Medicine Matters diabetes

What does DAPA-CKD add to what we knew from CREDENCE?

I think it's confirming the ability of this class of drug in terms of cardio and renal protection, really. Although, there is another trial that doesn't seem to see the same with one or the other as yet, too; we will have to learn from that.

Anyway, going back to the DAPA-CKD. It clearly shows us that these drugs work. The population studies in these two trials are too similar. Maybe some more microalbuminuric in the DAPA-CKD.

But clearly, what I would define as outstanding results for all of us and for the patients because these drugs might become extremely important and possibly position differently in the algorithm that we follow to treat patients with diabetes. I mean, with metformin or possibly before metformin.

Is the positive effect of dapagliflozin in people without diabetes important news for diabetologists, or only for nephrologists?

The nephrologists will get very excited. It was sort of expected by diabetologists because the fact that we see cardio or renal protection is quite rapid and nothing that we would expect in, say, that's driven by the improvement of glycemic control. So there is some independent mechanism that is driven by these drugs and clearly works in patients without diabetes.

There were different pathologies-- IgA nephropathy, focal segmental glomerulosclerosis, hypertensive nephropathy. And we'll have to learn more of the specific mechanisms that are activated or driven by SGLT2 antagonists in delaying the progression of this disease in a non-diabetic setting, if I may.

So it's evidence-based medicine, so it wakes up the nephrologists in clinic-- shall I use this drug? And when do I use it? And how it works exactly? What are the mechanism of action? That could open new avenues, new targets for other treatment. So really exciting times, I think, for renal nephrologists and the renal teams.

If the results in patients without diabetes are confirmed should there be a change in the guidelines?

There has to be because EMPA-RENAL [EMPA-KIDNEY] has been looking at the wider population with also a much broader spectrum of GFRs, remember. And I think already today we can actually-- these drugs do protect your heart and your kidney. They just should be used, period. They're really-- that effect conferred, elicited in the diabetic population is dramatic. And we should be using them more and more, I believe.

Importantly, I think there is, again, a reassurance on the amputations care. There was reason by a study on canagliflozin which was confirmed that in CREDENCE and now with DAPA we don't see that sort of predisposition to more amputation in a diabetic foot, and et cetera. So that is a reassurance these are pretty much safe drugs.

And I think if you look at DAPA with the recent DAPA-HF-- a fantastic study. I think. they really work so well, and dramatic effect on heart failure. And so cardiologists are all excited, as well. And nephrologists should also be excited now because these are drugs that cover really a broad spectrum of disease, which are affecting most-- not all, but most of the diabetic population, and also non-diabetic population. If you remember that heart failure data is also in patients without diabetes. So again, important class of drug.

A bit more data on that mechanism of action there in terms of fluids and interstitium and secreting volume is improved we preserved with the SGLT2, so better perfusion. Maybe it's true also for the kidney, who knows. But a dramatic and important effect.

More to learn, and really it is an interesting diuretic I would say. It is a diuretic. And it has this incredible beneficial effect on the cardiovascular renal system.