New drugs for people with diabetes seem to be constantly emerging. Medicines that help the body break down carbohydrates, medicines that increase the excretion of glucose in the urine, medicines that help the muscles to respond to insulin and medicines that stimulate the pancreas to produce it -; the list of pharmaceutical options for treating diabetes is getting longer and longer.
The downside of this wealth of treatment options is that it can be difficult for healthcare providers to stay up to date with the latest research and standards of care. Which drug is best for which patients? And what are the best prescription drugs that lower blood glucose and reduce the risk of cardiovascular disease?
Endocrinologist Johns Hopkins Medicine and Associate Professor Rita Rastogi Kalyani, Ph.D. Med., Is the author of an article for a review of clinical practice in the April 1 issue The New England Journal of Medicine (NEJM) which distills the latest research results and guidelines into a systematic approach to the treatment of patients with diabetes and the risk of cardiovascular disease. Kalyani’s article is the first review of clinical practice published by the journal on diabetes management in nearly ten years.
Unlike research studies, clinical practice reviews represent a common clinical problem and evidence supporting different treatment strategies, followed by a review of the author’s guidelines and clinical recommendations for optimizing patient care.
People who have type 2 diabetes are more than twice as likely to develop atherosclerotic cardiovascular disease and heart failure than people who do not have the disease. The NEJM The article presents a modern approach to health care providers in choosing glucose-lowering therapies for their patients with diabetes, especially to reduce the risk of cardiovascular disease.
The last few years have seen a big shift in diabetes care. We now have tools to better understand how to reduce both microvascular and macrovascular complications in people with type 2 ”diabetes.
Rita Rastogi Kalyani, Ph.D. Med., Associate Professor and Endocrinologist of Medicine Johns Hopkins
The article examines the cardiovascular benefits and risks of the most commonly used diabetes medications currently available in the U.S. market.
Kalyani cites specific agents in two newer classes of drugs as useful for diabetic patients who are already showing signs of cardiovascular disease.
Glucagon peptide-like receptor agonists (GLP-1), liraglutide, semaglutide for injection, and dulaglutide increase insulin production in the body, especially after meals.
Sodium glucose inhibitors cotransporter 2 (SGLT2) empagliflozin and canagliflozin reduce the amount of glucose that the body reabsorbs in the urine.
They all effectively help patients reduce the chances of a major cardiovascular event, such as a heart attack or stroke. The SGLT2 inhibitor, dapagliflozin, effectively helps reduce the chance of hospitalization for heart failure.
“Following metformin, which is widely considered to be the initial treatment for type 2 diabetes drugs, specific drugs in GLP-1 receptor agonists and SGLT2 inhibitors with shown cardiovascular benefit should be considered as adjunctive drugs for patients already with cardiovascular disease. whether their A1C level is targeted to reduce the risk of future cardiovascular events, ”says Kalyani, referring to the hemoglobin A1C test, which measures a patient’s average blood glucose level over three months.
Sugar binds to a protein in red blood cells that carries oxygen to organs and tissues and transports carbon dioxide to the lungs. The A1C test measures the average percentage of glucose in a person’s hemoglobin over several months. Healthy A1C levels are below 5.7%. In general, A1C levels higher than 6.5% indicate diabetes.
Kalyani notes that newer drugs are more expensive and the long-term effects are unknown. Prior to 2008, the U.S. Food and Drug Administration -; agency regulating the pharmaceutical industry -; did not require major studies of drug outcomes after their introduction to the market. As a result, Kalyani says, the cardiovascular effects of older drugs are still less certain.
The NEJM The article describes in detail specific medications that offer additional benefits for diabetic patients who have conditions such as risk factors for multiple cardiovascular disease, heart failure, and chronic kidney disease.
“Some agents like dulaglutide and dapagliflozin have also shown cardiovascular benefit in patients with multiple cardiovascular risk factors,” Kalyani says.
Furthermore, specific SGLT2 inhibitors may be useful for patients who have heart failure with a reduced ejection fraction -; a condition in which the heart muscle does not pump blood efficiently -; as well as for patients with chronic kidney disease.
The article includes comprehensive drug tables that include factors to consider in clinical practice when selecting a glucose lowering drug for patients with type 2 diabetes, including efficacy to reduce A1C, mode and frequency of administration, costs, effects on weight, risk of hypoglycemia, side effects and clinical benefits.
“Healthcare providers in primary care, endocrinology, cardiology and nephrology are now prescribing these newer glucose-lowering drugs to their patients,” Kalyani says. “Diabetes care in the future will have to work more and more together and, basically, stay patient-centered.”
Kalyani previously served as chairman of the American Diabetes Association’s Professional Practices Committee, which updates the Diabetes Medical Care Standards, the organization’s recommendations for clinical practice, each year. She is also a co-author of clinical guidelines published by the Endocrine Society and the American College of Cardiology.
Kalyani, RR (2021) Glucose lowering drugs to reduce cardiovascular risk in type 2 diabetes. New England Journal of Medicine (NEJM). doi.org/10.1056/NEJMcp2000280.