During the mini-symposium Improving Outcomes—A Multidisciplinary Year in Review on Friday, June 3, an interprofessional panel of experts provided their perspectives and reviewed some of the most current literature on improving outcomes across the cardio-renal-metabolic spectrum of diabetes.
James L. Januzzi Jr., MD, the Hutter Family Professor of Medicine at Harvard Medical School and staff cardiologist at Massachusetts General Hospital, opened the session with the cardiology perspective, focusing on the recently published Heart Failure: An Underappreciated Complication of Diabetes. A Consensus Report of the American Diabetes Association.
“This is a multidisciplinary consensus document sponsored by the ADA and endorsed by the American College of Cardiology. It focuses on a broad range of important topics relevant to heart failure and diabetes, including the very important concept of heart failure staging, which is particularly relevant to the person with diabetes,” said Dr. Januzzi, who served as vice chair of the consensus document writing committee.
Diabetes is the prototypical form of stage A heart failure, he said, in the sense that individuals with diabetes are at heightened risk for progressing to later stages of heart failure.
“It has now actually been demonstrated in epidemiologic studies and other surveys that many people with diabetes actually have stage B heart failure—that is, underlying structural heart disease without symptoms—but they don’t know it,” Dr. Januzzi said. “So, heightening our understanding of the underlying heart muscle disease that occurs in these patients is very important.”
Whether the patient is experiencing atherothrombotic complications or the direct effects of hyperglycemia on the heart muscle, Dr. Januzzi said aggressive care is critically important.
“Management of hyperglycemia in heart failure should take into consideration all risks and benefits of the therapies, but when the words ‘heart failure’ and ‘diabetes’ are in the same sentence, the focus should be on the use of SGLT2 (sodium-glucose cotransporter 2) inhibitors, with secondary options of GLP-1 (glucagon-like peptide-1) receptor agonists and metformin as next-line therapies,” he said. “Thorough treatment of heart failure across the wide spectrum of stages is critical if we are to improve the miserable outcomes in this highest-risk population.”
Tamara Isakova, MD, MMSc, the Margaret Gray Morton Professor of Medicine and Associate Professor of Medicine, Nephrology, and Hypertension at Northwestern University Feinberg School of Medicine, followed with an update on chronic kidney disease (CKD) and diabetes.
“Chronic kidney disease is among the most severe complications of diabetes, present in approximately 30% of people with type 1 and 40% of people with type 2,” Dr. Isakova said. “Indeed, diabetes is present in half of all cases of CKD and kidney failure or end-stage kidney disease worldwide.”
CKD also amplifies the risk of cardiovascular disease (CVD), said Dr. Isakova, noting that most of diabetes-associated excess CVD risk occurs in those with CKD. A holistic approach is needed, she said, to improve outcomes in patients with diabetes and CKD.
“We need rigorous, high-quality randomized controlled trials that compare multi-component, multi-level strategies to improve kidney health management in primary care, specialty clinics, and community and safety-net settings for populations experiencing disparities in CKD outcomes,” Dr. Isakova said.
Neda Rasouli, MD, Professor of Medicine in the Division of Endocrinology, Metabolism, and Diabetes at the University of Colorado School of Medicine, concluded the session with the diabetology perspective, pointing to the presentations by Drs. Januzzi and Isakova as evidence of the need for a multidisciplinary, team-based approach to diabetes treatment.
As an example, she cited the treatment of adults with type 2 diabetes, which was traditionally delivered in a single-specialist setting with a focus on glycemic control.
“However, as the treatment landscape evolved to consider the need to prevent cardiovascular disease and/or microvascular complications, so did the requirement to manage this complex, multisystem condition by multiple health care providers in both primary care and specialist settings,” Dr. Rasouli said. “We need all hands on deck. In the tsunami of diabetes, multidisciplinary, interdisciplinary therapy is essential if we are going to continue to improve outcomes.”