Expansion
The tides and the flozins, with benefits beyond glucose
Expansion
GLP-1 receptor agonists, the -tides: liraglutide, semaglutide, dulaglutide
- Incretin mimetics: increase glucose dependent insulin release, suppress glucagon, slow gastric emptying and increase satiety
- Significant weight loss, and cardiovascular benefit
- No hypoglycaemia alone, since the insulin effect is glucose dependent
- Side effects: nausea, vomiting, and rare pancreatitis. Mostly injected
SGLT2 inhibitors, the -flozins: dapagliflozin, empagliflozin
- Block renal glucose reabsorption, causing glycosuria
- Weight loss, modest blood pressure reduction
- Cardiovascular and renal benefit, now independent of diabetes, so they are used in heart failure and chronic kidney disease in patients without diabetes
- Side effects: genital and urinary infection, volume depletion, Fournier’s gangrene rarely, and euglycaemic diabetic ketoacidosis
“The flozins protect the heart and kidney even without diabetes.” That is the change that has most altered practice.
Euglycaemic ketoacidosis is the trap: ketoacidosis with a glucose that is normal or only mildly raised, precipitated by illness, surgery, fasting or a low carbohydrate diet. Stop the flozin during acute illness and before surgery, as part of sick day rules.