Indications for the use of SGLT-2 inhibitors in type 2 diabetes

Leszek Czupryniak, MD, PhD, is a professor of medicine and head of the Department of Diabetology and Internal Medicine at the Medical University of Warsaw, Poland. His areas of interest are type 1 diabetes, type 2 diabetes, diabetes accompanying other diseases, and chronic complications of diabetes, with special interest in oral antidiabetic agents and insulins.

In which clinical settings are there indications to initiate the treatment of type 2 diabetes with sodium-glucose cotransporter-2 (SGLT-2) inhibitors?

Leszek Czupryniak, MD, PhD: Traditionally we used to recommend metformin as the first pharmacologic option to treat patients with type 2 diabetes, but since 2018, and particularly 2022, when the most recent European Association for the Study of Diabetes (EASD) and the American Diabetes Association (ADA) consensus was published, which was in late 2022, we now have a clear option that in a relatively large group of patients we should not start with metformin only. We can use it, but not alone. And there is a great preference to use SGLT-2 inhibitors at the beginning of the treatment. The patients in whom it is compellingly indicated are patients with any sign, any shadow of heart failure, really, and also patients with newly diagnosed diabetes and chronic kidney disease, which was present either before the diabetes diagnosis or was diagnosed at the moment of diabetes diagnosis, which is not a rare case, but also if we have patients at high risk of cardiovascular complications, and that comprises 70%, 80%, if not more percent of patients with diabetes.

The high risk in the EASD/ADA consensus is defined as a person who is ≥55 years of age and has 2 out of 5 risk factors. These risk factors, cardiovascular risk factors, are very prevalent. It’s obesity, it’s smoking, it’s dyslipidemia, it’s hypertension, it’s albuminuria. So, if a patient is aged ≥55 years and has 2 out of these 5, they are eligible to be given an SGLT-2 inhibitor from the outset at the moment of diagnosis of type 2 diabetes. Also, patients with atherosclerotic cardiovascular diseases, any cardiovascular disease, any damage to the vasculature, they also benefit from SGLT-2 inhibitors. In fact, if we look at large at the population of patients with type 2 diabetes, newly diagnosed, the majority of them could be started on an SGLT-2 inhibitor with or without the addition of metformin, and this is largely left to the discretion of the managing physician. It is a new era in type 2 diabetes treatment. As I said, we used metformin as a first-line agent for the last 30 or 50 years, depending on the country, and within the last 3 to 4 years, it has abruptly changed. And it’s very good because SGLT-2 inhibitors have great evidence for preventing cardiovascular death, for delaying chronic kidney disease, for reducing cardiovascular risk. So, how can we deny the patients the benefits of this treatment?