Memorandum
This week’s issue of JAMA featured a reprint of a Medical Letter review of J&J’s Invokamet (canagliflozin/metformin) and AZ’s Xigduo XR (dapagliflozin/metformin XR) fixed-dose combinations (FDCs). The summary described the two component SGLT-2 inhibitors as relatively similar, with two main differences: (i) Xigduo XR allows for once daily dosing compared to twice daily dosing with Invokamet, and (ii) there was an imbalance in bladder cancer seen in AZ’s dapagliflozin’s clinical development program but not J&J’s canagliflozin’s. The review highlights SGLT-2 inhibitors’ weight, hypoglycemia, and convenience benefits and states that they have no efficacy advantage other second-line drugs for type 2 diabetes – some prescribers might perceive a slight edge over DPP-4 inhibitors based on a few clinical trials. From our view, it’s very surprising to hear “oh, except for weight and hypoglcyemia, there’s NO difference – we all know that weight is associated with cardiovascular disease and that severe hypoglycemia is associated with the emergency room in the worst case scenario. To hear “oh whatever” is insulting to patients and HCPs. An editorial in this week’s Lancet Diabetes & Endocrinology highlighted FDCs as a means to improve adherence (as well as simplify distribution and cut costs in the developing world) though a related article highlighted the proliferation of poor-quality diabetes FDCs in India (so let’s get rid of the poor quality drugs rather than use them as a cautionary tone). Other highlights from this week’s JAMA included a Senate Committee’s report on expanding the use of generics and a systematic review showing improvements in mortality with blood pressure lowering in type 2 diabetes patients with baseline blood pressures >140 mm Hg. This is certainly a far cry from back in the day when Close Concerns began (2002) when there were one or two pieces a year on diabetes in JAMA and the NEJM. Onward!