F1000Research F1000Research 2046-1402 F1000 Research Limited London, UK 10.12688/f1000research.158805.1 Research Article Articles Comparison of the severity of urinary tract infections between Metformin and SGL2 Inhibitors among Iraqi Type 2 Diabetics.

[version 1; peer review: 1 not approved]

 Hussien Diana Noori Conceptualization Data Curation Formal Analysis Investigation Methodology Project Administration Resources Software Validation Visualization Writing – Original Draft Preparation https://orcid.org/0009-0003-7970-9038 a 1 Ali Samara Mowafaq Conceptualization Data Curation Investigation Methodology Project Administration Resources Supervision Writing – Review & Editing https://orcid.org/0000-0001-7105-6966 1 Department of Pharmacology and Toxicology, College of Medicine, University of Baghdad, Baghdad, Baghdad Governorate, 10045, Iraq diana.abd2206m@comed.uobaghdad.edu.iq

No competing interests were disclosed.

 21 11 2024 2024 13 1397 11 11 2024 Copyright: © 2024 Hussien DN and Ali SM 2024 This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background

Many antidiabetic medications with distinct modes of action are available, The sodium glucose cotransporter-2 (SGLT-2) inhibitors are among the most recent oral antihyperglycemic medications. The American Diabetes Association recommends metformin, a biguanide medication, as the first option for oral control of type 2 diabetes because it has demonstrated promise in this regard.

 Aim of the study

To evaluate and compare the effects of metformin and SGLT-2 inhibitors on general urine parameters in T2DM patients from Iraq.

 Method

a prospective cohort study where 101 adult patients of both sexes aged under 70 years and newly diagnosed with T2DM, patients were divided into two groups, Metformin group (n=52), where metformin was prescribed as monotherapy by the clinician and SGLT-2 inhibitors group (n=49) where either dapagliflozin or empagliflozin were prescribed by the clinician, general urine examination was done for each patient in the first contact and after 12 weeks of treatment.

 Results

The mean age was 57±9 years for the metformin group and 54±9 years for the SGLT-2 inhibitors group. There was no significant difference in leukocytes, erythrocytes, or epithelial cell counts between the metformin group and the SGLT2 inhibitor group before and after 12 weeks of treatment. There was a significant difference (p-value =0.043) in leukocytes and a non-significant difference in erythrocytes and epithelial cell counts before and after treatment in the SGLT-2 inhibitors group.

 Conclusions

Diabetic patients on SGLT-2 inhibitors treatment demonstrated higher leukocyte count than metformin group patients, an indicator and predictor for higher susceptibility to urinary tract infections.

 Urinary Tract Infection Metformin SGLT-2 inhibitors diabetes mellitus. The author(s) declared that no grants were involved in supporting this work. Introduction

Diabetes mellitus type 2 (T2DM) is linked to a high rate of death and morbidity, and it may harm the patient’s cardiovascular, renal, and neurological systems. 1 One of the main risk factors for type 2 diabetes is a family history of the disease. It is characterized by gradual dysfunction of β-cells; numerous studies have employed C peptide levels as a biomarker of β-cell function. 2 Patients with coronary artery disease have more health issues as a result of insulin resistance, which is the primary cause of type 2 diabetes. 3 Diabetes mellitus type 2 frequently results in diabetic nephropathy. Urine and plasma contain neutrophil gelatinase-associated lipocalin (NGAL), which is detectable beginning two to four hours following a kidney injury. When GFR decreased, serum NGAL rose noticeably. Regarding type 2 diabetes mellitus, serum NGAL may be a prognostic sign for the early identification of diabetic nephropathy. 4 In the general population, diabetes mellitus type II (DM) is one of the main causes of osteoporosis. 5 Longer diabetes duration was associated with a higher risk of UTI rather than glycemic control (HbA1C). Women receiving pharmaceutical treatment for diabetes were primarily at higher risk, indicating a correlation between the severity of diabetes and UTI risk. The most frequently isolated organism in all women, including young women, was E. coli. 6 Among female diabetics with problems of neuropathy, nephropathy, and retinopathy, the prevalence of asymptomatic pyuria has increased. As diabetic microangiopathy worsens, the prevalence of asymptomatic pyuria rises with the increasing period of having diabetes. 7 Medication and lifestyle modifications are two methods for treating type 2 diabetes. The American Diabetes Association 8 recommends that the biguanide medication metformin be used as the primary option for oral therapy of type 2 diabetes because it has demonstrated promise. Weight loss, vascular protection, and glucose metabolism are all positively impacted by metformin. 9 Patients with type 2 diabetes (T2DM) may have considerable differences in their glycemic control and adiposity indicators due to a variety of factors, including metformin dosages and treatment adherence. Elevating the metformin dose did not correlate with body fat percentage or insulin resistance. 10 Dapagliflozin is a popular oral antidiabetic medication that selectively and reversibly inhibits the sodium-glucose co-transporter-2 (SGLT-2). It increases urine glucose excretion, which can dramatically reduce hyperglycemia without affecting the function of the pancreatic β cell. Compared to the control group, dapagliflozin improves hemoglobin concentration and corrects anemia in patients with heart failure and CKD. 11 SGLT-2 inhibitors provide bacteria with a substrate to feed on since they increase the amount of glucose in the urinary system. As a result, they have already been connected to genitourinary tract infections. 12 The current study aims to evaluate and compare the effects of metformin and SGLT-2 inhibitors on general urine parameters in T2DM patients from Iraq.

