Cardiologists urged to act on underuse of cardiorenal drugs in diabetes patients

Heart failure

By Michael Woodhead

19 Nov 2020

Patients with type 2 diabetes are missing out on the “compelling” cardiorenal benefits of SGLT2 inhibitors because different specialist groups are nitpicking over minor discrepancies in guidelines, experts say.

Urgent action is needed on clearer messaging because only a small proportion of patients with diabetes and cardiovascular risk, heart failure or renal disease are currently treated with SGLT2 inhibitors or GLP-1 receptor agonists despite strong evidence for their benefit, a paper in Lancet Diabetes and Endocrinology says.

The article is written by the authors  of recently updated recommendations by groups including the American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD) and European Society of Cardiology (ESC).

They say the recommendations from both endocrinology and cardiology groups recognise the strong evidence for agents from GLP-1 receptor agonist and SGLT2 inhibitor classes in patients with cardiovascular disease, independent of glycaemia.

But professional reaction to the recommendations has focused on differences such as the positioning of metformin as first line therapy.

“We are concerned that ongoing discussions focusing on the differences between the endocrinologists’ consensus report from the ADA and EASD and cardiologists’ guidelines from the ESC are contributing to clinical inertia, thereby effectively denying evidence-based treatments advocated by both groups to patients with type 2 diabetes and cardiorenal disease,” they write

“Both the ADA–EASD consensus report and the ESC guidelines agree on several compelling indications for the use of GLP-1 receptor agonists and SGLT2 inhibitors, which should be urgently implemented in clinical practice by cardiologists, endocrinologists, nephrologists, primary care providers, pharmacists, and other licensed health-care professionals.

The authors say their recommendations have four key common messages for people with T2D:

  • Those with prevalent cardiovascular disease or at high cardiovascular risk should be treated with a GLP-1 receptor agonist or an SGLT2 inhibitor.
  • Patients with type 2 diabetes and heart failure, particularly those with reduced ejection fraction, should be treated with an SGLT2 inhibitor.
  • Patients with chronic kidney disease should be treated with an SGLT2 inhibitor, or a GLP-1 receptor agonist if SGLT2i therapy is not tolerated or not preferred.
  • Treatment decisions should be made independent of background therapy, current glycaemic control, or individualised treatment goals.

“The debate is over. It is time for action to ensure that patients with diabetes at high cardiorenal risk receive the benefits of GLP-1 receptor agonists and SGLT2 inhibitors through the collaboration of practitioners involved in their care,” they conclude.

Their observations are supported by findings from an Australian study, which found that only 7% of patients with heart failure  were on an SGLT2 inhibitor despite 56% qualifying for treatment using DAPA-HF parameters.

Presented at the Australasian Diabetes Congress 2020, the study of 237 patients being treated for heart failure  at the Nepean Hospital, NSW, in 2018-2019, revealed “clinically significant underutilisation of SGLT2i amongst this heart failure cohort, despite strong evidence in favour of its use,” said study author Dr Ashish Munsif.

“Interdisciplinary care between cardiologists, endocrinologists, diabetes nurse educators and heart failure co-ordinators is of crucial importance to improve uptake of SGLT2 inhibitors where clinically indicated,” he said.

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