Diabetic Amputation Research Articles

Major lower-extremity amputations in diabetes: a response to "A Canadian population-based description of the indications for lower-extremity amputations and outcomes".

After reading the report by Kayssi and colleagues[1][1] that describes the nontraumatic lower-limb amputations in Canada during the 2006–2009 period, I would like to stress the importance of population-based studies focused in disease outcomes. Despite the lack of clinically detailed information

Major lower-extremity amputations in diabetes: a response to "A Canadian population-based description of the indications for lower-extremity amputations and outcomes": Author response.

Major lower-extremity amputations in diabetes: a response to "A Canadian population-based description of the indications for lower-extremity amputations and outcomes": Author response.

Diabetic foot ulcers—comparison of performance of ankle-brachial index and transcutaneous partial oxygen pressure in predicting outcome

Diabetic foot ulcer (DFU) is the commonest condition for hospital admission and usually the starting point of most diabetic related lower limb amputations. Considering the significant role played by vascularity in the outcome of ulcer healing, we undertook this study to find out the comparative utility of commonly used vascular assessment methods. This study was a single center prospective non-randomized observational study, conducted for a period of 6 months, in diabetic patients presenting with foot ulcers of Wagner Grade II and III. The aim of our study was to compare the performances of ankle-brachial index (ABI) and transcutaneous partial pressure of oxygen (tcPO2) measurement in predicting wound healing in diabetic ulcers and to define the optimal cut-off value for Indian patients. Five hundred sixty-four patients were included in this study, with the mean age of 58 years. Eighty-seven patients (15%) had peripheral arterial occlusive disease. Four hundred seventy ulcers (83%) healed with the mean healing days of 42.6 days. Age, duration of diabetes, serum creatinine level, and presence of infection were the factors with negative impact in wound healing. In our study, ABI value of 0.6 was found to have 100% sensitivity and 70% specificity, and tcPO2 value of 22.5 was found to have 75% sensitivity and 100% specificity in predicting wound healing. Both ABI and tcPO2 are complementary, but tcPO2 is a better predictor for amputation while ABI is a better predictor for ulcer healing. While assessing the ischemic status of foot ulcer, the cut-off values should be higher in diabetics than non-diabetics.

Using data to tackle the burden of amputation in diabetes

Using data to tackle the burden of amputation in diabetes

Diabetic Foot Awareness among Diabetic Patients in Saudi Arabia

Aim of the work: diabetic foot disease(DFD) is diabetic patient's foot affection by ulcers which are accompanied by peripheral vascular disease and/or diabetic neuropathy of the lower limb. Prevalence of diabetic ulcer is ranging from 2%-10%. High rate of lower limb amputation in DFD (More than 15%) and survival rate for undertaken amputation patient are short. Ninety diabetic amputations are performed monthly in Saudi Arabia capital of Riyadh. Identification of DFD and diabetic patient's awareness of DFD and how to take care of it will reduce the incidence of more complications like amputation. This study aimed to evaluate knowledge, education, attitude and practice with diabetic foot among diabetic patients all over Saudi Arabia. Patients and Method: cross-sectional study directed among the diabetic clinic visitors in Primary Health Care Centers (PHCs s). Selection of 55 PHCs was done by random sampling. Ten diabetic patients were randomly selected from each PHCs and collecting of data was done by interviews. Research questionnaire contains three parts; first part is asking about demographic data; second part is about data that are focusing on diabetes and its related questions and last part is the main part which asking about diabetic foot. Results: 519 diabetic patients were participated in this study. Only 180 participants were complaining of diabetic complications (34.7%). Most of participants (55.1%) get high score 7-8 out of 8 questions in Knowledge. Although, there were 166 persons (32%) who couldn’t reach full score in attitude evaluation. There was a large percentage of our participants (69%) had very low score 0-2 out of 6 in assessment of previous education of diabetic foot. More than half of participants (56.5%) had score 6-10 out of 15 in evaluation of practice with diabetic foot. Conclusion: diabetic foot in Saudi Arabia is existing, even amputations and other diabetic foot complications were also present. Diabetic patients have good knowledge and attitude toward diabetic foot. Education about diabetic foot and practice is still weak.