 Methods Study design

In a prospective study where 101 adult patients of both sexes aged under 70 years and newly diagnosed with T2DM based on the International Expert Committee criteria, 13 patients were recruited and called weekly from a single private clinician record who gave informed consent to access the weekly patient archives for 2 months. The recruited patients were then divided into two groups: the Metformin group (n=52), where metformin was prescribed as monotherapy by the clinician, and the SGLT-2 inhibitors group (n=49) where either dapagliflozin or empagliflozin were prescribed by the clinician, Each patient was invited to a private laboratory where sociodemographic data (age, education level, social status, and smoking status) and clinical data were collected during the face-to-face interviews with the patients. A microscopic general urine examination was then done for each patient on their first contact and after 12 weeks of treatment.

 Study settings

The study was conducted in cooperation with a single private internist clinic and a single private laboratory in Baghdad, Iraq. The patients were recruited and did their first general urine examination in the period between the 1 st of January 2023 and the 1 st of March 2023, All patients underwent their second test before the 1 st of May 2023, and all patients and other private parties provided their written and informed consent to participate in the study.

 Participants

Inclusion criteria

Adult Patients of both sexes aged under 70 years old, newly diagnosed with T2DM, 13 taking either metformin monotherapy or SGLT-2 inhibitors (Dapagliflozin or Empagliflozin).

Exclusion criteria

Patients who refused to participate in the study, patients with ongoing acute or chronic kidney diseases, and patients with ongoing urinary tract infections.

 Analytic procedures

Each patient was provided 15-30 ml of clean-catch midstream urine, the urine specimen was then prepared and examined under the High Power Field of the light microscope (Olympus BX51 Microscope, Olympus Corporation ®, Japan) to count the cells and provide the result of cellular microscopic examination.

 Outcome measures

Each patient underwent two microscopic general urine examinations separated by 12 weeks of continuous diabetes treatment, data on the Erythrocyte count, Leukocyte count, and epithelial cell count was then obtained in the Cell/HPF unit to evaluate and compare the effect of both metformin and SGLT-2 inhibitors on these urinary parameters.

 Sample size estimation

Each eligible patient completed the research tool in writing and completed the consent form. The following formula was utilized to determine the sample size 14 : n = Z 1 − α 2 2 σ 2 d 2

In this case, d indicates the precision of the quantitative variable estimate, n is the sample size, α is the first type, Z is the table-based normal distribution index that is taken into account at 5% type-one error (P<0.05), and σ stands for the small variable variance. 15 A first type error in this study has values of 0.05, 96.3, 7.38, and 0.99, correspondingly for z, σ, and d. XXX were taken into consideration as the sample size and were included in the data analysis after accounting for the 10% non-response. 16 For every region in the nation, a sample size of XXX was determined with a design effect of 2, 80% statistical power with a two-sided test, and α = 0.05 to detect a 10% decrease. It was assumed that 30% of people had an irregular legal status at time 1 (the current study) and 20% at time 2 (the subsequent study round). 17

Ethical considerations

The study was approved by the Institutional Review Board (IRB) in the College of Medicine/University of Baghdad (Approval no. 03-11 on 31 st of December 2023), the ethical approval for the current study was uploaded to the Zenodo: Ethical approval and reporting guidelines. https://doi.org/10.5281/zenodo.14037291. 18

This project contains the following file: (Ethical approval.jpg).

