A new clinical practice review article in The New England Journal of Medicine (NEJM) collates the latest trial results and guidelines into a systematic approach for the treatment of patients with diabetes and a risk of cardiovascular disease. It is the journal’s first such review by the journal in nearly a decade.
Clinical practice reviews differ from research studies in that they present a common clinical problem along with the evidence supporting various treatment strategies and review the guidelines. Finally, the author offers clinical recommendations for optimising patient care.
Compared to those without the disease, people with type 2 diabetes have over double the risk of developing atherosclerotic cardiovascular disease and heart failure. In South Africa, 10.1% of the population over 15 is believed to have type 2 diabetes, and is expected to cost the health sector R35.1 billion by 2030.
The NEJM article by Johns Hopkins Medicine endocrinologist and associate professor Rita Rastogi Kalyani, MD, presents an up-to-date approach for health care providers when choosing among glucose-lowering therapies for their patients with diabetes, particularly to reduce the risk of cardiovascular disease. Dr Kalyani reviews the cardiovascular benefits and risks of the most common diabetes drugs currently available on the US market.
“We’ve seen a major shift in diabetes care over the past few years,” said Dr Kalyani. “We now have tools to better understand how to reduce both microvascular and macrovascular complications in people with type 2 diabetes.”
Dr Kalyani highlighted specific agents in two newer drug classes, which she showed are beneficial for patients with diabetes who already show signs of heart or blood vessel disease.
The glucagon-like peptide 1 (GLP-1) receptor agonists liraglutide, injectable semaglutide and dulaglutide increase insulin production from the body, particularly after meals.
Sodium glucose cotransporter 2 (SGLT2) inhibitors empagliflozin and canagliflozin reduce the amount of glucose the body re-absorbs through urine.
All of these are effective in risk reduction for major cardiovascular events, such as heart attack or stroke. The SGLT2 inhibitor dapagliflozin is effective in reducing the risk of hospitalisation for heart failure.
“After metformin, which is widely considered the initial drug treatment for type 2 diabetes, specific drugs in the GLP-1 receptor agonist and SGLT2 inhibitor classes with demonstrated cardiovascular benefit should be considered as additional medications for patients who already have cardiovascular disease. This should be done irrespective of whether their A1C level is at target to reduce the risk of future cardiovascular events,” advised Kalyani.
The A1C test measures the average percentage of glucose in a person’s haemoglobin over the span of several months. Healthy A1C levels are below 5.7%, and typically, A1C levels over 6.5% indicate diabetes.
Newer drugs tend to be costlier, and long-term effects are unknown. Also, prior to 2008, the US Food and Drug Administration did not require large outcome trials for drugs after they were released onto the market, meaning that older drugs have less certain cardiovascular outcomes, said Dr Kalyani.
The NEJM article details specific drugs that offer additional benefits for patients with diabetes who have conditions such as multiple cardiovascular disease risk factors, heart failure and chronic kidney disease.
“Some agents such as dulaglutide and dapagliflozin also have demonstrated cardiovascular benefit in patients with multiple cardiovascular risk factors,” said Dr Kalyani.
Further, specific SGLT2 inhibitors can be beneficial for patients who have heart failure with reduced ejection fraction, as well for patients with chronic kidney disease.
Comprehensive drug tables in the article take into account factors for consideration in clinical practice when choosing a glucose-lowering drug for patients with type 2 diabetes, including A1C-lowering efficacy, route and frequency of administration, cost, impacts weight, hypoglycaemia risk, side effects and clinical benefits.
“Health care providers in primary care, endocrinology, cardiology and nephrology are now prescribing these newer glucose-lowering drugs for their patients,” Dr Kalyani said. “Diabetes care will need to be increasingly collaborative in the future and, at its core, remain patient-centered.”
Source: Medical Xpress
Journal information: Rita R. Kalyani et al. Glucose-Lowering Drugs to Reduce Cardiovascular Risk in Type 2 Diabetes, New England Journal of Medicine (2021). DOI: 10.1056/NEJMcp2000280
