New guidelines urge cardiologists to take the initiative in prescribing SGLT2 inhibitors or GLP1 receptor antagonists to reduce cardiovascular risk in their patients with diabetes.
Until now the drugs have been viewed as glucose-lowering agents with a ‘bonus’ effect of lowering cardiovascular risk, but now they should be seen as risk-reduction agents in their own right, according to the American College of Cardiology.
In a new Expert Consensus Decision Pathway, the ACC advises cardiologists to consider starting the agents as an additional cardiovascular risk reduction approach for patients who develop type 2 diabetes, or for pre-existing T2D patients who are being managed by a cardiologist.
The consensus statement says there is robust evidence for the two new classes of drugs to reduce the risk of major adverse cardiovascular Events (MACE) independently of their glucose-lowering actions.
“The arrival of these new agents proven to reduce adverse cardiovascular outcomes in patients with T2D has triggered a major paradigm shift beyond glucose control, to a broader strategy of comprehensive cardiovascular risk reduction,” it says.
“The potential of these new compounds has also stimulated re-examination of the traditional roles of various medical specialties in the management of T2D, compelling cardiovascular disease specialists to adopt a more active role in prescribing drugs that may previously have been seen primarily as glucose-modifying therapies …”
In its treatment pathway recommendations the ACC panel says a SGLT2 inhibitor may be preferred because of their potential to prevent heart failure hospitalisation, reduce BP and also because of the ease of oral dosing. Empagliflozin is suggested as the preferred agent in the SGLT2 inhibitor class based on the balance of benefits and risks in trials, and since there is no dose-repose relationship with CV risk reduction and patients can be maintained on the lowest dose.
However the consensus statement notes there are caveats with SGLT2 inhibitor therapy, such as the need to counsel patients about the possible risk of diabetic ketoacidosis (DKA)and genital candidiasis infections, as well as the possible risk of amputation with some agents in the class
GLP1 RA drugs are recommended for patients with kidney disease, for their weight loss effects and if patients prefer a weekly subcutaneous injection, with liraglutide the preferred agent.
The statement suggests that patients do not need to be on metformin therapy to achieve the cardiovascular risk reduction, although this has yet to be confirmed in prospective clinical trials. It also notes there are unanswered questions about whether the cardiovascular benefits are seen in patients with well controlled blood glucose levels rather than the high levels of glycaemia in clinical trials.
The ACC statement acknowledges that cardiologists may yet be reluctant to use these novel classes of drugs for cardiovascular lowering, “perhaps because these agents were originally approved for glucose reduction, or because of incomplete knowledge of their benefits and/or risks, lack of familiarity with their use and monitoring, or because of systems factors.”
“One potential approach to optimise their use would be employing what might be called the “consultative” approach, in which the discussion of these agents is encouraged in conversations or communication with the person caring for the patient’s diabetes and/or with the patient.
“This approach requires clear, open communication and does not require the cardiovascular medicine specialist to or preclude them from initiating and monitoring these medications,” it concludes.