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

 Statistical analysis

The obtained data were entered, coded, displayed, and examined using a computer utilizing the IBM SPSS-29 statistical package (IBM Statistical Packages for Social Sciences, version 29, Chicago, IL, USA) that was made accessible as a database software program. Simple metrics of frequency, percentage, mean, standard deviation, and range (minimum-maximum values) were used to present the data. 19 The Students-t test was used to determine the significance of the difference between two independent means (quantitative data). When evaluating the significance of differences in percentages (qualitative data), the Pearson Chi-square test (χ 2-test) was employed, along with Yate’s adjustment or the Fisher Exact test if necessary. The P value was considered statistically significant if it was equal to or less than 0.05. 20

Results Sociodemographic and clinical characteristics of the participants

The study included 101 patients with type 2 diabetes mellitus; 52 were receiving metformin, and 49 were receiving either dapagliflozin or empagliflozin. The mean age of the patients was 57±9 for metformin and 54±9 for SGLT2 inhibitors; 63.5% were illiterate, 94.2% of the metformin group and 93.9% of SGLT2 inhibitor group were married, 78.8% of the metformin group and 81.6% of SGLT2 inhibitor group were non-smokers, and 53.8% of metformin group and 57.1% of SGLT2 inhibitor group were hypertensive ( Table 1).

Sociodemographic and clinical characteristics of the participants.
Metformin SGLT-2 inhibitors P value
No % No %
Age (years) <40 years 2 3.8 5 10.2 0.397
40---49 8 15.4 11 22.4
50---59 23 44.2 22 44.9
60---69 14 26.9 9 18.4
≥70years 5 9.6 2 4.1
Mean±SD (Range) 57±9 (39-76) 54±9 (30-75) 0.097
Gender Male 15 28.8 16 32.7 0.678
Female 37 71.2 33 67.3
Marital status Married 49 94.2 46 93.9 0.940
Single 3 5.8 3 6.1
Education Primary & Secondary 36 69.2 33 67.3 0.839
Illiterate 16 30.8 16 32.7
Smoking Smoker 11 21.2 9 18.4 0.725
Not smoker 41 78.8 40 81.6
Hypertension Hypertensive 28 53.8 28 57.1 0.739
Not 24 46.2 21 42.9

Significant difference between percentages using Pearson Chi-square test (χ 2-test) at 0.05 level.

Significant difference between two independent means using Students-t-test at 0.05 level.

There was no significant difference (p-value > 0.05) in leukocytes, erythrocytes, or epithelial cell counts before and after treatment between the metformin group and the SGLT2 inhibitor group, as shown in Table 2.

General urine exam results before and after three months of treatment for both groups.
Metformin SGLT-2 Inhibitors P value MetxSGL2 first visit P value MetxSGL2 After 12 w
First visit After 12 w First visit After 12 w
No % No % No % No %
Test Positive 2 3.8 1 1.9 3 6.1 5 10.2 0.598 0.078
Negative 50 96.2 51 98.1 46 93.9 44 89.8
P value 0.558 0.461
Leukocytes (HPF) 1---2 12 23.1 9 17.3 3 6.1 9 18.4 0.196 0.252
3---4 21 40.4 35 67.3 26 53.1 28 57.1
5---6 9 17.3 4 7.7 9 18.4 4 8.2
7---8 8 15.4 3 5.8 8 16.3 3 6.1
9---10 2 3.8 1 1.9 3 6.1 5 10.2
P value 0.076 0.026 *
Erythrocytes (HPF) Absent 3 5.8 3 5.8 1 2.0 3 6.1 0.663 0.630
1---2 45 86.5 43 82.7 41 83.7 41 83.7
3---4 3 5.8 5 9.6 4 8.2 2 4.1
5---6 - - 1 1.9 1 2.0 2 4.1
7---8 - - - - 1 2.0 - -
9---10 1 1.9 - - 1 2.0 1 2.0
P value 0.637 0.700
Epithelial cells (HPF) Absent 2 3.8 1 1.9 2 4.1 1 2.0 0.875 0.583
Few 29 55.8 41 78.8 28 57.1 34 69.4
[+] 17 32.7 8 15.4 14 28.6 8 16.3
[++] 4 7.7 2 3.8 4 8.2 5 10.2
[+++] - - - - 1 2.0 1 2.0
P value 0.098 0.616

Significant difference between percentages using Pearson Chi-square test (χ 2-test) at 0.05 level.

