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European Endocrinology Highlights infection as an adverse event (6.4% versus 1.8%) but no increase in other adverse events. 6 The reported risk reduction was most likely multifactorial and not related only to glycaemic effects, since the difference in event rates occurred early during the study and glycaemic control was comparable in all study groups. SGLT-2 inhibitors may elicit vascular effects and may change renal as well as cardiac regulatory functions in water, electrolyte and blood pressure regulation. Albuminuria and uric acid as established surrogate parameters for cardiovascular risk were also reduced in the empagliflozin- treated patients. Other still unknown potentially beneficial effects of SGLT-2 inhibitors may also contribute to the study results. Do these findings now make it necessary to change diabetes treatment and guidelines immediately? Certainly, studies showing a significant beneficial effect on cardiovascular outcomes with antidiabetic agents are scarce and comparable studies with dipeptidyl-peptidase-4 inhibitors (DPP-4 inhibitors) have only shown non-inferiority versus standard care, but not superiority as the EMPA-REG OUTCOME trial. The results of the EMPA-REG OUTCOME study were achieved in a cohort with long-standing diabetes and cardiovascular disease and may not be 1. 2. 54 Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). UK Prospective Diabetes Study (UKPDS) Group, Lancet, 1998;352:854–65 Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group, Lancet, 1998;352:837–53 3. 4. 5. automatically generalised for patients with new onset type  2 diabetes before having developed concomitant vascular complications. Here, metformin is still standard and has proved to be advantageous. The long-term effects of SGLT-2 inhibitors and empagliflozin over >10  years are still unknown and have to be established in comparison to classic antidiabetic drugs. Adverse events and safety characteristics are of utmost importance in medications for chronic diseases. In this respect, the rare reports on ketoacidotic metabolic disturbances that have been associated with the use of SGLT-2 inhibitors have to be taken into account as well. The respective cardiovascular safety study results with the other available SGLT-2 inhibitors canagliflozin and dapagliflozin have also to be completed in order to confirm these data and in order to have a broader picture of the action of the drug class of SGLT-2 inhibitors. At present, there is an indication to treat patients with type 2 diabetes and a similar cardiovascular risk profile as seen in the study population of the EMPA-REG Outcome trial with empagliflozin. In addition, there are now stimulating and positive data to explore the action of SGLT-2 inhibitors further in order to explain the findings of the EMPA-REG Outcome study in more detail and in mechanistic pathophysiological models. This may help to evolve the drug class further and may help to identify patient groups that have a specifically high benefit from such a therapy. 7 ■ Inzucchi SE, Bergenstal RM, Buse JB, et al., Management of hyperglycemia in type 2 diabetes, 2015: a patient-centered approach: update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes, Diabetes Care, 2015;38:140–9 American Diabetes Association, Standards of Medical Care in Diabetes - 2016, Diabetes Care, 2016;39(Suppl. 1). Whalen K, Miller S, Onge ES, The role of sodium-glucose 6. 7. co-transporter 2 inhibitors in the treatment of type 2 diabetes, Clin Ther, 2015;37:1150–66. Zinman B, Wanner C, Lachin JM, et al.; EMPA-REG OUTCOME Investigators, Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes, N Engl J Med, 2015;373:2117–28. Ingelfinger JR, Rosen CJ, Cardiovascular risk and sodium– glucose cotransporter 2 Inhibition in type 2 diabetes, N Engl J Med, 2015;373:2178–9. US E ND OCRINOLOG Y