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Kathryn Wheeler, PharmD, BCPS, is assistant clinical professor of pharmacy practice, University of Connecticut School of Pharmacy, Storrs, Conn.

Articles

The FDA granted priority review for this drug due to the longstanding need for a treatment strategy that could improve upon the standard of care.

Novel Therapy Is Approved for Myasthenia Gravis

Adolescents often are at higher risk of unwanted pregnancy, unsafe abortion, and sexually transmitted infections due to the inadequate knowledge of protective practices.

Community Pharmacies Are Safe, Accessible Locations for Adolescent Reproductive Health Care

A phase 2 trial found RDX-002 significantly lowered triglycerides and reduced weight regain in patients who had recently stopped GLP-1 therapy.

Novel Therapy Could Help Patients Keep Weight Off After Stopping GLP-1s

At the Total Pharmacy Solutions Summit Summer 2025 event, Stephanie Zimmerman, Tom Napolitano, and Luke Gunderson discussed the benefits of Real Value Rx.

How Flexible Dosing Medications Can Help Your Pharmacy Thrive

Drug Topics connects pharmacists across retail, health system, and specialty practice with clinical updates, pharmacy trends, and regulatory news.

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This episode introduces the hosts and explores key legal issues facing independent pharmacies, including PBM terminations and state board compliance. 

Pharmacy Law Lowdown: Getting to Know the Hosts, Mid-Year Updates

Dae Lee, PharmD, Esq, CPBS and Lucas Morgan, Esq, discuss PBM and board of pharmacy enforcement actions, trends in PBM audits, and more.

Pharmacy Law Lowdown: PBM Audit Trends, Enforcement Actions

journal explores issues within pharmacy, from the impact advocacy can have in community pharmacies to staffing shortages across multiple sectors within pharmacy. This month’s issue also explored the importance of disease awareness months and how they are opportunities to maximize valued care. Check out a preview of this month’s issue here.

download the PDF of the Total Pharmacy August 2024 issue here

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 and get the latest drug information, industry trends, and patient care tips delivered straight to your inbox.

See what’s trending in pharmacy with a preview of the Total Pharmacy August issue.

Total Pharmacy

In This Issue: Total Pharmacy August 2024

Combining sodium glucose co-transporter 2 inhibitors (SGLT2is) with glucagon-like peptide-1 receptor agonists (GLP-1RAs) may offer additional protection against cardiovascular and kidney disease in patients with type 2 diabetes (T2D), according to the results of a new meta-analysis published in 

 and presented at the 61st European Renal Association Congress in Stockholm, Sweden.

Separately, SGLT2is and GLP-1RAs have demonstrated cardiovascular benefits. However, little clinical literature has focused on outcomes associated with using the medicines together. Due to the growing prevalence of GLP-1RAs in the 

 and obesity landscape, accelerated by an increasing number of indications for the agent class, this is a crucial area for further study.

The SGLT2 Inhibitor Meta-analysis Cardio-Renal Trialists’ Consortium (SMART-C) is the largest assessment of outcomes for the combined therapeutic use of SGLT2is and GLP-1RAs. The study gathered data from 12 large-scale, placebo-controlled trials of SGLT2is involving 73,238 patients with diabetes. Of these, 3065 were already receiving GLP-1RAs.

Overall, SGLT2is lowered the risk of major adverse cardiovascular events by 11% and hospitalization for heart failure or cardiovascular death by 23% compared to placebo. Notably, this benefit was seen regardless of whether patients were also taking GLP-1RAs.

When used together with GLP-1RAs, SGLT2is reduced the risk of chronic kidney disease progression by 33% and slowed the annual loss of kidney function by nearly 60%.

The study found no additional safety concerns when SGLT2is were used in combination with GLP-1RAs.

Study Reveals Robust Benefits of Semaglutide in Protecting Against Kidney, CV Events in Patients With T2D

Current meta-analysis results build off positive results of the landmark FLOW trial (

). Published earlier in May, results of the international, double-blind, randomized, placebo-controlled phase 3 trial spotlighted semaglutide’s effectiveness in lowering the risk of kidney failure, decelerating worsening kidney function, and protecting against the risk of cardiovascular events and death, in patients with T2D.

“SGLT2 inhibitors have clear protective effects against heart failure and chronic kidney disease, while GLP-1 receptor agonists can reduce the risk of heart attack, stroke, and also kidney disease—as recently demonstrated in the landmark FLOW trial,” said Brendon Neuen, lead author, clinical associate professor, senior research fellow at The George Institute for Global Health, and director of kidney trials at Sydney’s Royal North Shore Hospital, in a news release.

