Troy Trygstad, PharmD, MBA, PhD: Dr. Morales, when you’re prescribing the sodium glucose cotransporter 2 class of medications to a patient, are there concerns that you have? Do you provide any extra education on anything that they need to look for or monitor?
Javier Morales, MD, FACP, FACE: It’s important to recognize that this particular class of drugs tends to act like a thiazide-like diuretic. In my clinical practice, if I’m using a combination antihypertensive therapy that incudes either an ACE or an ARB in combination with a diuretic, I would probably peel away the diuretic and then institute the SGLT2 inhibitor. I’m doing so because I’m trying to avert dehydration, especially since the class of drugs does have a diuretic effect, and hypotension. Even though there’s a significant benefit that’s noted in this particular class of drugs, patients who are elderly, who may experience hypotension, could have the potential for falling and sustaining injury or may even experience a hip fracture. I think it’s important to take that into consideration and practice safely. I know that there are also some concerns, particularly with genital urinary tract issues, that have arisen and have been described in patients with this class of medications. These include mycotic genital infections, which occur more often in women and in uncircumcised men. There’s really no way to avert the risk of this happening, other than to encourage patients to drink a lot of fluids, try to avoid barrier protection, and learn to identify and treat a little bit sooner rather than later. One of things that patients ask myself, and other clinicians is, if they have a mycotic infection, do they need to stop the SGLT2 inhibitor while they’re being treated? I usually tell them, ''No. Stay on the medication. It’s working. Treat the mycotic infection. It will be fine.'
Dhiren Patel, PharmD: That’s a really good point, and a counseling point that I tell patients. I predominantly see male geriatric patients, where I am at, because we have a woman’s health clinic, where women are seen by a female provider. Mycotic infections, in males, are not common. They don’t know what to look for when it does happen. It’s even happened on the frontline. Clinicians who are looking at it, when it might be coming into urgent care or through the emergency room, will ask for a urine sample. They’ll look for urinary tract infections—nothing there. But a physical exam may have not been done. So, again, educating that patient on proper hygiene is important. I agree with the earlier points regarding the importance in looking at volume status and renal function, because you’re going to have some intravascular volume contraction. Recently, a question that has surfaced is in regard to some amputation risk with SGLT2s. Patients say, “Oh, I saw a commercial on TV.” Usually, that’s how it unfolds. They’re not all created equal, from a safety standpoint. We’ve agreed that some of the cardiovascular benefits seem to be a class effect. There’s an amputation risk, specifically with canagliflozin, which patients do come in and present with. And so, that’s something to be mindful of. You need to make sure that you address that, head on, rather than wait for the patient to read or hear about it later. That could put a different impression in their mind. So, you need to make sure that both sides of the drug are covered.
Javier Morales, MD, FACP, FACE: It’s important to recognize that in terms of those who did experience amputation, as described in that particular trial, about 2% of these patients wound up having established peripheral vascular disease. And those who were at greatest risk of amputation already had previous amputations. So, I think it’s important to recognize what the risk factor actually is. It’s not going to be a typical patient who’s going to be at significant risk. It’s obviously going to be the greater-risk individual with established peripheral vascular disease, or prior amputation, who may be at risk.
Troy Trygstad, PharmD, MBA, PhD: The No. 1 cause of amputation, blindness, and chronic kidney disease is diabetes. So, let’s not forget the importance in tackling this disease state as one of the most important public health endeavors.