I read the article last night. As you said – absolutely HUGE, but I will bet you that not very many people understand the significance of it.
There were several interesting points – the A1C difference was quite small 0.3.
“Even though investigators were encouraged to adjust glucose-lowering therapy according to local guidelines, many patients did not reach their glycemic targets, with an adjusted mean glycated hemoglobin level at week 206 of 7.81% in the Empa group and 8.1 in placebo”.
Yet despite this, there was a massive benefit to CV risk. Why did this success where ACCORD/ ADVANCE/ VADT failed? You know it – it’s because it gets rid of the sugar in the body. The key is that SGLT2’s lower insulin, instead of raising it. It is, as you said, the drug equivalent of Low Carb diets.
Yet the authors, Zinman an endocrinologist, clearly has no freaking clue why his drug was so beneficial. He writes “we infer that the mechanisms behind the cardiovascular benefits of empagliflozin are multidimensional, and possibly involve changes in arterial stiffness, cardiac function, and cardiac oxygen demand (in the absence of sympathetic-nerve activation), as well as cardiorenal effects, reduction in albuminuria, reduction in uric acid, and established effects on hyperglycemia, weight, visceral adiposity, and blood pressure.”
In other words, he is saying “I don’t really know why this drug worked, so I’ll use a bunch of buzzwords”.
It seems perfectly obvious to me that the problem in T2D is whole body burden of sugar, not blood sugar. By getting rid of the body sugar, you see benefit even as there is minimal improvement in blood sugar. Explains exactly Big Lie #2 “Lowering Blood sugars is the goal of treatment”.
Like you, I quite expected this result. In fact, this is not the first ‘low carb in a pill’ study. You can look at the attached graph from a JAMA paper in 2003 about acarbose.
By blocking carbohydrate absorption, you see the same effect of reducing glucose into the body. There was a 2.15 Absolute Risk Reduction (ARR) in primary end point (49% Relative Risk Reduction). This is very close to the 1.6% ARR seen in the current study. This was forgotten, because the effect was thought to be a blood glucose lowering effect rather than a blood insulin lowering effect. So now there are TWO drugs that lower insulin and show huge beneficial effects.
So this confirms the hypothesis that lowering INSULIN is the main goal of treatment – best way? LCHF and IF – low carb in a pill. Beautiful.
FYI – I already use SGLT2 as first line therapy with Acarbose second for type 2 diabetes. Metformin is my 3rd choice, not my first.
Dr. Jason Fung views type 2 diabetes in a revolutionary and deceptively simple way: as an overload of sugar in the entire body, not just in the blood. This points the way to the obvious cure that conventional treatment misses (resulting in a chronic progressive disease).
The cure is to get the sugar out of the body, by any means, thus reducing the chronically abnormally high insulin of type 2 diabetes, thus reducing insulin resistance. Thus normalising everything.
An SGLT2 inhibitor that removes sugar from the body is a fantastic tool, as the latest study shows. And the second drug that Dr. Fung mentions, Acarbose, reduces the amount of sugar going into the body.
Using Metformin as a 3rd choice is exciting to me, as it’s usually the 1st choice. But “demoting it” makes perfect sense when going for a cure.
I imagine a GLT-1 agonist would be the 4th drug, if needed, when using this paradigm.
It’s the successful way to cure a disease that is still usually considered chronic and progressive. A disease that affects half a billion people. It’s a revolution.