New drugs for people with diabetes seem to be popping up all the time. Drugs that help the body break down carbohydrates, drugs that increase the excretion of glucose in the urine, drugs that help muscles respond to insulin, and drugs that stimulate the pancreas to produce it -; The list of pharmaceutical options for treating diabetes continues to grow.
The downside to this plethora of treatment options is that it can be difficult for healthcare providers to stay up to date with the latest research and standards of care. Which drug is best for which patient? And what are the best drugs to both lower blood sugar and lower the risk of cardiovascular disease?
Endocrinologist and Associate Professor Rita Rastogi Kalyani of Johns Hopkins Medicine authored a clinical practice review article in the April 1 issue of the New England Journal of Medicine (NEJM), which provides the latest study results and guidelines on a systematic approach for The treatment of patients with diabetes and a risk for cardiovascular disease are grouped together. Kalyani’s article is the first clinical practice report the journal has published on diabetes management in nearly a decade.
Unlike research studies, clinical practice reviews are a common clinical problem and evidence to support various treatment strategies, followed by a review of the author’s guidelines and clinical recommendations for optimizing patient care.
People with type 2 diabetes are more than twice as likely to develop atherosclerotic cardiovascular disease and heart failure as people without the disease. The NEJM article presents an updated approach for healthcare providers to choose between glucose-lowering therapies for their patients with diabetes, particularly to reduce the risk of cardiovascular disease.
We have seen a big change in diabetes care over the past few years. We now have tools to better understand how to reduce both microvascular and macrovascular complications in people with type 2 diabetes. “
Rita Rastogi Kalyani, Associate Professor and Johns Hopkins Medicine Endocrinologist
The article examines the cardiovascular benefits and risks of the most widely used anti-diabetes drugs currently available in the US market.
Kalyani lists specific drugs in two newer drug classes as beneficial for patients with diabetes who already show signs of heart or blood vessel disease.
The glucagon-like peptide-1 (GLP-1) receptor agonists liraglutide, injectable semaglutide, and dulaglutide increase the amount of insulin the body makes, especially after meals.
Sodium glucose cotransporter 2 (SGLT2) inhibitors empagliflozin and canagliflozin reduce the amount of glucose that the body reabsorbs in the urine.
All of them help patients reduce the chance of a serious cardiovascular event such as a heart attack or stroke. The SGLT2 inhibitor dapagliflozin is effective in reducing the likelihood of hospitalization for heart failure.
“After metformin, widely recognized as the first drug treatment for type 2 diabetes, certain drugs of the GLP-1 receptor agonist and SGLT2 inhibitor classes with proven cardiovascular benefits should be considered as additional drugs for patients already on one cardiovascular disease. This should be the case. ” regardless of whether their A1C level is the goal of reducing the risk of future cardiovascular events, “says Kalyani, referring to the hemaglobin A1C test, which measures a patient’s average blood sugar level over three months.
Sugar binds to a protein in red blood cells that carries oxygen to organs and tissues and carries carbon dioxide to the lungs. The A1C test measures the average percentage of glucose in a person’s hemoglobin over a period of several months. Healthy A1C levels are below 5.7%. In general, A1C levels above 6.5% indicate diabetes.
Kalyani notes that the newer drugs tend to be more expensive and long-term effects are unknown. Prior to 2008, the US Food and Drug Administration -; the agency that regulates the pharmaceutical industry -; No extensive drug studies were required after their launch. As a result, Kalyani says, the cardiovascular effects of older drugs remain less certain.
The NEJM article describes specific medications that provide additional benefits for patients with diabetes who have conditions such as risk factors for multiple cardiovascular diseases, heart failure, and chronic kidney disease.
“Some drugs, such as dulaglutide and dapagliflozin, have also shown cardiovascular benefits in patients with multiple cardiovascular risk factors,” says Kalyani.
In addition, specific SGLT2 inhibitors may be beneficial for patients with heart failure with reduced ejection fraction -; a condition in which the heart muscle does not pump blood efficiently -; also for patients with chronic kidney disease.
The article provides comprehensive drug tables detailing the factors that should be considered in clinical practice when selecting a glucose lowering drug for patients with type 2 diabetes, including A1C lowering effectiveness, route of administration, and frequency of administration , cost, weight effects and risk of hypoglycemia, side effects, and clinical benefits.
“Healthcare providers in primary care, endocrinology, cardiology, and nephrology are now prescribing these newer glucose-lowering drugs to their patients,” says Kalyani. “In the future, diabetes care must be increasingly cooperative and essentially remain patient-centered.”
Kalyani previously served as chairman of the American Diabetes Association’s Professional Practice Committee, which annually updates the standards of medical care for diabetes, the organization’s recommendations for clinical practice. She has also co-authored clinical guidelines published by the Endocrine Society and the American College of Cardiology.
Source:
Journal reference:
Kalyani, RR (2021) Glucose-Lowering Drugs for Reducing Cardiovascular Risk in Type 2 Diabetes. The New England Journal of Medicine (NEJM). doi.org/10.1056/NEJMcp2000280.