Ghrelin attenuates vascular calcification in diabetic patients with amputation

Vascular calcification is established to be a critical factor in diabetes mellitus, which causes cardiovascular and amputation complication of diabetic patients. OPG/RANKL/RANK axis serves as a regulatory role in vascular calcification. Ghrelin, an endogenous ligand of growth hormone secretagogue receptor (GHSR), has been reported to exhibit potent cardiovascular protective effects. However, the role of ghrelin in the regulation of diabetic vascular calcification is still elusive. Here, we reported the role of ghrelin and its relationship with OPG/RANKL/RANK system in patients with diabetic foot amputation. In vivo and in vitro investigations were performed. Sixty type 2 diabetic patients with foot amputation were enrolled in vivo investigation, and they were divided into three groups through Doppler ultrasound: mild stenosis group (n=20), moderate stenosis group (n=20), and severe stenosis/occlusion group (n=20). Morphological analysis results showed diffused calcium depositions in the anterior tibial artery of diabetic amputees. Compared with the mild and moderate stenosis group, the severe stenosis/occlusion group had more spotty calcium depositions in atherosclerotic plaques. Western blot analysis indicated the expressions of osteoprotegerin (OPG) and ghrelin were downregulated, while the expression of receptor activator of nuclear factor kappa B ligand (RANKL) was upregulated with the vascular stenosis aggravation. Pearson correlation analysis revealed a negative correlation between calcium content and ghrelin levels (r=−0.58, P<0.001), as well as the ghrelin levels and sRANKL levels (r=−0.57, P<0.001). Meanwhile, OPG levels were positively correlated with ghrelin levels (r=0.63, P<0.001). From in vitro investigation, we found that the high-glucose (HG), high-lipid (HL), and β-glycerophosphate (β-GP) considerably increased the total calcium content, ALP activity, and expression of osteogenic markers in vascular smooth muscle cells (VSMCs). Ghrelin blunted calcification in a dose-dependent manner. In addition, ghrelin upregulated OPG expression and downregulated RANKL expression in VSMC calcification when anti-OPG antibody and RANKL were performed. Collectively, we therefore conclude serum ghrelin level may be a predictor of diabetic vascular calcification. The possible mechanism may be related with OPG/RANKL signal.

A study on positive impact of intensive psychological counseling on psychological well-being of type 2 diabetic patients undergoing amputation

Amputation is one of the most dreadful complications in diabetes. Diabetic amputees are at elevated risk of psychological distress due to their disability. Thus, the current study aimed to evaluate the effect of intensive counseling on psychological outcomes among type 2 diabetic patients undergoing amputation. The study was conducted among 62 consecutive patients admitted in the diabetic centre and who underwent an amputation. These patients were randomly assigned to a routine counseling group (RCG-26) and intensive counseling group (ICG-36). World Health Quality of Life (WHQOL) was administered individually to all the patients based on inclusion criteria. In the RCG group, psychological therapy was given before amputation. For patients in the ICG group, psychological therapy was given before and every day after amputation, till the day of discharge. WHQOL questionnaire scores together with the demographic details were also recorded accordingly. The finding highlighted that the overall quality of the life improves in ICG group in both BKA and Toe amputation, as compared to the RCG group. ICG has better impact on QOL than RCG in amputation patients. Thus, intensive assessment and intervention has to be included as part of routine management among patients with diabetes when they undergo a surgical amputation. Key words: Amputation, quality of life, psychological counseling, intensive counseling.

Diabetes and Poor Runoff Predict Late Major Amputation After Percutaneous Intervention for Claudication

Diabetes and Poor Runoff Predict Late Major Amputation After Percutaneous Intervention for Claudication

Major Limb Outcomes Following Lower Extremity Endovascular Revascularization in Patients With and Without Diabetes Mellitus

