DAPA -HF , DAPAGLIFLOZIN SLOWS TYPE2DM ONSET IN HEART FAILURE PATIENT
Good morning dear friends and fellow colleagues, Here is an update on Dapagliflozin. Dapagliflozin slows Type 2 DM onset in heart failure patients. DAPA-HF: Dapagliflozin Slows T2D Onset in Heart Failure Patients Dapagliflozin treatment of patients with heart failure but without diabetes in the DAPA-HF trial led to a one-third cut in the relative incidence of new-onset diabetes over a median follow-up of 18 months in a prespecified analysis from the multicenter trial that included 2,605 heart failure patients without diabetes at baseline. The findings represented the first evidence that a drug from dapagliflozin's class, the sodium-glucose cotransporter 2 (SGLT2) inhibitors, could prevent or slow the onset of type 2 diabetes. It represents "an additional benefit" that dapagliflozin (Farxiga) offers to patients with heart failure with reduced ejection fraction (HFrEF) like those enrolled in the DAPA-HF trial, Silvio E. Inzucchi, MD, said at the virtual annual scientific sessions of the American Diabetes Association. DAPA-HF had previously proved that treatment with this drug significantly reduced the study's primary endpoint of cardiovascular death or heart failure worsening. During 18 months of follow-up, 7.1% of patients in the placebo arm developed type 2 diabetes, compared with 4.9% in those who received dapagliflozin, a 2.2% absolute difference and a 32% relative risk reduction that was statistically significant for this prespecified but "exploratory" endpoint, reported Dr. Inzucchi, an endocrinologist and professor of medicine at Yale University, New Haven, Conn. For this analysis, a hemoglobin A1c level of at least 6.5% measured in two consecutive assessments was the criterion for diagnosing incident diabetes. The 2,605 enrolled patients without diabetes in the DAPA-HF trial represented 55% of the entire trial cohort of 4,744 patients with HFrEF. The 32% relative risk reduction for incident diabetes was primarily relevant to enrolled patients with prediabetes at entry, who constituted 67% of the enrolled cohort based on the usual definition of prediabetes, an A1c of 5.7%-6.4%. Among all 157 (6%) of the DAPA-HF patients who developed diabetes during the trial, 150 (96%) occurred in patients with prediabetes by the usual definition; 136 of the incident cases (87%) had prediabetes by a more stringent criterion of an A1c of 6.0%-6.4%. To put the preventive efficacy of dapagliflozin into more context, Dr. Inzucchi cited the 31% relative protection rate exerted by metformin in the Diabetes Prevention Program study (N Engl J Med. 2002 Feb 7;346[6]:393-403). The findings showed that "dapagliflozin is the first medication demonstrated to reduce both incident type 2 diabetes and mortality in a single trial," as well as the first agent from the SGLT2 inhibitor class to show a diabetes prevention effect, Dr. Inzucchi noted. Patients with both heart failure and diabetes are known to have a substantially increased mortality risk, compared with patients with just one of these diseases, and the potent risk posed by the confluence of both was confirmed in the results Dr. Inzucchi reported. The 157 HFrEF patients in the trial who developed diabetes had a statistically significant 70% increased incidence of all-cause mortality during the trial's follow-up, compared with similar HFrEF patients who remained free from a diabetes diagnosis, and they also had a significant 77% relative increase in their incidence of cardiovascular death. This analysis failed to show that incident diabetes had a significant impact on hospitalizations for heart failure coupled with cardiovascular death, another endpoint of the trial. "This is a tremendously important analysis. We recognize that diabetes is an important factor that can forecast heart failure risk, even over relatively short follow-up. A drug that targets both diseases can be quite beneficial," commented Muthiah Vaduganathan, MD, a cardiologist at Brigham and Women's Hospital in Boston. The impact of dapagliflozin on average A1c levels during the DAPA-HF trial was minimal, reducing levels by an average of 0.04% among those who entered with prediabetes and by 0.05% among the other patients. This suggests that the mechanisms by which dapagliflozin reduced incident diabetes were by routes that did not involve simply reducing hyperglycemia, and the observed decrease in incident diabetes was not apparently caused by "masking" of hyperglycemia by dapagliflozin, said Dr. Inzucchi. One possibility is that dapagliflozin, which also improved quality of life and reduced hospitalizations in the DAPA-HF trial, led to improved function and mobility among patients that had beneficial effects on their insulin sensitivity, Dr. Vaduganathan speculated in an interview. The new finding of dapagliflozin's benefit "is great news," commented Yehuda Handelsman, MD, an endocrinologist and diabetes specialist who is medical director of the Metabolic Institute of America in Tarzana, Calif. "It's an impressive and important result, and another reason to use dapagliflozin in patients with HFrEF, a group of patients whom you want to prevent from having worse outcomes" by developing diabetes. The DAPA-HF (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure) trial enrolled HFrEF patients at 410 centers in 20 countries during