T2D and CV Risk Reduction: Future Management
JUNE 12, 2019
MD Magazine Staff
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Let’s move on now to future directions. We want to say what we’re going to do with future CVD [cardiovascular disease] risk evaluation. Now, you’re not a soothsayer. You can’t really tell us about the future. But where do you think we’re going, Melissa?
Melissa L. Magwire, RN, MSN, CDE: I think we’re going to go with using these agents earlier and earlier on in the milieu of type 2 diabetes, even in prediabetes, hopefully. We know that macrovascular complications start even prior to the diagnosis of type 2. We usually tend to think of this after diagnosis, but macrovascular complications and damage actually start early on in the prediabetes stage with the inflammation and the cascades that go along with that. So we’d really like to see some of these medications used or actually approved for use earlier on, especially given the fact that some of these do not lower glucose to a significant level of hypoglycemia.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: You know, the first time many patients know they have heart disease, they have an event.
Melissa L. Magwire, RN, MSN, CDE: Exactly.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: And you can feel pretty good about 15 seconds before your heart attack.
Melissa L. Magwire, RN, MSN, CDE: Exactly.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: So you’re saying yes, you understand the outcome studies. They were well described. The atherosclerotic cardiovascular disease events [ASCVD] and then the decrease in heart failure. But you’re thinking maybe even before that?
Melissa L. Magwire, RN, MSN, CDE: Even before that. There are some studies that show an A1C [glycated hemoglobin] of 5.5% which we know is a normal hemoglobin A1C. You can already have some of the damage happening in the macrovascular system, especially if you have a familial history—if you have FH. If you have excess adipose tissue, you’ve got those inflammatory markers going; we know there is some damage already being done.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: But the guidelines have not been updated.
Melissa L. Magwire, RN, MSN, CDE: No.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: The major guidelines using these new drugs. But what do we have available to help guide the clinician?
Melissa L. Magwire, RN, MSN, CDE: Basically just using the data that we have available. I would really like to see what my peers think about this as well. Granted that we are forced sometimes to follow guidelines as far as payers for these medications. But do you feel like eventually we would be able to use products earlier on, even maybe potentially in prediabetes?
Seth J. Baum, MD, FACC, FACPM, FAHA, FNLA, FASPC: I think it’s a great point, and certainly mechanistically it makes sense. But I think we have to wait for the studies. I think we do have to wait for the studies.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: What do you think, earlier use before documented ASCVD? And we recognize that the studies, to a large extent, support it mainly in patients with ASCVD. We also recognize that the major guidelines have not yet adopted this approach, so these are opinions that we’re giving.
Peter McCullough, MD, MPH, FACC, FACP, FAHA, FCCP, FNKF: Right, OK. So here’s an opinion that has some data behind it. In 1 of the SGLT2 [sodium-glucose cotransporter 2] trials, about half the heart failure benefit was actually the prevention of the first heart failure hospitalization and half was preventing somebody who has an existing heart failure, as an example. I’m of the mind-set now that if I have a type 2 diabetic who’s on metformin and I have a next drug to choose, it looks as if what’s emerging is a compelling indication for cardiovascular and renal benefit to choose 1 of these newer agents, either an SGLT2 or a GLP-1 [glucagon-like protein 1]. I may modify the decision based on what’s the predominant other problem: hypertension, excess adiposity, and how to tailor it. But I can tell you, in my clinical practice I’m already moving there.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Well, it takes 3 to 4 years for major guidelines. With the lipids and the hypertension, when there was the shift from NHLBI [National Heart, Lung, and Blood Institute] to ACC [American College of Cardiology], AHA [American Heart Association], and the other major organizations, there was a gap of 6 to 7 years. If we wait till guidelines come into play—major guidelines, not the consensus pathways—we may have people who have heart attacks and strokes and proceed to end-stage renal disease who could have benefited. Is that reasonable?
Peter McCullough, MD, MPH, FACC, FACP, FAHA, FCCP, FNKF: Yeah, I’d agree with you. Everyone has to be within their comfort zone. I have a lot of compassion for primary care doctors. I practice internal medicine and cardiology, and to stay on top of it from an internal medicine perspective and then be ahead of the guidelines may be a bit much to ask of a primary care physician.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Well, we’re going to talk about this a little bit because Seth is going to tell us whether or not we, as cardiovascular specialists, should be embracing these drugs maybe even more than just the persons who traditionally treat diabetes. Any comment you want to make on this whole approach of where we’re going forward, recognizing that the major guidelines don’t say thou shalt do and that there are no class 1A major guideline evidence?
Christopher P. Cannon, MD: Well, the shift in the guidelines in the current EASD [European Association for the Study of Diabetes] document, then in the ADA 2019 [American Diabetes Association 79th Scientific Sessions], 1 of following just what you said, of using patient characteristics to choose classes of drugs. And so is there known ASCVD, or renal dysfunction, or heart failure, or the need to get more weight loss is 1 of the factors, or problems with hypoglycemia, there are specific drugs, or cost is the final pillar there. If that’s a real mind shift to say, wait a minute, let me look at this patient profile and see which class would be used, not just what’s the number. So that, I think, is a really big shift but a very positive one.
Seth J. Baum, MD, FACC, FACPM, FAHA, FNLA, FASPC: Melissa had raised the question though of the prediabetic, actually, so where doctors are currently using metformin in many of the prediabetic patients. And she questioned whether we’d be moving in the direction of using 1 of these other agents, let’s say in the prediabetic with established cardiovascular disease. Do you think it’s prime time for that, in your practice at least, either of you?
Christopher P. Cannon, MD: Well, I think 1 of the problems is that not all patients with prediabetes progress to diabetes. And my sense is that it would be helpful to work on predictors of who will progress and more risk stratification of this category. We’ve been actually tracking. So someone looks up the hemoglobin A1C before I go to clinic, and probably half my clinic has prediabetes. But then when I talk to them, it’s my emphasis on lifestyle, and food, and diet—that is what my big intervention there is to try to catch things early and get people on a little bit better trajectory. Very often, people say, “Oh, I’ve been so busy the last few years. I’ve slacked off on my getting to the gym.” So that’s been a key, and then metformin certainly is showing up as sort of the next step if people aren’t making progress, to try to get that started.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Do you think in terms of risks we’re not doing enough?
Seth J. Baum, MD, FACC, FACPM, FAHA, FNLA, FASPC: Oh, my God, we’re not doing enough, of course, on all counts.
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: Let me ask in a way so that it’s really clear for the audience. Are we doing enough?
Seth J. Baum, MD, FACC, FACPM, FAHA, FNLA, FASPC: We are not doing enough. So we’ve seen it from the lipid standpoint. We spoke about that. I would say less than 20% of patients with diabetes and established cardiovascular disease are at a lipid goal, the LDL [low-density lipoprotein] goal. That’s pretty abysmal, I think. From the standpoint of encouraging weight loss and therapeutic lifestyle changes and all that, we’re not doing enough. From the standpoint of putting patients on 1 of the agents that we’ve been speaking about, we’re not doing enough. So I think we’re not doing enough, but I think we’re talking about this and people are listening and people are paying attention. So I actually feel very optimistic and very encouraged that with the recent ADA position and the ACC and their alignment, that people will stop and consider their patients with diabetes and established cardiovascular disease and make a decision to use 1 of the agents we’re talking about.
Transcript edited for clarity.