There was no significant difference (p-value>0.05) in leukocytes, erythrocytes, or epithelial cell counts before and after treatment in the metformin group, as shown in Table 3.

General urine exam results before and after three months of treatment for the metformin group.
Metformin First visit After 12 weeks P value
No % No %
Test Positive 2 3.8 1 1.9 0.558
Negative 50 96.2 51 98.1
Leukocytes (HPF) 1---2 12 23.1 9 17.3 0.076
3---4 21 40.4 35 67.3
5---6 9 17.3 4 7.7
7---8 8 15.4 3 5.8
9---10 2 3.8 1 1.9
Erythrocytes (HPF) Absent 3 5.8 3 5.8 0.637
1---2 45 86.5 43 82.7
3---4 3 5.8 5 9.6
5---6 - - 1 1.9
7---8 - - - -
9---10 1 1.9 - -
Epithelial cells (HPF) Absent 2 3.8 1 1.9 0.098
Few 29 55.8 41 78.8
[+] 17 32.7 8 15.4
[++] 4 7.7 2 3.8
[+++] - - - -

Significant difference between percentages using Pearson Chi-square test (χ 2-test) at 0.05 level.

There was a significant difference (p-value = 0.026) in leukocytes and a non-significant difference in erythrocytes and epithelial cell counts before and after treatment in the SGLT2 inhibitor group ( Table 4).

General urine exam results before and after three months of treatment for the SGLT2 inhibitor group.
SGLT-2 Inhibitors First visit After 12 weeks P value
No % No %
Test Positive 3 6.1 5 10.2 0.461
Negative 46 93.9 44 89.8
Leukocytes (HPF) 1---2 3 6.1 9 18.4 0.026 *
3---4 26 53.1 28 57.1
5---6 9 18.4 4 8.2
7---8 8 16.3 3 6.1
9---10 3 6.1 5 10.2
Erythrocytes (HPF) Absent 1 2.0 3 6.1 0.700
1---2 41 83.7 41 83.7
3---4 4 8.2 2 4.1
5---6 1 2.0 2 4.1
7---8 1 2.0 - -
9---10 1 2.0 1 2.0
Epithelial cells (HPF) Absent 2 4.1 1 2.0 0.616
Few 28 57.1 34 69.4
[+] 14 28.6 8 16.3
[++] 4 8.2 5 10.2
[+++] 1 2.0 1 2.0

Significant difference between percentages using Pearson Chi-square test (c2-test) at 0.05 level.

There was a significant difference (p-value = 0.043) in leukocytes and a non-significant difference in erythrocytes and epithelial cell counts before and after treatment in the dapagliflozin group, as shown in Table 5.

general urine exam results before and after three months of treatment for the dapagliflozin group.
Oral hypoglycemic drug: Dapagliflozin SGLT-2 INHIBITORS First Visit After 12 weeks P value
No % No %
Test Positive 1 4.0 3 12.0 0.297
Negative 24 96.0 22 88.0
Leukocytes (HPF) 1---2 1 4.0 5 20.0 0.043 *
3---4 13 52.0 14 56.0
5---6 4 16.0 3 12.0
7---8 6 24.0 - -
9---10 1 4.0 3 12.0
Erythrocytes (HPF) Absent 1 4.0 - - 0.798
1---2 19 76.0 20 80.0
3---4 2 8.0 2 8.0
5---6 1 4.0 2 8.0
7---8 1 4.0 - -
9---10 1 4.0 1 4.0
Epithelial cells (HPF) Absent 1 4.0 - - 0.138
Few 11 44.0 18 72.0
[+] 11 44.0 4 16.0
[++] 2 8.0 2 8.0
[+++] - - 1 4.0

Significant difference between percentages using Pearson Chi-square test (χ 2-test) at 0.05 level.

