I try to stay up-to-date as much as possible with primary literature, but also review articles and other publications related to diabetes. A recent article caught my eye in late 2018 and has caused a buzz among colleagues, practitioners and other individuals involved with diabetes education and management. In November 2018, the American College of Cardiology (ACC) published the 2018 ACC Expert Consensus Decision Pathway on Novel Therapies for Cardiovascular Risk Reduction in Patients With Type 2 Diabetes and Atherosclerotic Cardiovascular Disease. This article was timely given the recent updates in the American Diabetes Association and European Association for the Study of Diabetes consensus guidelines on the management of hyperglycemia for type 2 diabetes (T2DM).
In the ACC publication, the focus is solely on patients with T2DM and ASCVD; therefore, the article extensively reviews the role of sodium glucose co-transporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists for this population. The cardiovascular group also endorses other nationally-based guidelines from the American Heart Association and American Diabetes Association, as there are some overlaps in terms of cardiovascular risk reduction and diabetes care.
From the ACC Expert Consensus Decision Pathway, here are a few highlights:
- It is important to evaluate a patient’s cardiovascular status when considering pharmacotherapy. If a person has T2DM and ASCVD, then a SGLT-2 inhibitor or GLP-1 receptor agonist should be considered.
- The preferred GLP-1 receptor agonist for people with T2DM and ASCVD is liraglutide, whereas the preferred SGLT-2 inhibitor is empagliflozin.These specific medications have been shown to reduce major cardiovascular events (MACE).A 3-point MACE would be a composite endpoint of nonfatal myocardial infarction, nonfatal stroke or cardiovascular mortality, whereas a 4-point MACE would include these three endpoints with unstable angina.
- It is important to evaluate and consider patient-specific factors before initiating SGLT-2 inhibitor or GLP-1 receptor agonist as both therapeutic classes have advantages and disadvantages.Therefore, a risk-benefit analysis should be conducted to determine the potential benefits of the drug for the person with diabetes, while considering if there are any contraindications.
- There are four scenarios in which a SGLT-2 inhibitor or GLP-1 receptor agonist could be initiated for a person with T2DM and ASCVD.These scenarios would include anytime during diabetes care; at the time of diagnosis of T2DM; at the time of diagnosis of ASCVD for a patient with T2DM or at the time of discharge from the hospital.
- There are similar benefits between SGLT-2 inhibitors and GLP-1 receptor agonists but there may be times when one is preferred over another.As an example, SGLT-2 inhibitor may be preferred for a person with history of heart failure in order to prevent hospitalization.As another example, GLP-1 receptor agonist does produce greater weight loss.Table 11 provides a summary of preferences for these two agents for use in clinical practice.
- Overwhelmed with the current evidence?Just wait… more is yet to come!
So, have you read the recent consensus guidelines supported by this organization? If so, what are your thoughts? Please share them in the comments below.
About the Author
Jennifer Clements received her Doctorate of Pharmacy from Campbell University in 2006 and completed a primary care residency at a Veterans Affairs Medical Center in 2007. She is also a certified diabetes educator and board certified in pharmacotherapy. Currently, she is an Associate Professor of Pharmacy Practice at Presbyterian College School of Pharmacy.