 “Our findings support using this combination to further improve outcomes in patients with type 2 diabetes who meet guideline recommendations for both therapies.”

Elevated glucose from diabetes can damage blood vessels in the heart and kidneys, increasing the risk of 

 and kidney disease. In fact, diabetes is the most common cause of chronic kidney disease.

Moreover, estimates predicting that T2D prevalence will more than double in the next 30 years, surpassing 1 billion global cases by 2050, further strengthen the need for research into diabetes care.

 According to Neuen in an interview with 

 conducted over email, the current study offers valuable insights for developing global treatment strategies for the condition.

"These findings, which represent the largest and most comprehensive evaluation of the combined use of SGLT2i and GLP-1RA, provides the clearest evidence yet that combined use of both medicines can further reduce cardiovascular and kidney disease," said Neuen. "We anticipate that these findings will inform how people with diabetes are treated worldwide, including influencing major clinical practice guidelines.

Although current results suggest that using SGLT2is and GLP-1RAs in tandem may offer robust protection against cardiovascular and kidney disease, further research is needed to fully understand the long-term effects of the combination therapy.

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1. Apperloo E, Neuen BL et al. Efficacy and safety of sodium glucose co-transporter 2 inhibitors with and without glucagon-like peptide-1 receptor agonists: A SMART-C collaborative meta-analysis of randomised controlled trials. 

. 2024. doi: 10.1016/S2213-8587(24)00183-9

2. Massaro L. Study reveals robust benefits of semaglutide in protecting against kidney, CV events in patients with T2D. 

https://www.drugtopics.com/view/study-reveals-robust-benefits-of-semaglutide-in-protecting-against-kidney-cv-events-in-patients-with-t2d

3. Combining popular diabetes drugs offers complementary heart and kidney benefits. News release. The George Institute for Global Health. July 9, 2024. Accessed July 10, 2024. 

https://www.georgeinstitute.org/media-releases/combining-popular-diabetes-drugs-offers-complementary-heart-and-kidney-benefits

4. Mayo Clinic Staff. Chronic kidney disease. Fact sheet. Accessed July 8, 2024. 

https://www.mayoclinic.org/diseases-conditions/chronic-kidney-disease/symptoms-causes/syc-20354521

5. Klein HE. Diabetes prevalence expected to double globally by 2050. 

https://www.ajmc.com/view/diabetes-prevalence-expected-to-double-globally-by-2050

When used together, sodium glucose co-transporter 2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) were able to lower the risk of major adverse cardiovascular events and kidney disease by 11% and 33%, respectively.

Clinical

SGLT2i, GLP-1RA Combination Therapy Offers Robust Protection Against Cardiovascular, Kidney Disease

Examining the Differential Diagnosis of Hypercortisolism

This video segment discusses hypercortisolism, a condition characterized by excessive cortisol production in the body. The discussion covers the differential diagnosis, emphasizing that hypercortisolism exists on a spectrum from overt Cushing syndrome with classic symptoms to a more common "hidden" form lacking typical physical signs like purple striae, buffalo hump, and easy bruising. The condition can be challenging to identify, particularly in its subtle presentations.

The causes of hypercortisolism fall into 3 main categories. First, exogenous corticosteroid use represents the most common cause and includes oral steroids for conditions like asthma or arthritis, inhaled steroids, topical creams, or injections. Second, endogenous overproduction involves Cushing disease (60%-70% of cases), caused by benign pituitary adenomas that overproduce adrenocorticotropic hormone, leading to excessive cortisol production by the adrenal glands. Additional causes include adrenal sources (20%-30% of cases), ectopic Cushing syndrome from nonpituitary tumors, and pseudo Cushing syndrome, where cortisol levels are mildly elevated due to chronic conditions like obesity, metabolic syndrome, uncontrolled diabetes, or chronic stress.

Early detection is crucial because chronic cortisol elevation affects multiple body systems and can lead to severe complications. Key impacts include resistant hyperglycemia, diabetes complications with associated inflammation, severe hypertension, and diabetic nephropathy. The condition also increases cardiovascular risk, which compounds existing risks in patients with diabetes, hypertension, and dyslipidemia. Additional complications include osteoporosis and psychiatric conditions. Since hypercortisolism is potentially treatable, early identification allows for prompt intervention that can normalize cortisol levels and provide significant health benefits, reducing the risk of serious long-term complications and mortality. 

