Researchers propose a modified guideline for type 2 diabetes treatment by evaluating patients’ cardiovascular risks when choosing anti-diabetic medications.
Previous studies have shown that those with diabetes are at an increased risk of cardiovascular disease despite the use of cholesterol-lowering agents. Because of this, Valentina Rodriguez from the Division of Endocrinology at the New York University School of Medicine and colleagues reviewed current diabetes treatments and their effects on cardiovascular disease. They published their review in the Journal of Clinical Lipidology.
As a result of their review, the researchers proposed a new algorithm for type 2 diabetes treatment. They note that the proposed algorithm would allow the physician to choose the most appropriate anti-diabetic medication for the diabetic patient with a history or risk of cardiovascular disease or heart failure. With the arrival of new anti-diabetic agents that reduce cardiovascular disease as well as control blood sugar, recent studies have demonstrated the cardiovascular safety of many other drugs used in diabetes treatment.
The sodium-glucose cotransporter-2 inhibitors (SGLT-2) are the newest class of anti-diabetic medications on the market. These agents cause weight loss and lower blood pressure, which are two important factors in promoting cardiovascular health. The major study (EMPA-REG OUTCOME) focused on empagliflozin (Jardiance). The study demonstrated both cardiovascular and heart failure benefits and reduced cardiovascular death in high-risk diabetic patients with a history of cardiovascular disease. Further studies are currently in progress to determine whether these findings are specific to empagliflozin or can be extrapolated to the other drugs in the SGLT-2 class.
The thiazolidinedione (TZD) class of medications, pioglitazone, and the first-line drug for diabetes treatment, metformin, both reduce triglyceride levels in the blood. TZDs must be used with caution in patients with heart failure; however, a trial studying the stroke risk of diabetic patients taking TZDs after a recent stroke showed a significant reduction in fatal and nonfatal stroke risk. More studies are required to analyze the cardiovascular benefit of metformin.
Glucagon-like peptide 1 (GLP-1) agonists are a new class of anti-diabetic medication. A positive side effect of this class of medication is weight loss. The cardiovascular benefit from GLP-1 agonists seems to be due to weight loss; however, more studies are underway to determine the precise mechanism for the reduced cardiovascular risk associated with this drug class. These drugs are less popular among patients because delivery requires a daily injection.
An Updated Algorithm for Diabetes Treatment is Necessary
Cardiovascular disease remains the primary cause of morbidity and mortality in diabetic patients. The SGLT-2, TZDs, and GLP-1 anti-diabetic drug classes show promising effects on cardiovascular disease. Other drug classes did not show any cardiovascular benefit in addition to their blood sugar lowering effects. This study indicates that selecting medications based solely on their ability to lower hemoglobin A1C is an outdated approach. An updated diabetes treatment algorithm that can be used in practice is necessary to help reduce a diabetic patient’s risk of having a stroke or heart attack. The authors propose a new algorithm for treatment in which medication is selected based on the presence or risk of coronary artery disease.
Written by Jessica Caporuscio, PharmD
Reference: Rodriguez V, Weiss MC, Weintraub H, et al. Cardiovascular disease leads to a new algorithm for diabetes treatment. J Clin Lipidol. 2017.