Absolute benefits of empagliflozin in type 2 diabetes: a game changer?

The modes of action and clinical implications of several of the newest classes of antidiabetic drugs used as monotherapy and as add-on therapy have been extensively reviewed in recent publications.1 2 Sodium-glucose cotransporter 2 (SGLT-2) inhibitors (eg, empagliflozin) belong to one such novel class and act via interference with proximal renal tubular reabsorption of glucose; about 90% of such reabsorption depends on this cotransporter. They therefore reduce blood glucose concentrations, promote weight reduction and lower blood pressure through glycosuria and osmotic diuresis. Moreover, since their activity is independent of insulin, they are efficacious even in the presence of pancreatic beta cell failure, which is in marked contrast to many other antidiabetic drugs. Furthermore, polyuria and polydipsia are uncommon. Gliptins (eg, saxagliptin) form another new class of oral antidiabetic agents that reduce glucagon secretion but promote insulin release by interfering with the degradation of incretins (intestinal hormones produced in response to ingested meals), and are generally well tolerated. Glucagon-like-peptide 1 (GLP1) receptor agonists (eg, exenatide) are incretin mimetics that constitute yet another class of new antidiabetics and, together with SGLT2 inhibitors, are the only antidiabetic drugs that have a favourable weight loss effect. Subcutaneous administration and gastrointestinal side effects are distinct disadvantages. In contrast to many other antidiabetic agents, treatments with drugs in these three classes and metformin confer a lower risk of hypoglycaemia.