Purpose: To determine whether diabetes mellitus has an independent impact on major limb outcomes at 1 year after endovascular treatment of lower extremity peripheral artery disease (PAD). Methods: The study involved 1906 consecutive patients (mean age 66 years; 1469 men) enrolled in the observational Excellence in Peripheral Artery Disease (XLPAD) registry (ClinicalTrials.gov identifier NCT01904851) between January 2005 and October 2015 after undergoing index endovascular procedures in 2426 limbs for arterial occlusive disease. Patient outcomes included 12-month target limb amputation (above ankle) and target limb revascularization as well as all-cause death. Kaplan-Meier analysis and adjusted Cox proportional hazard models were used for time-to-event analysis of outcomes for the entire study sample as well as for the critical limb ischemia (CLI) and claudication subgroups. Results of the Cox regression models are reported as the hazard ratio (HR) and 95% confidence interval (CI). Results: Diabetics undergoing endovascular procedures had higher rates of comorbid conditions (p<0.001), CLI (p<0.001), heavily calcified lesions (p=0.002), multivessel disease (p=0.030), and fewer infrapopliteal runoff vessels (p<0.001). Regression analysis after adjusting for confounders revealed significantly higher target limb major amputation in diabetics compared with nondiabetics (HR 5.02, 95% CI 1.44 to 17.56, p=0.011). However, repeat revascularization rates were similar. When considering CLI and claudication subgroups, diabetes was associated with a nonsignificant increased risk of 12-month major amputation only for patients presenting with CLI (HR 3.48, 95% CI 0.97 to 12.51, p=0.056). Diabetes was also associated with an increased risk of 12-month all-cause mortality in the overall study sample (HR 4.64, 95% CI 2.01 to 10.70, p<0.001) and in the CLI subgroup (HR 14.15, 95% CI 3.16 to 63.32, p<0.001) but not in the claudication subgroup (HR 1.42, 95% CI 0.45 to 4.54, p=0.552). Conclusion: Diabetes increases the risk of major amputation and all-cause death at 12 months following endovascular revascularization in patients with symptomatic PAD. These risks are especially heightened in patients presenting with CLI.

Resource Utilization and Cost Effectiveness of Negative Pressure Wound Therapy (NPWT) Versus Moist Wound Therapy (MWT) in Management of Diabetic Foot Transmetatarsal Amputation (TMA)

To evaluate resource utilization and direct economic costs of care for patients treated with negative pressure wound therapy (NPWT) in comparison with standard moist wound therapy (MWT) for preparation of diabetic foot TMA wounds for skin grafting. We retrospectively analyzed 56 patients who underwent transmetatarsal amputation (TMA) for infected diabetic foot from January 2014 to April 2015 at Jain Institute of Vascular sciences (JIVAS), Bangalore. Twenty-eight patients received negative pressure wound therapy (NPWT) (VAC® KCI, TX, USA) dressing while 28 received standard MWT daily. Resource utilization, revascularization procedures, number of secondary procedures (debridement), and total cost for wound bed preparation were calculated in both groups. There was no significant difference in both groups regarding age, gender, comorbidities, and number of revascularization procedures. All patients were having ankle brachial index (ABI) more than 0.8 or ankle pressures more than 80 mmHg before enrolling to study group. MWT group required more debridement (15 vs. 2; P = 0.0001). Average number of dressing changes performed per patients were 25 (range 20–32) for MWT versus 3 (range 2–5) in NPWT group. MWT group had more OPD visits compare to NPWT (14 vs. 2; P value =0.0001). Mean duration for wound bed preparation was 24.61 ± 3.20 days (range 20–32 days) in MWT group and significantly higher than NPWT group 9.11 ± 2.38 days (range 6–15 days) (P = 0.0001; 95% CI difference 13.99 to 17.01). The average total cost for wound bed preparation of TMA wound was Rs 26,875 ± 6810.5 in MWT group and was significantly higher than compared to Rs 23,089.29 ± 6637.5 in NPWT group (P = 0.03; 95% CI difference 182.54 to 7388.89). NPWT resulted in lower resource utilization, reduced costs, and acceleration of wound bed preparation for diabetic foot TMA wound in comparison to standard MWT.

DEVELOPMENT AND VALIDATION OF PREDICTION MODELS WITH NON-TRADITIONAL MARKERS FOR 10-YEAR RISK OF ISCHEMIC LEG AMPUTATION AMONG PERSONS WITH DIABETES: THE ATHEROSCLEROSIS RISK IN COMMUNITIES (ARIC) STUDY

Background: The ability of non-traditional markers for predicting ischemic leg amputation in diabetes is unknown. Methods: In 3321 ARIC participants with diabetes (45-73 y during 1987-98), we identified traditional factors contributing to ischemic leg amputation (ICD code of leg amputation [84.1x]