February 2017–August 2018. The study's primary endpoint was the composite incidence of cardiovascular death or worsening heart failure, which occurred in 16.3% of patients randomized to receive dapagliflozin and in 21.2% of control patients on standard care but on placebo instead of the study drug, a statistically significant relative risk reduction of 26% (N Engl J Med. 2019 Nov 21;381[21]:1995-2008). In the 2,605-patient subgroup without type 2 diabetes at baseline the primary endpoint fell by a statistically significant 27% with dapagliflozin treatment, the first time an SGLT2 inhibitor drug was shown effective for reducing this endpoint in patients with HFrEF but without diabetes. DAPA-HF did not enroll any patients with type 1 diabetes. DAPA-HF was sponsored by AstraZeneca, the company that markets dapagliflozin (Farxiga). Dr. Inzucchi has been a consultant to AstraZeneca and to Abbott, Boehringer Ingelheim, Merck, Novo Nordisk, Sanofi/Lexicon, and vTv Therapeutics. Dr. Vaduganathan has been an adviser to AstraZeneca and to Amgen, Baxter, Bayer, Boehringer Ingelheim, Cytokinetics, and Relypsa. Dr. Handelsman has been a consultant to several drug companies including AstraZeneca. SOURCE: Inzucchi SE et al. ADA 2020, abstract . With regards, Dr Sepuri Tirumala Devi.
Yes mam this is elaborative post on subject yes new study DAPA HF conducted by Astra Zeneca and found this molecule very helpful in reducing hba1c and hfrEf without hyperglycemia or useful in prediabetics with HF Tomarrow 18 june will have a webinar on subject and to be adressed by dr Peter Lin
Very informative posting. When can we start using DAPA in clinical practice along with metformin for prevention of Diabetes mellitus
Very informative,ma'm. Thanks
Informative post madam
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55 yrs female...pt...weight 75 kg...exertional dysnea..and wheezing...since 4 month..h.o..asthma on asthalin inhaler....htn...on amlokind 5 mg since 1 yrs.....now on Investigation sugar diagnosed....ecg..and all test done....now Dysnea on exertion..increase...since 1 month... knee pain..and recurrent urination....BP.. 150..90..now..so pls sugest how can manage this case....line of medication suggest...comment also on ecg....@Dr. Dineshchandra Sharma @Dr. Shivraj Agarwal
Dr. Chand Sharwale1 Like11 Answers - Login to View the image
You can find here key changes in ADA guidelines. They are published in Diabetes Care once yearly in the month of January. GENERAL CHANGES The field of diabetes care is rapidly changing as new research, technology, and treatments that can improve the health and well-being of people with diabetes continue to emerge. With annual updates since 1989, the ADA has long been a leader in producing guidelines that capture the most current state of the field. To that end, the “Standards of Medical Care in Diabetes” now includes a dedicated section on Diabetes Technology, which contains preexisting material that was previously in other sections that has been consolidated, as well as new recommendations. SECTION 1. IMPROVING CARE AND PROMOTING HEALTH IN POPULATIONS Additional information was included on the financial costs of diabetes to individuals and society. Because telemedicine is a growing field that may increase access to care for patients with diabetes, discussion was added on its use to facilitate remote delivery of health-related services and clinical information. SECTION 2. CLASSIFICATION AND DIAGNOSIS OF DIABETES Based on new data, the criteria for the diagnosis of diabetes was changed to include two abnormal test results from the same sample (i.e., fasting plasma glucose and A1C from same sample). The section was reorganized to improve flow and reduce redundancy. Additional conditions were identified that may affect A1C test accuracy including the postpartum period. SECTION 3. PREVENTION OR DELAY OF TYPE 2 DIABETES This section was moved and is now located before the Lifestyle Management section to better reflect the progression of type 2 diabetes. The nutrition section was updated to highlight the importance of weight loss for those at high risk for developing type 2 diabetes who have overweight or obesity. Because smoking may increase the risk of type 2 diabetes, a section on tobacco use and cessation was added. SECTION 4. COMPREHENSIVE MEDICAL EVALUATION AND ASSESSMENT OF COMORBIDITIES On the basis of a new consensus report on diabetes and language, new text was added to guide health care professionals’ use of language to communicate about diabetes with people with diabetes and professional audiences in an informative, empowering, and educational style. A new figure from the ADA-European Association for the Study of Diabetes (EASD) consensus report about the diabetes care decision cycle was added to emphasize the need for ongoing assessment and shared decision making to achieve the goals of health care and avoid clinical inertia. A new recommendation was added to explicitly call out the importance of the diabetes care team and to list the professionals that make up the team. A recommendation was added to include the 10-year atherosclerotic cardiovascular disease (ASCVD) risk as part of overall risk assessment. The fatty liver disease section was revised to include updated text and a new recommendation regarding when to test for liver disease. SECTION 5. LIFESTYLE MANAGEMENT