Recent clinical trials are changing the evidence base clinicians use to select the most appropriate treatment for type 2 diabetes. Metformin may be the common starting point for most patients, but individual factors determine what agents to add for patients with concomitant cardiovascular and/or chronic kidney disease.
Tina Vilsbøll, MD, DMSc, Professor of Medicine at the University of Copenhagen and Consultant at the Steno Diabetes Center Copenhagen in Denmark, will discuss adding a GLP-1 receptor agonist to metformin during Saturday’s Current Issues session Choosing Evidence-Based Therapy for Type 2 Diabetes Mellitus with Cardiovascular Disease, which will begin at 5:00 p.m. in N-Hall E (North, Exhibition Level). Silvio E. Inzucchi, MD, Professor and Director of the Yale Medicine Diabetes Center, will discuss the advantages of adding an SGLT2 inhibitor.
Cardiovascular disease has long been recognized as the number one killer of individuals with diabetes. How has the evidence changed to support multiple treatment alternatives?
Dr. Vilsbøll: The change began with early evidence showing improved cardiovascular outcomes with empagliflozin in the EMPA-REG trial in 2015. We have known for years that lowering glucose levels not only improves glycemic control, it improves microvascular complications. Finally, we have evidence that glucose-lowering drugs—several classes—are beneficial in cardiovascular outcomes.
What’s the practical impact of having two of classes of diabetes agents with demonstrated cardiovascular benefits, SGLT2 inhibitors and GLP-1 receptor agonists?
Dr. Vilsbøll: When I was a young PhD student, it was not a major challenge to handle the outpatient clinic for my professor since we didn’t do much with respect to glucose levels, hypertension, lipids, or comorbidities, in general. We had sulfonylurea, metformin, and insulin. If metformin and sulfonylurea were not sufficient, we initiated insulin. Today, if you have a high-risk patient with type 2 diabetes with renal disease or cardiovascular disease or some other comorbid condition who is not on either an SGLT2 inhibitor or a GLP-1 receptor agonist, they are not on modern diabetes treatment. It’s mandatory to consider what you can and should do to reduce the risk of additional complications.
How much influence do clinical trials have on clinical practice in the short term?
Dr. Vilsbøll: Trial results mean a lot to clinicians and to guidelines, which should be adjusted on a regular basis. For example, we just had CREDENCE with good evidence for canagliflozin in patients with kidney disease. Since the data from EMPA-REG, empagliflozin has been my preferred SGLT2 inhibitor, but now we all have to take a second, deeper look at the evidence. We just had DECLARE showing dapagliflozin to be beneficial in heart failure. Additional cardiovascular outcome trials, PIONEER 6 and REWIND, will be presented here at the Scientific Sessions. Staying updated can be a challenge as evidence changes from one conference to another.
How can clinicians stay up to date?
Dr. Vilsbøll: You can start by coming to this session to hear about these two classes of diabetes drugs. Yes, there are differences between different drugs, but the first step is to learn about differences between the classes that are beneficial and how to use them in our patients. We are all challenged to use the right drug in the right patient at the right time to get the best outcome, improve quality of life, and, preferably, spend money for prevention instead of treating additional complications to diabetes. We should be considering either an SGLT2 inhibitor or a GLP-1 agonist for our patients who have cardiovascular disease, renal disease, or risk factors for them.