Panelists discuss how hypercortisolism represents a spectrum from overt Cushing syndrome to hidden forms that lack classic physical signs, with causes including exogenous corticosteroid use, endogenous overproduction from pituitary adenomas or adrenal sources, ectopic tumors, and pseudo Cushing syndrome, emphasizing that early detection is crucial because chronic cortisol elevation can lead to severe complications including resistant diabetes, hypertension, cardiovascular disease, osteoporosis, and psychiatric conditions that significantly impact morbidity and mortality if left untreated.

Video Series

Although sodium-glucose cotransporter 2 inhibitors (SGLT2i)–induced erythrocytosis is prevalent, investigators found it was not associated with thrombotic risk, according to results of a study published in 

“In our study, treatment with SGLT2is was associated with a mean increase of 0.35 and 0.37 g/dL in hemoglobin and a 1.4% and 1.5% increase in hematocrit compared with DPP-4is and GLP-1RAs, respectively,” the study authors said.

 “The rise in hemoglobin was slightly lower than in previous randomized clinical trials and observational studies that reported an increase in hemoglobin, ranging between 0.5 and 1.0 g/dL.”

SGLT2i include canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin, which are approved to treat type 2 diabetes by improving blood sugar. The drugs can prevent reabsorption of filtered glucose from the tubular lumen. Although FDA-approved indications include glycemic control, reduction of major adverse cardiovascular events, and reduction in risk of cardiovascular hospitalization and death for patients with heart failure, off-label uses include management of obesity in combination with glucagon-like peptide-1 (GLP-1) and metabolic dysfunction–associated steatotic liver disease.

One of the risks of SGLT2i has been an increase in hematocrit levels, ranging from 2.3% to 3.5% in clinical trials, according to data from a case series published in 

 This rise raises concerns about an elevated risk of thrombotic events; however, the investigators noted that current guidelines and recommendations do not address the concern.

Investigators of the study aimed to determine the prevalence, risk factors, and temporal trends of SGLT2i-induced erythrocytosis as well as erythrocytosis associated with an increased risk of arterial and venous thrombosis. Investigators included patients who initiated SGLT2i or a comparator, including GLP-1s or dipeptidyl peptidase 4 inhibitors (DPP-4i). Patients were 18 years and older with type 2 diabetes and participated from January 1, 2015, through June 30, 2024.

Investigators included 2 cohorts: 68,776 pairs of individuals receiving either DPP-4i or SGLT2i and 65,756 pairs of those receiving GLP-1s or SGLT2i. Before treatment initiation for the SGLT2i and DPP-4i groups, the prevalence of erythrocytosis was 6.7% and 5.6%, respectively, rising to 12.1% in the SGLT2i group and decreasing to 3.5% in the DPP-4i group. Investigators found similar trends for stricter erythrocytosis criteria. As for the SGLT2i and GLP-1 groups, before treatment, the incidence of erythrocytosis was 6.1% and 6.3%, respectively. After treatment, the SGLT2i group had an increase to 11.9%, and the GLP-1 group had a decrease to 5.1%.

For thrombotic risk, investigators said that new-onset erythrocytosis was not associated with an increased risk of myocardial infarction, venous thromboembolism, or stroke when evaluating strict criteria. For more lenient criteria, investigators noted that erythrocytosis was associated with a reduced risk of stroke. For all events in the Kaplan-Meier analysis, there was no difference in risk for those treated with SGLT2i and those who were not.

The hemoglobin levels for the SGLT2i group compared with the DPP-4i group were 13.37 g/dL at baseline to 13.72 g/dL 1 year after treatment and 13.28 g/dL to 13.09 g/dL, respectively. For SGLT2i and GLP-1, hemoglobin levels were 13.36 g/dL to 13.72 g/dL and 13.38 g/dL to 13.37 g/dL, respectively. As for hematocrit levels, SGLT2i had an increase from 41.07% to 42.49% at 1 year of treatment when compared with DPP-4i, and from 41.02% to 42.52% when compared with GLP-1s.

“In our study, SGLT2i-induced erythrocytosis was not associated with an increased risk of arterial or venous thrombosis. These findings strengthen the limited existing literature that previously explored the association between SGLT2i-induced erythrocytosis and thrombotic events,” the study authors concluded.

 “Interestingly, at lower erythrocytosis thresholds, as defined in our study using the lenient criteria, there was even a reduction in the risk of stroke.”

