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from the blood. The drug decreases glucose reabsorption by approximately 50 percent, which increases the amount of glucose that enters the urine, according to David M. Nathan, MD, Director of the Diabetes Center at Massachusetts General Hospital in Boston. "This is essentially like putting a spigot for glucose in your kidney," Dr. Nathan says. "You are kind of tapping o" or draining o" the glucose into the urine, which does have a modest e" ect on lowering blood glucose levels and long-term measures of glycemia, like the hemoglobin A1C assay. It's like a diuretic for glucose, but when you put more glucose in the urine — and this happens in people with diabetes out of control — it draws with it water and electrolytes, like sodium and potassium, and so it depletes people of volume and some electrolytes." Why empaglifl ozin reduces cardiovas- cular disease morbidity and mortality is unclear. In the EMPA-REG OUTCOME trial, the drug did not reduce rates of nonfatal heart attack or nonfatal stroke, avenues of exploration for the future, according to experts. LIMITED IMPACT? The FDA approved empaglif lozin for T y p e 2 d i a b e t e s i n 2 014 a nd , l a s t December, authorized its indication to reduce the risk of cardiovascular death for diabetes patients who have cardio- vascular disease. Dr. Nathan says it is important for clinicians to remember empaglifl ozin has proved e¬ cacious in a specifi c subset of diabetes patients. "Based on the EMPA-REG OUTCOME trial and the previous studies that went along with it, empaglifl ozin hasn't been shown to lower [cardiovascular] compli- cations in most people with diabetes," he says. "I would reserve this drug for people with Type 2 diabetes who have already had a heart attack or stroke and may need some extra lowering of their glucose because they're not hitting their goa ls. That is the population the tria l suggests will benefi t." ■ which led the researchers to conclude that the lower rate of cardiovascular death was responsible for the 14 percent reduction in the primary endpoint. According to one of the trial's investigators, David Fitchett, MD, a cardiologist at St. Michael's Hospital in Toronto and Associate Professor of Medicine at the University of Toronto, that factor, along with a decrease in car- diovascular disease mortality that the investigators observed within the first one to two months of the trial, likely means the mechanism of benefi t is unrelated to a decrease in atherosclerosis. "It is more likely that empaglif lozin reduces cardiovascular mortality through the prevention of heart failure or its complications, either as a result of reduced loading or a metabolic process," he says. Pinpointing why the drug has a posi- tive e" ect on cardiovascular morbidity and mortality, as well as investigating its potential e¬ cacy in reducing risk of heart failure and complications of diabe- tes, such as nerve disease, are important Beyond Cardiovascular Benefi ts Data from the EMPA-REG OUTCOME trial demonstrate empaglifl ozin improves kidney outcomes for individuals with Type 2 diabetes and cardiovascular disease. The rate of new or worsening kidney disease for patients who received empaglifl ozin was 39 percent less than for those who took a placebo. Empaglifl ozin also reduced patients' need for dialysis or other kidney replacement therapy by 55 percent. M D N E W S . C O M /// M D N E W S C L E V E L A N D /A K R O N / C A N T O N ■ M AY/J U N E 2 017 1 5