Clear Consensus—Treat Cardiovascular Disease Concurrent with Diabetes

An American College of Cardiology expert statement advises clinicians to take a more concerted, consistent effort in achieving cardiovascular risk reduction in patients with both type 2 diabetes and atherosclerosis.

With Brendon Everett, MD, MPH, and Daniel Einhorn, MD

Clinicians caring for patients with type 2 diabetes (T2D) and atherosclerotic cardiovascular disease (ASCVD) now have more guidance in recommending the best treatment to manage both conditions.1

The American College of Cardiology issued an expert consensus statement—the Expert Consensus Decision Pathway on Novel Therapies for Cardiovascular Risk Reduction in Patients with T2D and ASCVD,1 and published in Journal of the American College of Cardiology.

ACC Consensus pushes early treatment for heart disease in patients with diabetes.

ACC Decision Pathway Guides Treatment in Patients with T2D and CVD

 “The guidelines are expected to be change practice, at least for some,” said Brendan Everett, MD, MPH, FACC, assistant professor of medicine at Harvard Medical School and director of the General Cardiology Inpatient Service at Brigham & Women's Hospital who was a co-chair of the writing committee. 

"I think it's a paradigm shift," he told EndocrineWeb. What the new guidelines suggest, Dr. Everett said, is that treating at-risk patients should involve not just managing blood glucose but simultaneously addressing cardiovascular event reduction.

This guidance identifies three key areas in which clinicians gain better insights into the thereapeutic options to assist with the management of patients with type 2 diabetes. These are:

  • Screening for T2D in those with CVD or at high risk
  • Treating CV risk factors aggressively
  • Incorporating data for new antihyperglycemic agents into routine practice.

The preferred medications are two novel classes of antidiabetes medications—Sodium-glucose co-transporter-2 (SGLT2) inhibitors (gliflozins) and glucagon-like peptide-1 receptor agonists (GLP-1 RA).1

"Endocrinologists have typically focused on blood glucose," in treating diabetes patients, Dr. Everett said, while "cardiologists typically have stayed away from glucose reduction. Here you have a clinical guideline document from ACC suggesting that cardiologists should prescribe medication or think about treatments that were developed to treat blood sugar in patients with diabetes."

The specialties must and should work together, he said. The new approach should be multidisciplinary coordination of care. By that he suggests that patient management will require not just physicians—both endocrinologists and cardiologists—but also pharmacists, registered dietitians/nutritionists, diabetes educators, nurses, and staff, as active partners on the care teams.

And this comprehensive therapeutic approach should apply whether the treatment setting is an academic medical center or a private practice setting.

While this ACC consensus document is meant primarily for cardiologists, "it's been endorsed by the American Diabetes Association as well," Dr. Everett said. The latest document is part of ACC's ongoing Clinical Pathway efforts aimed at providing cardiovascular professionals practical guidance in areas of emerging science where evidence is limited,1 according to the American College of Cardiology writing committee. 

The guidelines are timely given the recently published results from several randomized clinical trials demonstrating efficacy for major adverse cardiovascular events using SGLT2 inhibitors and GLP1-RAs,2 and responsive to the growing number of patients who present with both T2D and atherosclerotic CVD,1 Dr. Everett said. In the future, the hope will be to expand our management focus to address other related conditions, such as heart failure.

As for patients with type 2 diabetes and cardiovascular disease, "my sense is that cardiologists have not been prescribing these drugs as frequently as might they should, given the clear benefit in these patient,” he said. The expectation is that he ACC consensus statement will change current prescribing practices and that endocrinologists will be able to more actively participate in treatment recommendations for their patients.