There was no significant difference (p-value> 0.05) in leukocytes, erythrocytes, or epithelial cell counts before and after treatment in the empagliflozin group, as shown in Table 6.

general urine exam results before and after three months of treatment for the empagliflozin group.
Oral hypoglycemic drug: Empagliflozin SGLT-2 INHIBITORS First Visit After 12 weeks P value
No % No %
Test Positive 2 8.3 2 8.3 -
Negative 22 91.7 22 91.7
Leukocytes (HPF) 1---2 2 8.3 8 33.3 0.144
3---4 13 54.2 10 41.7
5---6 5 20.8 1 4.2
7---8 2 8.3 3 12.5
9---10 2 8.3 2 8.3
Erythrocytes (HPF) Absent - - 3 12.5 0.081
1---2 22 91.7 21 87.5
3---4 2 8.3 - -
5---6 - - - -
7---8 - - - -
9---10 - - - -
Epithelial cells (HPF) Absent 1 4.2 1 4.2 0.849
Few 17 70.8 16 66.7
[+] 3 12.5 4 16.7
[++] 2 8.3 3 12.5
[+++] 1 4.2 - -

Significant difference between percentages using Pearson Chi-square test (χ 2-test) at 0.05 level.

 Discussion

Our study’s findings show that the metformin group and the SGLT2 inhibitor group did not significantly differ in their counts of leukocytes, erythrocytes, or epithelial cells before or after treatment, as shown in Table 2. In comparison to other antidiabetic medications, the use of SGLT2 inhibitors is not linked to an increased incidence of UTIs, according to the findings of a study conducted by Wajd Alkabbani in 2022 to evaluate the risk of UTIs related to SGLT2 inhibitors in type 2 diabetes. 21 Additionally, Table 3 shows no statistically significant difference in the metformin group’s counts of leukocytes, erythrocytes, or epithelial cells before and after treatment. In a study published in 2022, Fu-Shun Yen compared the morbidity and mortality linked to sepsis and UTI in patients with diabetes between metformin users and nonusers. The findings indicated that among patients with type 2 diabetes, metformin use was not significantly associated with a lower risk of sepsis, recurrent UTI, or UTI. Compared to metformin nonuse, it was linked to a decreased risk of death from a UTI or sepsis. 22 In contrast, the SGLT2 inhibitor group’s data revealed a non-significant change in the numbers of erythrocytes and epithelial cells before and after treatment but a significant difference in leukocytes ( Tables 4, 5). According to research by Zhigui Zheng, they were published in 2023, dapagliflozin 10 mg/day for a treatment period longer than 24 weeks was associated with a significantly higher risk of urinary tract infection (UTI) than placebo or other active treatments. As a result, patients with type 2 diabetes mellitus should carefully consider the risk of UTI before beginning high-dose, long-term dapagliflozin therapy or adding it on top of existing treatment. 23 However, when one of the four SGLT2 inhibitors—dapagliflozin, canagliflozin, empagliflozin, and ipragliflozin is used in a meta-analysis study to estimate the association between the use of these drugs and the risk of UTI, the results indicate that dapagliflozin appears to independently increase the risk of UTI, though the mechanism underlying this intra-class variation in risk is unclear. 24 Another study conducted in 2013 by Kristina M. Johnsson revealed a small increase in the incidence of urinary tract infection when type 2 diabetes is treated with once-daily dapagliflozin 5 or 10 mg. Most infections were mild to severe and controlled clinically. 25 Our findings about empagliflozin indicated that there was no discernible change in the counts of leukocytes, erythrocytes, or epithelial cells in the group receiving therapy before and after the medication (see Table 6). According to the results of a study conducted in 2024 by Cristina Rebordosa, patients with type 2 diabetes who started taking empagliflozin compared to those who started taking a dipeptidyl peptidase-4 (DPP-4) inhibitor had higher risks of DKA and GI and lower risks of ALI, AKI, CKD, and severe UTI complications when using empagliflozin. 26 However, results from a study conducted in 2021 by Arbinda Pokhare on type 2 diabetes patients using empagliflozin revealed that UTIs (17.8%), nasopharyngitis (11.9%), and hypoglycemia (10.71%) were the most often reported side effects of the medication. 27 According to Chunmei Xu’s study, SGLT2i was found to have comparable anti-hyperglycemic efficacy to metformin monotherapy, including reducing blood glucose and HbA1c without significantly raising the incidence of UTIs. It also significantly reduced cardiovascular risk factors. However, a study by Mustafa Tanriverdi 28 revealed that glucosuria and SGLT-2i use predicted UTI in T2D patients. It also suggested that urine culture is crucial when determining the kind and mode of administration of antibacterial treatment, particularly for patients on SGLT-2i treatment. 29 In contrast to individuals on non-SGLT2 inhibitors, patients taking dapagliflozin and empagliflozin had a higher incidence of UTIs, according to a study by Uitracul. Furthermore, when treated with SGLT2 inhibitors, patients who were older and female had a considerably higher incidence of UTI, but patients who had permanent jobs had a reduced risk. 30 Among 17 trials evaluating dapagliflozin, 499 events suggestive of UTIs were recorded in 7145 participants (raw event rate 7.0%). A meta-analysis of these trials revealed that, in comparison to the control, dapagliflozin was linked to an increased risk of events that could be indicative of UTIs. 31 Furthermore, SGLT2 inhibitor-induced glucosuria probably contributes to an increased risk of genital infections and urinary tract infections to a lesser degree. Treatment with SGLT2 inhibitors does not raise the risk of upper UTIs (pyelonephritis). Furthermore, SGLT2 inhibitors have been linked to an increase in benign urine symptoms brought on by osmotic diuresis, such as an increase in urine output. This might have also made it more likely that patients on SGLT2 inhibitors would have been diagnosed with infections. 32

