Diabetes Research Centre, University of Leicester, Leicester, UK.
Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
Diabetes Obes Metab. 2022 Nov;24(11):2071-2080. doi: 10.1111/dom.14805. Epub 2022 Aug 4.
Sodium-glucose cotransporter-2 (SGLT2) inhibitors are now seen as an integral part of therapy in type 2 diabetes to control not only blood glucose but to improve cardiovascular and kidney outcomes. Diabetic ketoacidosis (DKA) is an uncommon but serious complication of type 2 diabetes, which has a high case fatality rate. The absolute risk of DKA in large, prospective randomized clinical trials in people with type 2 diabetes using SGLT2 inhibitors has been low, although the relative risk is higher in those assigned to SGLT2 inhibitors compared with placebo. In those without diabetes but prescribed SGLT2 inhibitors for heart failure or chronic kidney disease, the risk of DKA is similar to placebo. Over the course of the COVID-19 pandemic, cases of DKA have also been reported in cases of COVID-19 hospitalizations. Consensus guidelines have recommended that SGLT2 inhibitors should be avoided in cases of serious illness and suggest they are not recommended for routine in-hospital use. However, recent data suggest potential beneficial effects of SGLT2 inhibitors in the setting of acute illness with COVID-19 with no increase in adverse events and low rates of DKA, which were non-severe. Given the low rates of DKA in cardiovascular outcome trials and in hospitalized patients with type 2 diabetes, the potential for SGLT2 inhibitors not being re-initiated following discharge and their cardiovascular and kidney benefits, we believe the practice of routine 'sick day' guidance should be re-examined based on current evidence with a call for further research in this area. Furthermore, high-quality trials of initiation of SGLT2 inhibitors in people admitted to hospital with cardiovascular disease or kidney disease, and trials of continuation of SGLT2 inhibitors in people, with careful monitoring of DKA should be conducted. These should be further supplemented with large observational studies.
钠-葡萄糖共转运蛋白 2（SGLT2）抑制剂现在被视为 2 型糖尿病治疗的一个组成部分，不仅可以控制血糖，还可以改善心血管和肾脏结局。糖尿病酮症酸中毒（DKA）是 2 型糖尿病一种不常见但严重的并发症，其病死率很高。在使用 SGLT2 抑制剂的 2 型糖尿病大型前瞻性随机临床试验中，DKA 的绝对风险较低，尽管与安慰剂相比，接受 SGLT2 抑制剂治疗的患者相对风险较高。在没有糖尿病但因心力衰竭或慢性肾病而开 SGLT2 抑制剂的患者中，DKA 的风险与安慰剂相似。在 COVID-19 大流行期间，也有 COVID-19 住院患者发生 DKA 的报道。共识指南建议在严重疾病的情况下避免使用 SGLT2 抑制剂，并建议不在常规住院使用。然而，最近的数据表明，在 COVID-19 急性疾病中，SGLT2 抑制剂可能具有潜在的有益作用，不会增加不良事件，且 DKA 发生率较低，且非严重。鉴于心血管结局试验和 2 型糖尿病住院患者中 DKA 的发生率较低，以及 SGLT2 抑制剂在出院后可能不再重新开始使用的潜在益处及其心血管和肾脏益处，我们认为应根据当前证据重新审查常规“不适日”指导的实践，并呼吁在该领域开展进一步研究。此外，应在仔细监测 DKA 的情况下，开展 SGLT2 抑制剂在患有心血管疾病或肾脏疾病的住院患者中的起始以及在患有 DKA 的患者中的 SGLT2 抑制剂的继续使用的高质量试验，这些试验还应进一步辅以大型观察性研究。
