Cardiorenal and metabolic risk as important as glucose levels in T2 Diabetes
The new American Diabetes Association Standards of Care in Diabetes guideline reinforces the importance of educating patients on the importance of managing cardiorenal and metabolic risk in addition to glucose levels. In fact, the ADA Standards of Care puts managing cardiorenal and metabolic risk at the same level as that of managing blood glucose levels.
Individuals with type 2 diabetes are at increased risk of both renal and cardiovascular events. The convergence of type 2 diabetes, chronic kidney disease, and cardiovascular disease, including heart failure, requires management by a multidisciplinary health care team. Primary care clinicians are likely to be the first and most frequent point of contact for individuals with type 2 diabetes who are at high risk of cardiorenal disease and therefore play a pivotal role in early diagnosis, establishment of effective treatment strategies, and coordination of care.
A Paradigm Shift in Diabetes Management
The new paradigm of diabetes management emphasizes cardiorenal risk reduction and weight management in addition to focusing on glucose control and the prevention and management of microvascular and macrovascular complications with non–glucose lowering agents. While non–glucose lowering agents such as statins and angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) have long been prescribed for prevention and risk reduction of cardiorenal disease, evidence-driven changes to the Standards of Care in Diabetes now call for the prescribing of diabetes medications to manage cardiorenal risk regardless of glycemic control. SGLT2 inhibitors are recommended first-line medications for T2D patients with heart failure (both with preserved and reduced ejection fraction) and chronic kidney disease.
Similarly, for patients with atherosclerotic cardiovascular disease (ASCVD) or at risk for ASCVD, either a GLP-1 receptor agonist or a SGLT2 inhibitor with proven cardiovascular benefit is recommended. For patients with indications for both GLP-1 receptor agonists and SGLT2 inhibitors, the addition of the alternate medication is indicated if additional glycemic control or risk-factor reduction is needed. These recommendations are updated annually in the American Diabetes Association’s Standards of Care in Diabetes, which summarizes evidence-based guidelines for comprehensive management of diabetes, cardiometabolic risk, and diabetes-related complications, including an abridged version for PCPs that also highlights key updates each year.
In 2008, the US Food and Drug Administration (FDA) mandated that all new glucose-lowering therapies have long-term cardiovascular outcome trials providing evidence to exclude an increased risk for major adverse cardiovascular events. Since then, multiple trials have shown both glycemic efficacy and cardiovascular safety of dipeptidyl peptidase (DPP-4) inhibitors, SGLT2 inhibitors, and GLP-1 receptor agonists. An unexpected finding in these trials was that many SGLT2 inhibitors and GLP-1 receptor agonists demonstrated cardiovascular benefit. Subsequent studies have demonstrated consistent benefits in heart failure, coronary artery disease, and chronic kidney disease, transforming the PCP’s strategy to diabetes management.