Limitations of the study

Superior evidence could be provided by studying more urinary parameters on a larger sample of T2DM Iraqi patients taking metformin and SGLT-2 Inhibitors and by extending the monitoring period to evaluate the risk and incidence of urinary tract infections among these patients in controlled trials.

 Conclusions

Diabetic patients on SGLT-2 inhibitors treatment demonstrated higher leukocyte count than metformin group patients, an indicator and predictor for higher susceptibility to urinary tract infections.

Ethical considerations

The study was approved by the Institutional Review Board (IRB) in the College of Medicine/University of Baghdad (Approval no. 03-11 on 31 st of December 2023), the ethical approval for the current study was uploaded to the Zenodo: Ethical approval and reporting guidelines. https://doi.org/10.5281/zenodo.14037291. 18

This project contains the following file:

(Ethical approval.jpg).

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

 Consent to participate

All patients and other private parties provided written and informed consent to participate in the study.

 Authors’ contribution

DNH contributed to conceptualization, data curation, formal analysis, investigation, methodology, project administration, resources, software, validation, visualization, and writing-original draft preparation. SMA contributed to conceptualization, data curation, investigation, methodology, project administration, resources, supervision, writing – review & editing.

 Data availability Underlying data

Zenodo: “Impact of Metformin vs SGLT-2i on urinary parameters (Latest Version)”, https://doi.org/10.5281/zenodo.14055980. 33

This project contains the following underlying data file:

( Data: Latest version.xlsx).

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

 Reporting guidelines

STROBE criteria for cohort studies was used as reporting criteria for the current study. The complete filled-in reporting guideline document for the current study was uploaded to Zenodo: Ethical Approval and Reporting Guidelines. https://doi.org/10.5281/zenodo.14037291. 18

This project contains the following file:

(Reporting guidelines.doc).

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0) ( https://creativecommons.org/licenses/by/4.0/).

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Zenodo. 10.5256/f1000research.174446.r354138 Reviewer response for version 1 Umapathysivam Mahesh M. 1 2 3 Referee Nguyen Huyen 4 Co-referee Royal Adelaide Hospital, The University of Adelaide, Adelaide, South Australia, Australia Southern Adelaide Diabetes and Endocrine Service, Flinders Medical Centre, Bedford Park, Australia The University of Adelaide Adelaide Medical School, Adelaide, South Australia, Australia Endocrine, Southern Adelaide Local Health Network, Bedford Park, South Australia, Australia

Competing interests: No competing interests were disclosed.