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1. Lewis M, Burrack N, Heymann A, Grossman A, Neuman T, Abuhasira R. Sodium-glucose cotransporter 2 inhibitors, erythrocytosis, and thrombosis in adults with type 2 diabetes. 

. 2025;8(6):e2517086. doi:10.1001/jamanetworkopen.2025.17086

2. Padda IS, Mahtani AU, Parmar M. Sodium-glucose transport protein 2 (SGLT2) inhibitors. In: 

. StatPearls Publishing; 2025-. Updated June 3, 2023. Accessed August 14, 2025. https://www.ncbi.nlm.nih.gov/books/NBK576405/

3. Verissimo D, Pereira BR, Vinhais J, Ivo C, et al. SGLT-2 inhibitors-induced erythrocytosis: a case series. 

. 2024;99EP426. doi:10.1530/endoabs.99.EP426

Investigators also report that sodium-glucose cotransporter 2 inhibitors are not associated with thrombotic risk.

Results Show SGLT2 Inhibitors Are Associated With Erythrocytosis

Due to events stemming from the COVID-19 pandemic, community pharmacists have since been touted as the most convenient and accessible health care providers for patients seeking immunization. In a world where patients mostly went to physicians for their immunization needs, community pharmacies have become the ideal destination for receiving vaccinations.

“Community pharmacies are open on weekends, late in the evening,” said Hashim Zaibak, PharmD, CEO of Hayat Pharmacy. “It's a lot more convenient for people who are busy to come and get the vaccine in a community pharmacy vs getting it in a clinic or by appointment.”

Zaibak founded Hayat Pharmacy in 2011 and operates 19 pharmacy locations across southeastern Wisconsin. Throughout the pandemic, Hayat Pharmacy administered over 100,000 COVID-19 vaccines and has since been administering a variety of immunizations to its community.

To better understand how Hayat’s immunization services have evolved since the pandemic, Zaibak joined 

to discuss the sheer convenience of community pharmacies and how these locations have stepped up to boost vaccine uptake.

Pharmacists Help Emphasize Importance of Immunizations for Patients

: What is the importance of immunization as a whole and how have community pharmacists particularly been able to step in and manage patients’ vaccinations?

When it comes to vaccination, it is definitely one of the most effective ways to reduce infectious disease in a community, whether it is COVID, [influenza, or] meningitis. It's obviously scientifically proved to be effective. When it comes to community pharmacy, it is the most accessible location to get a vaccination.

You can walk into a community pharmacy and get vaccinated 7 days a week. You don't have to make an appointment. Community pharmacies are open on weekends [and] late in the evening. It's a lot more convenient for people who are busy to come and get the vaccine in a community pharmacy vs getting it in a clinic or by appointment.

: As an independent community pharmacy, how have your vaccination services changed since the COVID-19 pandemic compared with before?

Before the pandemic, it was mainly the flu vaccine. More than 90% of the vaccines we administered before the pandemic were influenza vaccines. Randomly, we would [administer] other vaccines. People thought, ‘Oh, I need to go to the doctor to get my vaccines.’ But with the pandemic, people recognized that pharmacists are truly the most accessible health care providers [and] that pharmacists are easy to talk to.

In this location..., we gave over 100,000 COVID-19 vaccines in this building. People started to recognize that pharmacists can vaccinate and administer other vaccines. Now we get requests for a lot of different [ones].

People can come and get vaccines at our pharmacy 7 days a week, and they can vaccinate their children and...parents. It's a lot more convenient, and I think that convenience will make it easier for us to reach people that normally we don't reach because of how busy people are. The more convenient it is, the more likely people are going to get vaccinated.

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 and get the latest drug information, industry trends, and patient care tips delivered straight to your inbox.

Hashim Zaibak, PharmD, CEO of Hayat Pharmacy, discussed how immunization services at his pharmacy locations have evolved since the COVID-19 pandemic. 

Q&A: Community Pharmacies Help Increase Immunization Convenience, Uptake

Community pharmacies show potential in the early detection of cognitive decline; however, implementation remains limited due to consistency and feasibility. In an article published in 

, the study authors stated that early detection would be beneficial for individuals with limited internet and social media use, irregular sleep patterns, and lower education levels.

“[Community pharmacies are] the ideal setting for detecting and initiating the first management of SCD [subjective memory complaint],” the authors wrote.

Community pharmacies emerge as key players in early cognitive decline detection, offering vital screening tools and support for at-risk patients.

Lucas Morgan, Esq

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