How to prioritize CV risk reduction in type 2 diabetes
YOUR DOSE OF MEDICINE - Charles C. Chante MD (The Philippine Star) - October 13, 2019 - 12:00am


The pooled analysis showed that initiation of SGLT2 inhibitors was associated with a significantly lower risk of heart failure events, compared with other glucose-lowering drugs (risk ration, 0.61; P less than .001.). The researchers observed an overall 39 percent lower risk of heart failure hospitalization, 51 percent reduction in total death, and 46 percent reduction in the composite of heart failure hospitalization or death.

“There was no heterogeneity across countries, despite the fact that the health care systems were very different and the prescribing patterns were very different,” noted that 13 percent of patients from CVD-REAL had established CVD, while 87 percent did not. When comparing the results within these two key subgroups, “what’s striking is the difference in event rates, stratified by treatment allocation.”

“If you look at the composite outcome of heart failure or death, you see an almost sevenfold difference in annualized events rates – about seven percent per year in patients with established CVD, compared with about one percent per year in the primary prevention cohort.

“But the relative risk reduction associated with SGLT2 inhibitors versus other glucose-lowering drugs is identical across both patient groups. That’s a good lesson in epidemiology: You can have patients with dramatically different absolute risks, dramatically different absolute risk reductions, and therefore dramatically different numbers needed to treat, but identical relative risk reduction.”

It was also pointed out that heart failure is emerging as one of the most important outcomes in trials patients with type 2 diabetes. “That’s because people with diabetes who developed heart failure have very poor outcomes. Among elderly patients with type 2 diabetes who develop new heart failure, there’s less than 25 percent survival at five years. That’s the reason, that if you really want to impact survival and complication rates in people with diabetes, preventing and treating heart failure is one of the surest ways of doing so.

“You shouldn’t just think of the patients in front of you as someone who has an A1c  of seven percent, eight percent, or nine,” “You should also start thinking of where the patients is on the spectrum of cardiovascular disease, all the way from CVD risk factors only to symptomatic heart failure.”

Some evidence already exists to help clinicians make treatment decisions based on where the patients fall on that spectrum. For example, clinical trials have demonstrated that, in patients with established atherosclerotic cardiovascular disease, GLP-1 receptor agonists and SGLT2 inhibitors can reduce the risk of cardiovascular events, including, in some cases, cardiovascular death.

“We don’t have a lot of data demonstrating benefit for patients with recent acute coronary syndrome.” “Some compounds have proven to be neutral, but none has been proven to save lives in this patient group.”

“Now, we also have data for people with prior stroke that pioglitazone may be beneficial in managing those patients to prevent recurrent stroke and MI, based on the recent IRIS trial, provided they don’t have heart failure at baseline.”

“We don’t have definitive data yet in people with established heart failure, but those studies are ongoing.”

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