Podiatric risk screening in patients with type 2 diabetes in Antananarivo

Le pied diabétique pèse lourdement sur la santé des diabétiques, étant responsable d’une grande morbidité et de graves incapacités. Leur prévention reste incontournable. Notre étude vise à réduire le taux d’amputation chez les diabétiques. Nous avons fait une étude rétrospective descriptive, transversale et multicentrique du dépistage du risque podologique chez les diabétiques de type 2, au service d’Endocrinologie de l’Hôpital Universitaire de Befelatanana et à la Clinique AMADIA, Faravohitra, sur une période de 6 mois. L’âge moyen de nos patients était de 54,43 ans. Le genre masculin prédominait (60%). Leur diabète évoluait, en moyenne, depuis 7,35 ans. Les antécédents les plus observés étaient le tabagisme et les ulcérations chroniques du pied. Plus de la moitié de nos patients avaient un diabète déséquilibré, une microalbuminurie et une rétinopathie. Nous avons enregistré 56,50% de patients conscients du risque mais moins de 46% donnant des exemples précis sur les conduites adaptées. Seulement 13,33% de nos patients bénéficiaient d’un examen des pieds avant la présente étude. Leur risque podologique était très élevé. Les facteurs prédictifs d’ulcération identifiée étaient le tabagisme, l’antécédent d’ulcération chronique des membres inférieurs, le mauvais équilibre du diabète et l’existence d’une déformation du pied. La stratégie de prévention efficace des amputations doit comporter le dépistage et l’identification de la population à risque d’ulcération.

Pedobarography as a clinical tool in the management of diabetic feet in New Zealand: a feasibility study

BackgroundThe peripheral complications of diabetes mellitus remain a significant risk to lower-limb morbidity. In New Zealand, risk of diabetes, comorbidity and lower-limb amputation are highly-differential between demographic groups, particularly ethnicity. There is growing and convincing evidence that the use of pedobarography – or plantar pressure measurement – can usefully inform diabetic foot care, particularly with respect to the prevention of re-ulceration among high-risk patients.MethodsFor the current feasibility study, we embedded pedobarographic measurements into three unique diabetic foot clinic settings in the New Zealand context, and collected pedobarographic data from n = 38 patients with diabetes using a platform-based (Novel Emed) and/or in-shoe-based system (Novel Pedar). Our aim was to assess the feasibility of incorporating pedobarographic testing into the clinical care of diabetic feet in New Zealand.Results and ConclusionsWe observed a high response rate and positive self-reported experience from participants. As part of our engagement with participants, we observed a high degree of lower-limb morbidity, including current ulceration and chronic foot deformities. The median time for pedobarographic testing (including study introduction and consenting) was 25 min. Despite working with a high-risk population, there were no adverse events in this study. In terms of application of pedobarography as a clinical tool in the New Zealand context, the current feasibility study leads us to believe that there are two avenues that deserve further investigation: a) the use of pedobarography to inform the design and effectiveness of offloading devices among high-risk diabetic patients; and b) the use of pedobarography as a means to increase offloading footwear and/or orthoses compliance among high-risk diabetic patients. Both of these objectives deserve further examination in New Zealand via clinical trial.

Comment on "Prevalence and Risk Factors for Diabetic Lower Limb Amputation: A Clinic-Based Case Control Study".

Comment on "Prevalence and Risk Factors for Diabetic Lower Limb Amputation: A Clinic-Based Case Control Study".

Possible consequences of regionally based bundled payments for diabetic amputations for safety net hospitals in Texas

ObjectiveOngoing health reform in the United States encourages quality-based reimbursement methods such as bundled payments for surgery. The effect of such changes on high-risk procedures is unknown, especially at safety net hospitals. This study quantified the burden of diabetes-related amputation and the potential financial effect of bundled payments at safety net hospitals in Texas. MethodsWe performed a cross-sectional analysis of diabetic amputation burden and charges using publically available data from Centers for Medicare and Medicaid and the Texas Department of Health from 2008 to 2012. Using hospital referral region (HRR)-level analysis, we categorized the proportion of safety net hospitals within each region as very low (0%-9%), low (10%-20%), average (20%-33%), and high (>33%) and compared amputation rates across regions using nonparametric tests of trend. We then used charge data to create reimbursement rates based on HRR to estimate financial losses. ResultsWe identified 51 adult hospitals as safety nets in Texas. Regions varied in the proportion of safety net hospitals from 0% in Victoria to 65% in Harlingen. Among beneficiaries aged >65, amputation rates correlated to the proportion of safety net hospitals in each region; for example, patients in the lowest quartile of safety net had a yearly rate of 300 amputations per 100,000 beneficiaries, whereas those in the highest quartile had a yearly rate of 472 per 100,000 (P = .007). Charges for diabetic amputation-related admissions varied almost 200-fold, from $5000 to $1.4 million. Using reimbursement based on HRR to estimate a bundled payment, we noted net losses would be higher at safety net vs nonsafety net hospitals ($180 million vs $163 million), representing a per-hospital loss of $1.6 million at safety nets vs $700,000 at nonsafety nets (P < .001). ConclusionsRegions with a high proportion of safety net hospitals perform almost half of the diabetic amputations in Texas. Changes to traditional payment models should account for the disproportionate burden of high-risk procedures performed by these hospitals.

