straight to Metformin for all patients. It is actually preferred now that patients be placed on SGLT2i therapy first, if they have kidney or heart risk factors. 

Let’s meet a patient to practice and see the added benefits of SGLT2-inhibitors:

BC, a 64-year-old male, has been seen in your clinic for the treatment of his type 2 diabetes. When assessing his past medical history, you note that he also has a diagnosis of stage 3 chronic kidney disease with no other medical conditions. BC wants to discuss the medical conditions that he currently has and what he can do to improve his quality of life. He wants to get his medical conditions under control so that he can improve his life expectancy. This would be an ideal candidate for a SGLT2-inhibitor. It would not only help the patient to improve their diabetes, by increasing the amount of glucose that is being excreted in the urine, but it would also provide dual benefits and slow the progression of his current kidney disease. 

What are my options when it comes to SGLT2-inhibitors and what are the doses?

  • Invokana (canagliflozin)
    • Starting dose: 100 mg once daily 
    • Maintenance dose: 300 mg once daily
      • Only titrate to this dose if the patient can tolerate the starting dose 
    • Patients with an eGFR of 45 to less than 60 mL/min/1.73m2 should limit the dose to 100 mg once daily 
    • If the eGFR is less than 45 ml/min/1.73m2, it is not recommended to use this medication 
  • Farxiga (dapagliflozin)
    • Diabetes:
      • Starting dose: 5 mg once daily 
      • Maintenance dose: 10 mg once daily
        • Only titrate to this dose if the patient can tolerate the starting dose 
      • Not recommended for patients who have an eGFR of less than 45 mL/min/1.73m2.
    • Heart failure:
      • Maintenance dose: 10 mg once daily
        • Do not need to use a starting dose 
      • No dose adjustments are needed for patients with eGFR > 30 mL/min/1.73m2
  • Jardiance (empagliflozin)
    • Starting dose: 10 mg
      • May titrate up to 25 mg if the patient tolerates the starting dose 
    • Do not initiate therapy if eGFR is less than 45 mL/min/1.73m2
      • Stop therapy if eGFR is less than 45 mL/min/1.73m2
    • If a patient has a diagnosis of heart failure, therapy can be continued as long as eGFR ≥ 20 mL/min/1.73m2 
  • Steglatro (ertugliflozin)
    • Starting dose: 5 mg, take in the morning and it can be taken with or without food
      • May titrate up to 15 mg, as long as the patient tolerates the starting dose 
    • Do not initiate if eGFR < 30 mL/min/1.732
      • Not recommended for initiation in patients with eGFR 30 to 60 mL/min/1.732   
      • Therapy should be discontinued if the patient’s eGFR is consistently between 30 to 60 mL/min/1.732  

References: 

  1. American Diabetes Association Professional Practice Committee; 11. Chronic Kidney Disease and Risk Management: Standards of Medical Care in Diabetes—2022. Diabetes Care 1 January 2022; 45 (Supplement_1): S175–S184.
  2. Invokana [package insert]. Titusville, NJ: Janssen Pharmaceuticals, 2013. 
  3. Farxiga [package insert]. Wilmington, DE: AstraZeneca Pharmaceuticals LP, 2020. 
  4. Jardiance [package insert]. Indianapolis, IN: Boehringer Ingelheim Pharmaceuticals, Inc., 2016. 
  5. Steglatro [package insert]. Whitehouse Station, NJ: Merck & CO., INC., 2017.