 17 1 2025 Copyright: © 2025 Umapathysivam MM and Nguyen H 2025 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation reject

Summary of Context:

Multiple agents are available for the treatment of type 2 diabetes. Current American diabetes association guidelines suggest initial treatment with metformin and intensification with SGLT2i or GLP-1RA as preferred second line agents depending on patient characteristics. SGLT2i reduce glycaemia by increasing urinary glucose an effect that has been associated with candidiasis but whilst large cardiovascular outcome trials have not demonstrated increased rates of UTI (these should be referenced), this study design can miss safety signals.

This study aimed to contribute to the literature in the field on this complication by prospectively following patients with either metformin or SGLT2 monotherapy and then examining a surrogate for urinary tract infection - number of leucocytes per high power field on microscopy at base line and then at 12 weeks. Notably this end point may be limited due to increased urinary volume with SGLT2i treatment or increased leukocyte number in setting of non-bacterial infection e.g. candidiasis.

The study reports the number of leucocytes in various categories and other cell populations before and after therapy with metformin and SGLT2i. There was no difference when groups were compared but there was an increase in urinary leucocytosis after 12 weeks of SGLT2i compared to baseline. In the text it does not explicitly state at any point state if this is increased or decreased or the magnitude of change. . The results report.

I have not recommended for indexing in current state as there is inconsistency between results and conclusion and this need to be addressed prior to consideration of indexing.

The following specific suggestions are offered to strengthen the article;

Title:

Use people first language i.e. “diabetic” is not appropriate it should be “person with diabetes” or similar.

The title should reflect what was measured i.e. urinary tract infections were not measured urinary leucocytosis was measured.

Abstract:

This should follow STROBE format more closely.

Remove “because it has demonstrated promise in this regard”.

State T2DM in full then abbreviate.

Be clearer in the language around the results and state direction of effect and magnitude.

Conclusion is not consistent with results –

The results state “There was no significant difference in leukocytes, erythrocytes, or epithelial cell counts between the metformin group and the SGLT2 inhibitor group before and after 12 weeks of treatment” whilst conclusion states “Diabetic patients on SGLT-2 inhibitors treatment demonstrated higher leukocyte count than metformin group patient”.

Please check capitalisation throughout.

Introduction:

Remove content that does not relate to the proposed study – e.g. discussion of relation between diabetes and osteoporosis and discussion of NGAL. This section should focus on setting up the justification for the study.

Reference 12 for association between SGLT2i and infection is incorrect. Please review.

Samples size section is incomplete with multiple areas marked XXX.

Methods:

Ethics:

Patients completed written informed consent but study states 63.5% were illiterate please clarify.

It would be helpful to know renal function and Hba1c at baseline and at 12 weeks if possible.

It would be helpful to know why individuals were treated with SGLT2i monotherapy rather than metformin. Are these populations very different? Ascertainment bias should also be included as a limitation.

A definition of a “positive test” need to be provided.

Results:

More description of results is required. It would help the reader to know the direction of effect for significant results and the magnitude of the difference.

 Presentation of the average number of leukocytes with comparison of students T test would be useful

I am unsure what “it was assumed that 30% of people had an irregular legal status at time 1 and 20% at time 2” means

Conclusion:

There is conflict throughout between the reporting of results and interpretation. To my reading there is no statistical difference between metformin group and SGLT2i group. There is an increase statistically significant increase in leukocytes after initiation of SLT2i compared to before. This should form the basis of discussion.

Is the work clearly and accurately presented and does it cite the current literature?

No

If applicable, is the statistical analysis and its interpretation appropriate?

No

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

No

Are sufficient details of methods and analysis provided to allow replication by others?

Partly

Reviewer Expertise:

Type 2 Diabetes, Genetics, SGLT2i DKA, inpatient glucose management, incretin hormones

We confirm that we have read this submission and believe that we have an appropriate level of expertise to state that we do not consider it to be of an acceptable scientific standard, for reasons outlined above.

References : Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes. N Engl J Med .2015;373(22) : 10.1056/NEJMoa1504720 2117-28 26378978 10.1056/NEJMoa1504720 : Dapagliflozin and Cardiovascular Outcomes in Type 2 Diabetes. N Engl J Med .2019;380(4) : 10.1056/NEJMoa1812389 347-357 30415602 10.1056/NEJMoa1812389