Metformin remains gold standard for reducing mortality and complications in diabetes


Preventive Cardiology Conference proceedings
Metformin remains gold standard for reducing
mortality and complications in diabetes
SGLT2 inhibitors have no drug interactions,
They also reduce HbA1c-Prof. Ahmad Bilal

GAMBAT: Prof. Ahmad Bilal Dean Faculty of Medicine at Faisalabad Medial University was the keynote speaker at the inaugural session of 6th Preventive Cardiology conference held at Gambat Institute of Medical Sciences from 8th to 10th March 2019. The topic of his presentation was “SGLT2 Inhibitors: A star in the Spot”. Change in life, he opined is a must. He discussed in detail the overall approach in the treatment of Type2 diabetes and laid emphasis on patient centered approach. In the past too much emphasis was given on preventing complications but one solution does not fit all in the real world. Metformin, he further stated remains the gold standard for reducing mortality and complications in diabetes.

Inferior control, he further stated will lead to more deaths but the life goes and now there are superior drugs which reduce the complications. UKPDS had showed that an ideal Antidiabetic should be safe, effective, tolerable, and low cost with clinical experience and it should also prevent heart attacks. Metformin is prescribed for longer use and it should be continued. Diabetics should never stop taking this medication nor should it be forgotten. UKPDS showed mortality reduction and compilations were also reduced but other trials did not show this mortality reduction. It was the ACCORD trial which in fact showed that with intensive blood glucose control mortality increased by 22%. It created lot of discussion and then this trial was analyzed in depth which revealed that hemoglobin was not monitored. Hyperglycemia is also dangerous, it will kill the patient in many years but hypoglycemia will kill the patient soon. There was 10% weight increase and weight gain will increase mortality. As such we should not only look at blood glucose control but also look at reduction in complications.

Prof. Ahmad Bilal

CV outcome trail has showed that now we have new safe molecules like Empagliplazin. EMPA not only reduces overall mortality but also cardiovascular deaths, non-fatal MI and stroke were also reduced. This drug also resulted in weight loss. It is essential that any new drug is safe, effective, tolerable as well as affordable but all new drugs like SGLT2 Inhibitors are very expensive. He then discussed their mechanism of action in detail. He also talked about familial glycosuria. These drugs will lead to weight loss as well as reduction in blood pressure. Ketone bodies will enhance heart body function. SGLT2 inhibitors have no drug interactions; they also reduce HbA1c by 0.6 to 0.9%. As add on they are superior to monotherapy. One can add them in combination with all other drugs as it can be used in combination with every drug. These drugs work better in patients with normal renal threshold. They are also better choice for weight loss and heart failure. They lead to two to three Kg weight loss in six months. White fats are dangerous while brown fat reduce adiposity. They do increase appetite. Most diabetics are also suffering from hypertension but low blood pressure will not kill. His advice to his colleagues was never leave Metformin but add SGLT2 inhibitors. They will reduce left ventricular hypertrophy (LVH). They do ECM remodeling. Their superior function in heart is due to ketones which these drugs provide.

Prof. Ahmad Bilal concluded his presentation by stating that SGLT2 inhibitors reduce mortality, heart failure and they are also known as modern decorative diuretics. SGLT2 and ACE Inhibitors provide kidney protection. In patients with eGFR <30 they are contra indicated. However, they do not result in dreadful hypoglycemia. Their benefits include weight loss, reduction in blood pressure, and reduction in HbA1c. In patients with history of heart failure they reduce Reno protection. As regards their adverse effects, DKA, fractures, genitourinary infections, amputations have been reported with SGLT2 Inhibitors. One should be extremely careful while using them in patients with low renal function and monitor them in genitourinary infections, he added.