Peripheral sensory neuropathy in type 2 diabetes patients: A case control study in Accra, Ghana

ObjectivePeripheral sensory neuropathy (PSN) is a common cause of ulceration and amputation in diabetes (DM) patients. The prevalence of PSN in DM patients is largely undetermined in sub-Saharan African population. We studied the burden of PSN in DM patients using a validated questionnaire and quantitative sensory test. MethodsIn a case-control design, PSN was measured in 491 DM patients and 330 non-DM controls using Michigan neuropathy screening instrument (MNSI) and vibration perception threshold (VPT). PSN was defined as MNSI symptom score ≥7, MNSI examination score ≥2 or VPT ≥25V. ResultsThe prevalence of PSN screened by MNSI symptom score, MNSI examination score and VPT was 7.1%, 51.5% and 24.5% in DM patients; and 1.5%, 24.5% and 8.5% in non-DM participants respectively. The major determinants of PSN screened by MNSI examination score were diabetes status [OR (95% CI): 4.31 (2.94–6.31), p < 0.001], age [1.03 (1.01–1.05), p < 0.001], previous [4.55 (2.11–9.82), p < 0.001] and current [8.16 (3.77–17.68), p < 0.001] smoking status. The major determinants of PSN screened by VPT were diabetes status [1.04 (1.02–1.06), p < 0.001], age [1.02 (1.01–1.03), p = 0.047], heart rate [1.78 (1.08–2.92), p = 0.023], second-hand smoking [3.66 (2.26–5.95), p < 0.001] and body height [3.28 (1.65–8.42), p = 0.015]. ConclusionOur study has shown high burden of PSN in DM patients in Ghana using simple, accurate, and non-invasive screening tools like MNSI and neurothesiometer.

Self-Efficacy in Diabetic Amputees: An Empirical Analysis

Abstract: -Self-efficacy according to Bandura (1997) is a person‟s belief in his or her ability to succeed in a particular situation. A relatively lower level of Self-efficacy can be seen in amputees as they lose a part of their body (Bosse et al., 2002) and diabetes is one of the major precursor to amputation (Viswanathan, 2007). The study investigated the effect of gender, family type and marital status on the levels of Self-efficacy in diabetic amputees. A purposive sampling method was employed to select participants belonging to the age range of 5060 years. A sample of 60 participants (30 men and 30 women) was approached through hospitals. They were administered the Chronic Disease Self-efficacy Scale developed by Lorig et al. (1996). The data was subjected to t-test. The results indicated a significant effect of gender on the level of Self-efficacy as men managed symptoms of their disease better than women. A significant effect of the family type was seen as participants living in nuclear families had more Self-efficacy to get information about the disease and also they were able to manage symptoms better than those living in joint families. Marital status had a significant effect on the Selfefficacy as married participants exercised more and managed their symptoms better than widowed participants. This study throws light on the difficulties faced by amputees and also makes diabetic patients aware of the risk factors of their disease and that they must undertake steps to prevent any further complications.

Unintended Consequences of Bundled Payments in Surgery: Disproportionate Burden of Diabetic Amputations Among Safety Net Hospitals in Texas

Unintended Consequences of Bundled Payments in Surgery: Disproportionate Burden of Diabetic Amputations Among Safety Net Hospitals in Texas

Decrease in (Major) Amputations in Diabetics: A Secondary Data Analysis by AOK Rheinland/Hamburg.

