Dose Makes the Poison Protection: Several critical protective endpoints look to be strongly dose-dependent in canagliflozin
By Alicia Downs RN MSN CDCES BC-ADM
In a recent post hoc analysis of the double blind CANVAS studies investigating safety and both cardiovascular and renal outcomes of 4330 participants with type 2 diabetes and at least 2 known risk factors for cardiovascular disease or a known CVD diagnosis.
A surprising finding is that a 72-month (6 years) follow-up showed significant differences between 300mg and 100mg doses of canagliflozin.
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This is of note because patients often ask whether they would benefit from starting on a low dose of a medication for a prophylactic benefit rather than its main indication.
For example, it is common practice for people who have had type 1 diabetes for >10 years who are >35 to start on a low dose of an ACE inhibitor like Lisinopril for its demonstrated prophylactic renal benefits (ACE inhibitors and diabetic nephropathy: How they help and more).
However, this data indicates that low-dose use of canagliflozin (and until we get more data on more SGLT2 molecules, we tend to extrapolate these findings out to cover the class at large) may not provide the anticipated prophylactic effect.
Because we do not have an FDA indication for any SGLT2 medication for type 1 diabetes, it is recommended that patients seeking payor coverage for these medications seek dual diagnosis for both types 1 and 2 diabetes. (This is a specific area of specialty for me, and I encourage anyone struggling with their insurance or prescribers in this area to contact our office to schedule a consultation for an individualized appeals plan).
It is also good to note that payers may not be willing to cover the higher dose if patients are not demonstrating a clinical need (in terms of glycemic variability or elevation). However, risk reduction may become grounds for medical necessity for coverage depending on one’s individual risk profile.
It is also important, as with all medications, to discuss your personal risk profile with your prescriber to determine whether the reduction of risks and benefits to using an SGLT2 medication would be worth the potential risks, and if the higher dosage is right for you.
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