Prescribe SGLT2 inhibitors or GLP1 receptor agonists to reduce CV risk in diabetes: Expert Consensus
The American College of Cardiology has released the 2020 expert consensus decision pathway (ECDP) on novel therapies for cardiovascular risk reduction in type 2 diabetes (T2D) patients.
The
guidance, published in the Journal of the American College of Cardiology
suggests that clinicians should consider prescribing sodium-glucose
cotransporter 2 (SGLT2) inhibitors or glucagon-like peptide 1 (GLP-1) receptor
agonists for patients with diabetes and high cardiovascular risk in order to
reduce CV risk.
This ECDP reflects the change in the paradigm of how the CV specialist should
approach the care of patients with T2D. Earlier, CV specialists focused on the
optimization of risk factor in diabetes patients. Medications used for blood
sugar control were not adjusted by CV specialists, in part because they were
not expected to demonstrate direct CV benefit.
The recent developments of SGLT2 inhibitors and GLP-1RAs has, for the first
time, demonstrated that specific treatments developed for glucose lowering can
directly improve CV outcomes. In large, well-conducted, randomized clinical
trials, specific medications in these 2 classes have been proven to reduce
rates of acute MI, stroke, and CV death in patients with T2D (most with
established ASCVD). These benefits appear to be independent of their effects on
HbA1c. Thus, CV specialists now need to incorporate these agents into their
care of patients with T2D, and coordinate care with the primary diabetes care
providers, to optimize clinical outcomes in patients with diabetes.
This guideline provides a practical guide to CV specialists on initiation and
monitoring of SGLT2 inhibitors and GLP-1RAs with the express goal of reducing
CV risk.
Key points of this ECDP:
This ECDP and associated treatment algorithms should be used in concert with established risk factor modification guidelines for the prevention of MACE in patients with T2D, including guidelines on lipids, blood pressure, and antiplatelet therapy.
This ECDP should also be applied in the context of guideline-directed diabetes care. Although intended to facilitate clinical decision making, the information provided in this ECDP should complement, rather than supersede, good clinical judgement.
The main goals of care for these high-risk patients should be improving survival and quality of life. Achieving these important goals requires a team-based approach to achieve optimal outcomes.
If used appropriately, the SGLT2 inhibitors and GLP-1RAs discussed in this ECDP should significantly reduce CV morbidity and mortality in these patients.
The writing committee has highlighted the
potential benefits and risks associated with these novel therapies and has
sought to provide a context for the rational use of these medications.
Further evidence is still emerging, and
other CV outcomes trials are currently underway. As such, this area of care for
affected patients is likely to continue evolving rapidly. We anticipate that
the algorithms proposed here will change as new evidence emerges but that the
overarching goal of improving CV outcomes in patients with T2D and clinical
ASCVD will remain consistent," concluded the authors.