Clinicians should consider sodium-glucose cotransporter-2 (SGLT2) inhibitors or glucagon-like peptide-1 (GLP-1) receptor agonists for patients with diabetes and cardiovascular disease (CVD), according to a new decision pathway from the American College of Cardiology.
The Expert Consensus Decision Pathway recommendations apply only to patients with both type 2 diabetes and clinically evident atherosclerotic CVD, which was defined as history of an acute coronary syndrome or myocardial infarction; stable or unstable angina; coronary heart disease with or without revascularization; and other arterial revascularization, stroke, or peripheral artery disease assumed to be atherosclerotic in origin. They were published on Nov. 26 by the Journal of the American College of Cardiology.
The pathway advises cardiologists to consider periodic screening for diabetes by measuring HbA1c at variable intervals based on past results, for example, annually in patients with a recent HbA1c close to 6.5%. Patients with new diabetes diagnoses should begin guideline-based therapy with lifestyle changes and metformin, and use of an SGLT2 inhibitor or a GLP-1 receptor agonist should be discussed. Among the SGLT2 inhibitors, empagliflozin is currently the preferred agent based on the available evidence and overall benefit-risk balance, the expert panel wrote.
A detailed clinician-patient risk discussion is recommended to review risks, potential benefits, and different treatment options. Specifically, potential side effects, drug interactions, and safety issues should be explained; patient preference and other concerns should be considered; and cost should be discussed, because SGLT2 inhibitors and GLP-1 receptor agonists are expensive and out-of-pocket costs could be high, the panel noted.
Other recommendations included the following:
- Patients starting an SGLT2 inhibitor should be informed about the higher risk of genital mycotic infections and should be told that this risk could be lowered with “meticulous attention to personal hygiene.”
- Patients should be informed about the unlikely risk of euglycemic diabetic ketoacidosis and should be advised to seek immediate care if they develop symptoms potentially associated with diabetic ketoacidosis, such as nausea, vomiting, abdominal pain, or generalized weakness.
- Patients taking insulin or an insulin secretagogue, such as a sulfonylurea or glinide, should be advised of the risk of hypoglycemic events when newer antihyperglycemic therapies are added for cardiovascular benefit.
- Therapy with SGLT2 inhibitors may cause a modest decrease in estimated glomerular filtration rate, so monitoring renal function in the first several weeks of therapy is reasonable, particularly in patients with impaired renal function at baseline.
- Increased risk of lower-limb amputation has been noted with canagliflozin, so caution is advised when prescribing it to patients with a history of prior amputations, significant peripheral artery disease, or active lower-extremity soft tissue ulcers or infections.