Conference Coverage

GLP-1 agonists, SGLT2 inhibitors offer more options in diabetes management


 

EXPERT ANALYSIS FROM CARPS 2019

– The big news in diabetes management this year is “happy cardiologists and nephrologists.”

Christine Kessler is an award-winning nurse practitioner, national/international speaker, author, researcher and consultant. She recently founded Metabolic Medicine Associates in King George, Va. Jeff Craven/MDEdge News

Christine Kessler

According to Christine Kessler, MN, ANP-C, CNS, BC-ADM, FAANP, founder of Metabolic Medicine Associates in King George, Va., these specialists are happy because the American College of Cardiology and the American Diabetes Association both recently updated their respective societies’ guidelines to include evidence that treating patients with type 2 diabetes with glucagonlike peptide-1 (GLP-1) agonists, sodium-glucose cotransporter 2 (SGLT2) inhibitors, or metformin can lower risk of cardiovascular disease and chronic kidney disease.

“Finally, the ACC is aligned with the ADA,” Ms. Kessler said in her presentation. “This is amazing, and it’s good news.”

Recent innovations in diabetes management technology, such as continuous glucose monitors, are also helping to make diabetes management easier. “If you’re not using some of this technology in your primary care practice, it’s coming to you, and it’s amazing the data it can provide to us,” said Ms. Kessler at the Cardiovascular & Respiratory Summit by Global Academy for Medical Education.

In endocrinology, diabetes is thought of in terms of macrovascular and microvascular disease, she said. Macrovascular disease is cardiovascular disease and stroke, while microvascular disease is nephropathy, neuropathy, and retinopathy. Diabetes is a cardiovascular risk factor and puts patients at higher risk for cardiovascular death, all-cause mortality, and hospitalization because of myocardial infarction or stroke, compared with patients who do not have type 2 diabetes. There is also a higher risk of kidney disease, nerve damage, blindness, nonalcoholic fatty liver disease, depression, complications during pregnancy, periodontal disease, and erectile dysfunction, said Ms. Kessler, who also is a nurse practitioner and researcher.

However, the “bottom line” in diabetes management is still initiating lifestyle changes, including getting enough sleep, dietary interventions that target weight loss and blood glucose control, and increasing physical activity that has cardiopulmonary benefits. Clinicians should also treat underlying conditions that contribute to increased cardiovascular risk, such as obesity, dyslipidemia, hypertension, and nonalcoholic fatty liver disease.

Addressing insulin resistance and hyperglycemia are also important, but patients must avoid hypoglycemia. “Any patient with diabetes, we don’t want to drive them there because that’s a cardiac risk,” said Ms. Kessler. The endothelial microvascular and macrovascular damage is believed to be caused by glycemic swings, she added.

For pharmacologic therapy, patients with type 2 diabetes should stay on metformin if they are already on the drug, and it can even be used in cases where patients have reduced kidney function, with a glomerular filtration rate (GFR) between 30 and 60 mL/min per 1.73 m2, with a lower dose used between 30 and 45 mL/min per 1.73 m2. To treat patients with atherosclerotic cardiovascular disease, recent evidence has shown GLP-1 agonists are beneficial and can also promote appetite satiety, prandial support, and reduce a patient’s weight, but the drug is expensive, and about 15% of patients will not see therapeutic benefit while on the medication, said Ms. Kessler. Clinicians should also watch for increased risk of pancreatitis while patients use GLP-1 agonists, and it should not be prescribed in patients with a history of thyroid medullary cancer or multiple endocrine neoplasia type 2 (MEN2).

SGLT2 inhibitors can benefit type 1 diabetes and type 2 diabetes patients with heart failure and diabetic kidney disease, but should be the second or third choice in therapy. The dosage of SGLT2 inhibitors should be cut in half when used with insulin and sulfonylurea, and the drug can also increase LDL cholesterol.

Ms. Kessler noted that while GLP-1 agonists and SGLT2 inhibitors prevent or reduce cardiovascular risk, they are not currently approved to treat cardiovascular disease.

Ms. Kessler reports being an advisor and speaker for Novo Nordisk on the subject of obesity. Global Academy for Medical Education and this news organization are owned by the same parent company.

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