Sodium/Glucose Cotransporter 2 Inhibitors in Patients With Diabetes Mellitus and Chronic Kidney Disease
Turning the Page
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Article, see p 119
The link between cardiovascular disease (CVD) and diabetes mellitus has long been recorded, extending back to the advent of insulin therapy, when that therapeutic advance increased patient survival, allowing atherosclerotic complications to become more evident.1 Attention to the relationship between diabetes mellitus and CVD grew, fostered by forces such as the epidemic of obesity and diabetes mellitus, improved post–myocardial infarction survival, and increasing data linking these 2 common, chronic problems. For example, the East-West Study placed the cardiovascular risk of diabetes mellitus in a context easily grasped by cardiologists: the chances of a future myocardial infarction in those with diabetes mellitus and no CVD history equaled those of myocardial infarction survivors with no history of diabetes mellitus.2 Although still debated, this “cardiovascular risk equivalency” offered an easy shorthand that helped recast the nature and treatment of diabetes mellitus. The arrival of new glucose-lowering drugs and therapeutic strategies created expectations about the next chapter to come: glucose lowering in diabetes mellitus would decrease cardiovascular events. That story, however, unfolded with unexpected twists, including a new subplot concerning the cardiovascular safety of glucose-lowering agents. Ultimately, a long, often disappointing, contradictory saga of the “glucose paradox” emerged; although hyperglycemia increases cardiovascular risk, lowering glucose levels did not reverse this relationship.3 Even when the cardiovascular safety of a drug was established, no cardiovascular risk reduction was found.4 In the past 2 years, 2 classes of antidiabetic drugs have demonstrated an improved primary major cardiovascular end point in a large prospective trial using 2 different agents within each class, namely glucagon-like peptide–1 agonists (liraglutide, semaglutide) and sodium/glucose cotransporter 2 (SGLT2) inhibitors (empagliflozin, canagliflozin).5–8 The page …