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Effects of Sotagliflozin Added to Insulin in Patients with Type 1 Diabetes

Garg SK, Henry RR, Banks P, Buse JB, Davies MJ, et al.

N Engl J Med. 2017 Sep 13. doi: 10.1056/NEJMoa1708337.

Editorial comment by Vivian Fonseca

Achieving optimal glycemic control in type 1 diabetes remains challenging despite advances in insulins, pumps CGM etc. It is particularly hard to reduce variability in blood glucose from day to day with frequent high and low blood glucose causing patients a lot of distress. The application of knowledge gained from treating type 2 diabetes with new drugs may help alleviate these problems.

SGLT2 inhibitors are approved for treating type 2 diabetes and lower glucose by increasing glycosuria and work independent of insulin secretion / action etc., thus raising the possibility of using the drugs in type 1 diabetes. Small clinical trials have previously demonstrated a benefit with this class. Sotagliflozin is a new drug in this class that also inhibits SGLT1, which is present in the kidney and also the gut. It could therefore increase glycosuria further and decrease glucose absorption in the gut as well – both independent of insulin.

This large clinical trial demonstrates a beneficial effect of the drug in improving glucose control and getting more patients’ A1c below 7 % than with insulin alone. Further addition of the drug led to weight loss and a decrease in blood pressure (both known effects of the class), as well as reduction in hypoglycemia (perhaps due to less insulin use). Thus, the benefits appear very promising. There was, however, an increase in keto acidosis – a problem previously recognized with this class, and some caution is needed with this possible side effect as it may not be always recognized.

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