Going Forward: Initiate Dual Activing Agents to Address Overall Medical Risks

Among the key highlights from this diabetes treatment guidance are suggestions as to when to use and which to incorporate these newer therapies: SGLT2 inhibitors and GLP-1 RAs in patients who present with both CVD and diabetes, with a goal of reducing cardiovascular risk and improving glycemic outcomes, as early and as effectively as possible.1

Clinicians are encouraged to start one of these agents at the time of diagnosis of clinical atherosclerotic CVD in a patient with type 2 diabetes who is not currently receiving a drug regimen that does not include either of these agents. Similarly, endocrinologists might be proactive in adding one of these medications at the time of diagnosis of T2D in patients with established ASCVD. Endocrinologists are encouraged to advise that patients receive one of these agents upon discharge from the hospital after treatment for an cardiovascular- or diabetes-related adverse event.1

The guidelines also encourage physician-patient discussions that assess for risk of patient-specific complications and a discussion of benefits and treatment options to establish patient buy-in and better therapy adherence.1 Medication cost and insurance reimbursement, of course, must be considered in this decision-making process, when considering whether to prescribe SGLT2 inhibitors and GLP1-RAs, said Dr. Everett.

The guidelines provide a full rationale regarding when to prescribe each of the drugs for which patients, specifically the SGLT2 inhibitors, specifically empagliflozin (Jardiance) and canagliflozin (Invokana), or the only GLP-1RA approved as of 2018 by the Food and Drug Administration, liraglutide (Victoza).

In the discussion,1 the consensus expert panel noted, "The recent development of two novel classes of therapies—SGLT2 inhibitors and GLP-1RAs—''has, for the first time, demonstrated that treatments developed for glucose lowering can directly improve cardiovascular outcomes. In large-well-conducted, randomized clinical trials, specific medications in these two classes have been proven to reduce rates of acute MI, stroke, and CV death, and, in the cases of SGLT2 inhibitors, to reduce heart failure hospitalizations, in patients with T2D (the majority with established ASCVD)."

Now Universal Agreement to Deliver Early, Aggressive Treatment to Diabetes Patients

The statement stands as a strong advisory that ''there is a change in understanding of what is best practice for their patients with type 2 diabetes  (T2D) who have established cardiovascular disease (CVD)," said Daniel Einhorn, MD, FACP, FACE, medical director of the Scripps Whittier Diabetes Institute and clinical professor of medicine at UC San Diego; he reviewed the guidelines for EndocrineWeb.

"It will take time for this to sink in, probably years, but the standard of care for these patients is changing," Dr. Einhorn said. "This [consensus statement] should push those who control access to medication formularies to more readily allow patients access to SGLT2 inhibitors and GLP1-RAs earlier in their treatment course, without the delays and high costs currently inherent in the typical staged, tiered prescribing system.“

"Today, besides always having to start with metformin, clinicians now typically have to prove failure with generic drugs, like sulfonylureas and/or pioglitazone, before they can prescribe SGLT2s or GLP1s. And even then, they are at a higher tier, so many patients cannot afford them," he said. Another consideration in managing these patients is selecting weight neutral drugs since overweight and obesity play a signficant role in the onset and outcomes of both T2D and CVD.

Last but not least, Dr. Einhorn said, "by popularizing the concept of CVD protection, this should encourage patients to be proactive and to adhere to their medications and related care issues."

He has embraced the American Academy of Clinical Endocrinology (AACE) algorithm,3 "which has suggested GLP1s and SGLT2s after metformin for many years. This ACC guidance simply advances what AACE has already proposed. My choices for agents will therefore not change, but hopefully it will improve ease of access to these meds for my patients via formulary changes."

"These agents are conferring benefits in an additive manner to all the other therapies we have. While we do not understand why these improvements in outcomes occur, the effects appear to be consistent and powerful," Dr. Einhorn told EndocrineWeb. "To the extent that we can progress their adoption among as many clinicians and patients as possible, we have the opportunity and ability to advance public health greatly —and relatively easily.

“I believe that the cost:benefit and risk:benefit analyses will favor wide adoption of both SGLT2i’s and GLP1-RA’s for some patients and in the future, I believe these medications will be indicated for all of those at risk for CVD, which is most adults with type 2 diabetes."

Continue Reading:
Predicting Cardiovascular Disease Events in Type 2 Diabetes
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