So, we’ve heard about all this recent “exciting” cardiovascular outcome data in type 2 diabetes, but is there a real tangible benefit to our own patients outside of a clinical trial setting? How should we be incorporating it into our own clinical practice?
Availability of type 2 diabetes medications
Over the last ten years the explosion in the number of type 2 diabetes medications available has been overwhelming and made decision making a lot more difficult. There is much talk of the cardiovascular protective effects seen in CV outcome trials with several of the SGLT2 inhibitors and GLP1 agonists, but it can be difficult to relate these clinical trials to everyday decisions we are making on the ground. The NICE 2015 type 2 diabetes guidelines, while sturdy and still allowing good individualised care, are becoming rapidly outdated by this new data and were always somewhat “wordy” on the eye. In November 2017 the SIGN 154 guidelines came out from Scotland which began to clearly incorporate some of the new evidence. Last month the American Diabetes Association and the European Association for the Study of Diabetes jointly brought out a new user-friendly treatment algorithm (ADA/EASD 2018 guideline) which reflects a lot of the new evidence and how to relate that to our own primary care patients.
Managing overall cardiovascular risk
Instead of thinking of type 2 diabetes as mainly a disease of managing hyperglycaemia, there has been a real shift towards thinking of it as managing overall cardiovascular risk. The current evidence for cardiovascular protection with the newer agents is in secondary prevention, in the presence of pre-existing cardiovascular disease. The ADA/EASD algorithm guides us down a particular path depending on cardiovascular disease state, as well as the presence of chronic kidney disease, where we also have evidence for protective effects from some of the newer medications.
For example, if Mr P has pre-existing CV disease, has already been established on metformin and requires further intensification, they guide us to using an SGLT2 inhibitor or GLP agonist which has been proven to improve cardiovascular outcomes in secondary prevention (currently empagliflozin, canagliflozin, liraglutide and semaglutide, the latter will be available to prescribe in the UK from Jan 2019). If Mrs S requires a second line medication but does not have CVD or CKD, it guides us to make a choice depending on the degree of need to: avoid hypoglycaemia, promote weight loss, or avoid high costs. This reflects good individualised patient care.
The algorithm is well worth a look and makes incorporating the new data into our prescribing choices in type 2 diabetes very clear. Of course, as we have seen, the research is moving at a ferocious pace and later this month we will have data from another CV outcome trial on an SGLT2 inhibitor which looks at the potential role in reducing CV risk in primary prevention. This obviously represents a large proportion of our own patients. A similar study is also following for a GLP1 agonist. Both of these studies have already announced top line positive findings, details still to follow. This may well yet again alter our thinking. It may even be that in future these medications will be used increasingly in a cardiovascular setting, above and beyond the treatment for hyperglycaemia - stay tuned and we will keep you updated!
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This blog was originally published via the Hot Topics Blog, NB Medical on 8th November 2018.