How Sweet is Your Heart?
Nov 24, 2015, 09:46 AM
I
finally had a chance to enroll in one of the AADE15 Sessions On-demand. If you were not able to attend the live Meeting in New Orleans, you can get on-demand access through My Learning on the AADE website.
I decided to enroll in a presentation titled How Sweet is Your Heart? Cardiovascular Effects of Diabetes Drugs. The presenter was Emily Evans, PharmD, who is a Clinical Associate Professor and Clinical Pharmacist with the LSU-Health Shreveport. This presentation was a good review, as it emphasized the cardiovascular outcomes of available diabetes medications. These medications obviously lower fasting and/or post-prandial glucose levels, including A1C concentrations. We emphasize these effects with patients, but also consider the effect on microvascular and microvascular complications with diabetes. As practitioners, we have great evidence with medications and their effect on lowering the risk or preventing microvascular complications. However, the evidence with macrovascular complications varies based on the patient population in the studies. As the speaker pointed out, established vascular disease and other comorbid conditions are considered, using the ADA/EASD guidelines, when determining if a patient’s A1c goal should be more or less stringent.
The Food and Drug Administration (FDA) mandates that any new medication for diabetes needs to have cardiovascular outcomes.
The presentation provides a good summary of the well-established medications, such as metformin, sulfonylureas and insulin, as well as their potential impact on cardiovascular markers (i.e. C-reactive protein) and any cardiovascular outcomes. Insulin appears to have a neutral effect on cardiovascular outcomes. There is evidence with the GLP-1 agonists, DPP-IV inhibitors and SGLT-2 inhibitors; however, it is important to make note that the Food and Drug Administration (FDA) mandates that any new medication for diabetes needs to have cardiovascular outcomes. Therefore, we will have more evidence on GLP-1 agonists, DPP-IV inhibitors and SGLT-2 inhibitors over the next 2-7 years.
When reviewing and listening to Dr. Evans’ presentation, it was relevant as
a recent trial with empagliflozin was published in New England Journal of Medicine. The EMPA-REG Outcome study evaluated death from cardiovascular cause, nonfatal myocardial infarction and nonfatal stroke among 7000 patients with type 2 diabetes and established cardiovascular disease. For the primary outcomes, empagliflozin had lower cardiovascular events and death, compared to placebo (10.5% versus 12.1%). This result was statistically significant as p-value was <0.001 (non-inferiority) and <0.04 (superiority) with a numbers-needed-to-treat of 63. While this endpoint was positive in the trial, practitioners should weigh the risk of SGLT-2 inhibitor, such as urinary tract infection and volume depletion, prior to prescribing. While empagliflozin may have an edge over other SGLT-2 inhibitors, it is essential to counsel patients on the effect of their prescribed medications on glycemic control, but also cardiovascular outcomes.
About the Author
Jennifer Clements received her Doctorate of Pharmacy from Campbell University in 2006 and completed a primary care residency at a Veterans Affairs Medical Center in 2007. She is also a certified diabetes educator and board certified in pharmacotherapy. Currently, she is the Interim Chair and Associate Professor in the Department of Pharmacy Practice at Presbyterian College School of Pharmacy.