ACC Updates Guidance on Reducing CV Risk Among Patients With Type 2 Diabetes
The American College of Cardiology (ACC) has released the “2020 Expert Consensus Decision Pathway on Novel Therapies for Cardiovascular Risk Reduction in Patients With Type 2 Diabetes.” The guidance is an update to the expert consensus decision pathway that the ACC had released in 2018.
Using data from emerging studies, the updated document provides guidance on initiating and monitoring the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide 1 receptor agonists (GLP-1RAs) among patients with type 2 diabetes (T2D), in an effort to lower these patients’ cardiovascular (CV) risk.
“Data proving that SGLT2 inhibitors and GLP-1RAs improve outcomes in patients with T2D and CV disease have triggered a major paradigm shift beyond glucose control to a broader strategy of comprehensive CV risk reduction,” the authors wrote.
“The potential of these compounds has also stimulated re-examination of the traditional roles of various medical specialties in the management of T2D, compelling CV specialists to adopt a more active role in prescribing drugs that may previously have been seen primarily as glucose-lowering therapies,” the authors continued. “This evolving role has created a need for novel clinical care delivery models that are collaborative, interprofessional, and multidisciplinary in their approach to managing this high-risk patient group with multiple comorbidities.”
The algorithm for using an SGLT2 inhibitor to manage atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), or diabetic kidney disease (DKD) risk is for patients aged 18 or older who have T2D and at least 1 of the following: ASCVD, HF, DKD, or a high risk of ASCVD.
According to the guidance, clinicians should consider initiating an SGLT2 inhibitor with proven ASCVD, HF, or DKD benefit if the patient is not pregnant or breastfeeding and if the patient’s estimated glomerular filtration rate is less than 30 ml/min/1.73m2. If after a provider-patient conversation the patient wants to initiate an SGLT2 inhibitor, canagliflozin, dapagliflozin, or empagliflozin may be appropriate therapy options. No dose titration is needed, according to the authors.
The algorithm for using a GLP-1RA to manage ASCVD risk is for patients aged 18 or older who have T2D and at least 1 of the following: ASCVD or a high risk of ASCVD.
If a patient is not pregnant or breastfeeding, initiating a GLP-1RA with proven ASCVD benefit can be considered. If after a provider-patient conversation the patient wants to initiate a GLP-1RA, dulaglutide, liraglutide, or injectable semaglutide may be appropriate. According to the guidance, clinicians should start at the lowest dose and follow the labelling instructions for dose titration to minimize adverse effects.
Whether a patient is receiving an SGLT2 inhibitor or a GLP-1RA, clinicians should adjust other antihyperglycemic therapies if necessary. Along with monitoring the patients’ response to the therapy, further therapies to reduce CV risk should also be considered.
—Colleen Murphy
Reference:
Writing Committee, Das SR, Everett BM, et al. 2020 expert consensus decision pathway on novel therapies for cardiovascular risk reduction in patients with type 2 diabetes: a report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. Published online August 5, 2020. doi:10.1016/j.jacc.2020.05.037