Evidence continues to suggest that there is NOT an ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes. Therefore, more discussion was added about the importance of macronutrient distribution based on an individualized assessment of current eating patterns, preferences, and metabolic goals. Additional considerations were added to the eating patterns, macronutrient distribution, and meal planning sections to better identify candidates for meal plans, specifically for low-carbohydrate eating patterns and people who are pregnant or lactating, who have or are at risk for disordered eating, who have renal disease, and who are taking sodium–glucose cotransporter 2 inhibitors. There is NOT a one-size-fits-all eating pattern for individuals with diabetes, and meal planning should be individualized. A recommendation was modified to encourage people with diabetes to decrease consumption of both sugar sweetened and nonnutritive-sweetened beverages and use other alternatives, with an emphasis on water intake. The sodium consumption recommendation was modified to eliminate the further restriction that was potentially indicated for those with both diabetes and hypertension. Additional discussion was added to the physical activity section to include the benefit of a variety of leisure-time physical activities and flexibility and balance exercises. The discussion about e-cigarettes was expanded to include more on public perception and how their use to aide smoking cessation was not more effective than “usual care.” SECTION 6. GLYCEMIC TARGETS This section now begins with a discussion of A1C tests to highlight the centrality of A1C testing in glycemic management. To emphasize that the risks and benefits of glycemic targets can change as diabetes progresses and patients age, a recommendation was added to reevaluate glycemic targets over time. The section was modified to align with the living Standards updates made in April 2018 regarding the consensus definition of hypoglycemia. SECTION 7. DIABETES TECHNOLOGY This new section includes new recommendations, the self-monitoring of blood glucose section formerly included in Section 6 “Glycemic Targets,” and a discussion of insulin delivery devices, blood glucose meters, continuous glucose monitors (real-time and intermittently scanned, and automated insulin delivery devices. The recommendation to use self-monitoring of blood glucose in people who are not using insulin was changed to acknowledge that routine glucose monitoring is of limited additional clinical benefit in this population. SECTION 8. OBESITY MANAGEMENT FOR THE TREATMENT OF TYPE 2 DIABETES A recommendation was modified to acknowledge the benefits of tracking weight, activity, etc., in the context of achieving and maintaining a healthy weight. A brief section was added on medical devices for weight loss, which are not currently recommended due to limited data in people with diabetes. The recommendations for metabolic surgery were modified to align with recent guidelines, citing the importance of considering comorbidities beyond diabetes when contemplating the appropriateness of metabolic surgery for a given patient. SECTION 9. PHARMACOLOGIC APPROACHES TO GLYCEMIC TREATMENT The section on the pharmacologic treatment of type 2 diabetes was significantly changed to align, as per the living Standards update in October 2018, with the ADA-EASD consensus report on this topic. This includes consideration of key patient factors: (a) important comorbidities such as ASCVD, CKD, and HF, (b) hypoglycemia risk, (c) effects on body weight, (d) side effects, (e) costs, and (f) patient preferences. To align with the ADA-EASD consensus report, the approach to injectable medication therapy was revised. A recommendation that, for most patients who need the greater efficacy of an injectable medication, a GLP-1 agonist should be the first choice, ahead of insulin. A new section was added on insulin injection technique, emphasizing the importance of technique for appropriate insulin dosing and the avoidance of complications (lipodystrophy, etc.). The section on non-insulin pharmacologic treatments for DM1 was abbreviated, as these are not generally recommended. SECTION 10. CARDIOVASCULAR DISEASE AND RISK MANAGEMENT For the first time, this section is endorsed by the American College of Cardiology. Additional text was added to acknowledge heart failure as an important type of cardiovascular disease in people with diabetes for consideration when determining optimal diabetes care. The blood pressure recommendations were modified to emphasize the importance of individualization of targets based on cardiovascular risk. A discussion of the appropriate use of the ASCVD risk calculator was included, and recommendations were modified to include assessment of 10-year ASCVD risk as part of overall risk assessment and in determining optimal treatment approaches. The recommendation and text regarding the use of aspirin in primary prevention was updated with new data. For alignment with the ADA-EASD consensus report, two recommendations were added for the use of medications that have proven cardiovascular benefit in people with ASCVD, with and without heart failure. SECTION 11. MICROVASCULAR COMPLICATIONS AND FOOT CARE To align with the ADA-EASD consensus report, a recommendation was added for people with type 2 diabetes and chronic