Aim. In two German regions with 11.1 million inhabitants, 6 networks for specialized treatment of DFS were implemented until 2008. Data provided for accounting purposes was analysed in order to determine changes in the rate of diabetics requiring amputations in the years before and after the implementation. Method. Data covering 2.9 million people insured by the largest insurance company between 2007 and 2013 was analysed by the use of log-linear Poisson regression adjusted for age, gender and region. Results. The rate of diabetics needing major amputations fell significantly by 9.5% per year (p < 0.0001) from 217 to 126 of 100,000 patients per year. The rate of diabetics needing amputations of any kind fell from 504 to 419 of 100,000 patients per year (p = 0.0038). Discussion. The networks integrate health care providers in an organised system of shared care. They educate members of the medical community and the general public. At the same time, a more general disease management program for people with diabetes was implemented, which may also have contributed to this decrease. At the end of the observation period, the rate of diabetics requiring amputations was still high. For this reason, further expansion of organised specialized care is urgently needed.

Cardiovascular Safety of Current and Emerging Glucose-Lowering Therapies.

Cardiovascular disease (CVD) remains the most common major comorbidity in patients with diabetes. Individual short-term studies have failed to show that glycemic control over the short term does not have an impact on CVD. However, until recently, it remained uncertain whether the choice of glycemic drug has a beneficial impact on CVD outcomes. A small study suggesting CVD benefit has resulted in the primacy of metformin for glycemic control. Multiplemeta-analyses of studies with sulphonylurea agents have shown either no CVD benefit or potential harm. Despite the common use of insulin and the potential for both cardiovascular and noncardiovascular harm, only 1 study examining the impact of insulin on cardiovascular outcomes, the Outcome Reduction with Initial Glargine Intervention (ORIGIN) trial, has been undertaken, and the outcome was neutral. The thiazolidinediones (TZDs) have heterogeneous effects; pioglitazone shows potential cardiac benefit and rosiglizone shows possible harm. After a well-publicized meta-analysis of rosiglitazone studies showed potential harm, the US Food and Drug Administration (FDA) issued safety requirements prior to the licensing of new glycemic medications. Since these requirements were instituted, more than 18 studies have been initiated to study dipeptidyl peptidase-4 (DPP4) inhibitors, glucagon-like peptide-1 (GLP-1) agonists and sodium-glucose co-transporter type 2 (SGLT-2) inhibitors. The completed DPP4 and GLP-1 trials meet the safety criteria without improved CVD outcomes. In contrast, the first CVD outcome trial of an SGLT-2 inhibitor, the Empagliflozin Cardiovascular Outcome Event (EMPA-REG) Outcomes trial showed that empagliflozin, in a population of patients with type 2 diabetes and established CVD, reduced CV death and all-cause mortality by 38% and 32%, respectively, and hospitalization for heart failure by 39% in patients with established CVD already treated with metformin. Future guidelines are likely to recommend empagliflozin for patients with type 2 diabetes and CVD. Diabetes confers a substantial risk for the development of atherosclerotic CVD. The life expectancy of a patient with diabetes is 5 to 10 years shorter than that of a person without diabetes (1), largely as a result of the earlier development of coronary heart disease (2). Over the lifetime of a patient with diabetes, there is a greater than 75% chance of developing cardiovascular disease (3), and most patients with diabetes will die as a consequence of CVD. Peripheral vascular disease is common in patients with diabetes, and diabetes is the most common cause for limb amputation. Although patients with diabetes fear blindness, dialysis and amputation, they have a very much greater chance of dying from CVD than suffering one of the feared consequences of diabetes. The risk for CVD increases with the degree of dysglycemia. Both the level of fasting blood glucose and the glucose level after a standard glucose load correlate with the incidence of CVD events (4). The levels of glycated hemoglobin (A1C) predict the incidence of myocardial infarction and mortality (5). However, there is a closer relationship between A1C levels and the development of microvascular events such as nephropathy and retinopathy than is observed for macrovascular CVD events. Over the past 20 years, there has been a marked increase in the number of agents available for glycemic control. Thirty years ago, insulin, first-generation sulphonylureas and phenformin were the only agents available. Subsequently, metformin, glucosidase inhibitors, thiazolidinediones, meglitinides, GLP 1 agonists, DPP4 antagonists and sodium-glucose cotransporter-2 (SGLT2) antagonists have expanded the range of agents for glycemic control. Until recently there was no controlled safety or efficacy data to show whether individual agents had properties beyond glycemic control that were either harmful or beneficial. * St Michael’s Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario M4V 1W5, Canada. E-mail address: fitchettd@smh.ca Can J Diabetes 39 (2015) S176–S182