Prescribing Antidiabetic Therapy & Reducing CV Risk in T2D
JUNE 12, 2019
MD Magazine Staff
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: I’m going to go across the panel. We say we’re not doing enough. We talk about the outcomes trials, the benefits even before patients with documented ASCVD [atherosclerotic cardiovascular disease]. Do you prescribe these drugs?
Peter McCullough, MD, MPH, FACC, FACP, FAHA, FCCP, FNKF: I do. I’m an internist and a cardiologist, and I have prescribed these drugs both in my role in internal medicine as well as in cardiovascular disease. I think just like statins, once they became proven to reduce cardiovascular events, I think it really was paramount for cardiologists to embrace statin prescriptions and run with it.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: I’m smiling because I was around when statins were first developed, and Chris, you were around too. Cardiologists were not the first. There were GI [gastrointestinal] docs; there were lipid specialists. And when we started to see 4S [Scandinavian Simvastatin Survival Study], and then we saw West of Scotland [Coronary Prevention Study in the 1990s], we say, “Wow, maybe they’re right. Let’s start using these drugs.”
Peter McCullough, MD, MPH, FACC, FACP, FAHA, FCCP, FNKF: Yeah, absolutely. I distinctly remember in 1993, I wanted to prescribe a statin to a patient with coronary disease, and my faculty mentor said we are not going to do this until it’s proven that it reduces cardiovascular events. And that was just around the time.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: So you were kind of late to the game with statins.
Peter McCullough, MD, MPH, FACC, FACP, FAHA, FCCP, FNKF: In cardiology we needed the evidence. But we were needed as a community—and many times we’re the captain of the ship in cardiovascular disease—to drive it forward. And the fear is that with these newer antidiabetic agents, everyone is passing the ball to somebody else. “Oh, I’m not responsible” or “I’m not really…” I think we have to embrace it in cardiovascular disease, and we have to teach our fellows and our cohort.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Before I go to the other members of the panel on whether they prescribe these drugs—and I know, Melissa, you do, so you’ll be last, and you’ll tell us how.
Seth J. Baum, MD, FACC, FACPM, FAHA, FNLA, FASPC: She’ll tell us how to do it, right?
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: But before we go to the other members of the panel, you use that passing-the-ball analogy. In basketball, when the clock is running down—10, 5 seconds—sometimes there is that team on which everybody is scared to take that shot. Sometimes the time runs out and the last shot is not taken.
Peter McCullough, MD, MPH, FACC, FACP, FAHA, FCCP, FNKF: I know, we need Mr Big Shot. Remember him?
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Yeah.
Peter McCullough, MD, MPH, FACC, FACP, FAHA, FCCP, FNKF: He just grabbed the ball and he took the shot, and I think in cardiology we need to do that. We need to be Mr Big Shot.
Christopher P. Cannon, MD: So I am, although trying to learn how to do this is hard with the colleagues.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: It’s a lot, sure.
Christopher P. Cannon, MD: Very often, a patient with diabetes has been managed, say, for 10 years by somebody. And then they see me for cardiac risk evaluation, and suddenly I say, “Oh, well, you’re here. I’m going to change your whole regimen.” A lot of times, we’re actually doing a project—Jorge Plutzky at Brigham and Women’s Hospital in Boston, Massachusetts, is leading it—trying to teach cardiologists how do this. And we’re realizing that having a team and support is so helpful, so that we have an endocrinologist on the team who’s given us a script of, “OK, if you want to start a patient, here are the 3 things you have to tell them.” Because, you know, I know that I should be saying something such as “Here are the adverse effects and what to watch out for.” And then close follow-up has actually been requested by many to say we’ve got to make sure that someone follows up in 2 weeks. The team has become sort of a key part—and probably appropriately should be for a patient with diabetes and cardiovascular disease.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Before I go to Seth and Melissa—because I know Melissa is an expert in this area, and I’m going to see what Seth does with these drugs—just saying we’re going to refer you to the endocrinologist or the diabetic specialist won’t cut it, because there are not enough.
Peter McCullough, MD, MPH, FACC, FACP, FAHA, FCCP, FNKF: Right.
Christopher P. Cannon, MD: For the patient to hear that I’m worried about their diabetes because of the cardiac risk, we can advance the discussion certainly. And then in the right patients, who actually started, make sure we get the information transferred to the primary care doctor who’s been managing. But making sure that we stay as a team of doctors and other educators, I think, has been important.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: OK, Seth, you’re next up. Do you prescribe these drugs?
Seth J. Baum, MD, FACC, FACPM, FAHA, FNLA, FASPC: I do, and I’ll tell you briefly my journey. Your comment about the endocrinologist is right on. When I started, I would put it in my note: a recommendation to go on this drug. It wouldn’t happen. Probably my notes are never read because they’re so bad, but I don’t know. Then I would try calling the endocrinologist or the internist, and that didn’t work out. And finally I just gave up and said, “OK, I’m going to do this.” Now, my start point was that I haven’t managed diabetes in years. I don’t really want to manage diabetes, but I have to get this patient on this drug. So I began thinking about it more like colesevelam in that that was a lipid drug with a side benefit of lowering blood sugar. Well, I’m thinking of this as a cardiovascular drug with a side benefit of lowering blood sugar. And so I’m using it not to manage diabetes but to manage cardiovascular risk. That’s how I’m doing it now.
Transcript edited for clarity.