kidney disease to consider agents with proven benefit with regard to renal outcomes. The recommendation on the use of telemedicine in retinal screening was modified to acknowledge the utility of this approach, so long as appropriate referrals are made for a comprehensive eye examination. Gabapentin was added to the list of agents to be considered for the treatment of neuropathic pain in people with diabetes based on data on efficacy and the potential for cost savings. The gastroparesis section includes a discussion of a few additional treatment modalities. The recommendation for patients with diabetes to have their feet inspected at every visit was modified to only include those at high risk for ulceration. Annual examinations remain recommended for everyone. SECTION 12. OLDER ADULTS A new section and recommendation on lifestyle management was added to address the unique nutritional and physical activity needs and considerations for older adults. Within the pharmacologic therapy discussion, de-intensification of insulin regimes was introduced to help simplify insulin regimen to match individual’s self-management abilities. SECTION 13. CHILDREN AND ADOLESCENTS Introductory language was added to the beginning of this section reminding the reader that the epidemiology, pathophysiology, developmental considerations, and response to therapy in pediatric-onset diabetes are different from adult diabetes, and that there are also differences in recommended care for children and adolescents with type 1 as opposed to type 2 diabetes. A recommendation was added to emphasize the need for disordered eating screening in youth with type 1 diabetes beginning at 10–12 years of age. Based on new evidence, a recommendation was added discouraging e-cigarette use in youth. The discussion of type 2 diabetes in children and adolescents was significantly expanded, with new recommendations in a number of areas, including screening and diagnosis, lifestyle management, pharmacologic management, and transition of care to adult providers. New sections and/or recommendations for type 2 diabetes in children and adolescents were added for glycemic targets, metabolic surgery, nephropathy, neuropathy, retinopathy, nonalcoholic fatty liver disease, obstructive sleep apnea, polycystic ovary syndrome, cardiovascular disease, dyslipidemia, cardiac function testing, and psychosocial factors. SECTION 14. MANAGEMENT OF DIABETES IN PREGNANCY Women with preexisting diabetes are now recommended to have their care managed in a multidisciplinary clinic to improve diabetes and pregnancy outcomes. Greater emphasis has been placed on the use of insulin as the preferred medication for treating hyperglycemia in gestational diabetes mellitus as it does not cross the placenta to a measurable extent and how metformin and glyburide should not be used as first-line agents as both cross the placenta to the fetus. SECTION 15. DIABETES CARE IN THE HOSPITAL Because of their ability to improve hospital readmission rates and cost of care, a new recommendation was added calling for providers to consider consulting with a specialized diabetes or glucose management team where possible when caring for hospitalized patients with diabetes. SECTION 16. DIABETES ADVOCACY The “Insulin Access and Affordability Working Group: Conclusions and Recommendations” ADA statement was added to this section. Published in 2018, this statement compiled public information and convened a series of meetings with stakeholders throughout the insulin supply chain to learn how each entity affects the cost of insulin for the consumer, an important topic for the ADA and people living with diabetes.
Dr. Peerzada Ovais Ahmad6 Likes7 Answers - Login to View the image
I have a 45 yrs old patient who is a known T2 diabetic of 3 yrs duration. He is a marketing manager, who has a erratic eating pattern and a hectic roaming field work He is very content with my treatment because just last month,he has achieved good glycemic control with a HbA1c of 6.52 % , FBS 96 mg/dl , PPBS 128 mg/dl. He has no other comorbid conditions or any complications. He is neither a hypertensive nor hypothyroid. His Medication includes DAONIL 5mg 1 tablet Before breakfast, VOGLIBOSE .3 mg 1 tablet three times before meals . Today at around 230 PM, He called me very agitated on my mobile to say that he has not been feeling well since 2 hrs. He was complaining that he has been feeling weak, giddy, heart beating faster and some trembling of hands. He doubted this situation to be an episode of hypoglycaemia and confirmed with his glucometer reading at 62 mg/dl. He took his lunch one hour early comprising 2 rotis and potato curry but still has been having the same troublesome symptoms. What do you think I should have suggested him on the phone to relieve him of his hypoglycaemia immediately as he cannot come to your clinic at that moment ?
Dr. Chakradhar Nannapaneni7 Likes19 Answers - Login to View the image
36 /m c/of oral pain and loose teeth since 1year. H/O loosing 4 teeth spontaneously within 6 months. C/0 increased thirst, polyuria. Dehydration +. S.E ..revealed hypernateraemia. Diagnosis? .
Dr. Mrs Husna Shahzad9 Likes28 Answers - Login to View the image
spot the diagnosis a pt.of uncontrolled DM type 2, suddenly developed skin lesions
Dr. V.k. Goyal4 Likes18 Answers
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