In the statement, the authors discuss evidence from multiple large, international, randomized controlled trials of sodium glucose co-transporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1 RAs). In these trials, conducted through March 2020, the authors found that the 2 classes of medicines assessed should be considered for people with CKD and T2D to protect against the potential for heart and kidney disease, as well as other serious complications.
Additionally, the authors said these classes of medications would also be beneficial to manage the risk for CVD in those who are at risk of or who have already had the disease. Based on the findings from the trials, the authors observed that SGLT2 inhibitors and GLP-1 RAs can safely and significantly reduce the risk of CVD events and death, reduce hospitalization, and slow the progression of chronic to end-stage kidney disease, which includes the risks of dialysis, transplantation, or death.
“A collaborative treatment approach among primary care doctors and specialists in diabetes, cardiology and kidney disease that, when indicated, includes treatment with these two classes of medications could add more heart- and kidney disease-free years and greatly extend survival for people with type 2 diabetes,” said chair of the statement writing committee, Janani Rangaswami, MD, FACP, FAHA, associate chair of research in the department of medicine at Einstein Medical Center and associate clinical professor at the Sidney Kimmel College of Thomas Jefferson University, in a press release.
Patients with T2D commonly experience CKD as a long-term complication, as well as experience an increased risk for high blood pressure and CVD, resulting in events such as heart attacks, heart failure, and stroke.
In the statement published by the AHA, the authors detail practical guidelines for providers when treating patients who may benefit from SGLT2 inhibitor and GLP-1 RA medications in order to prevent them from suffering from these life-threatening complications.
The recommendations the authors made in the statement included the following:
- Conduct early and ongoing risk assessment for patients with kidney and heart disease who may benefit from the medicines.
- Tailor medication options to the needs of each patient.
- Monitor and control occurrences of high blood pressure in patients.
- Identify risks for hypoglycemia and educate patients on warning signs that would require that they seek immediate treatment.
- Adjust all medications in unison with these medicines and consider the burden of needing to take 5 or more medications daily for multiple conditions, which is common among patients with T2D.
- Counsel patients regarding the risks and symptoms of euglycemic diabetic ketoacidosis (DKA) while taking SGLT2 inhibitors, as well as risks and symptoms of classic DKA (the occurrence of very high blood sugar and the buildup of ketones in the body), the results of which can be fatal.
- Conduct regular screenings and counsel patients regarding foot care to prevent ulcers or blisters that could become infected and result in amputation.
The authors also noted that there are 2 additional subgroups of patients who may benefit from these medications, including people with heart failure with reduced ejection fraction (HFrEF) with or without T2D and people with CKD who do not have T2D. However, the authors explained that currently more data are needed to validate the use of SGLT2 inhibitors and GLP-1 RA medications for these at-risk patients.
In 2005, GLP-1 RA medicines were approved by the FDA for glycemic control. In 2013, SGLT2 inhibitors were approved for treating patients with T2D. Each class of medicine works differently, as SGLT2 inhibitors decrease blood sugar by causing the kidneys to remove sugar through passing it in urine, whereas GLP-1 RAs work by simulating the body’s natural incretin hormones that lower blood sugar levels after meals.
Prior research on SGLT2 inhibitors have demonstrated that they can reduce the risk of heart failure, slow the progression of CKD, and reduce risk of death from CVD. GLP-1 RAs have been shown to reduce risk of heart attack, ischemic stroke, and/or death from CVD.
Yet SGLT2 inhibitors and GLP-1 RAs are not widely prescribed for patients who present with higher risks for CVD and CKD, despite the research showing their use in managing the potential for these complications. A recent study showed that among more than 1 million commercially insured and Medicare Advantage adult beneficiaries, only 7% of patients with T2D were being treated with an SGLT2 inhibitor.
“The most important question that needs to be addressed in the future is the actual implementation of these medicines in clinical practice,” Rangaswami said in the press release. “When multidisciplinary teams can identify high-risk patients and ensure targeted delivery of these therapies, as appropriate, we could greatly reduce the burden of heart and kidney disease for millions of people with Type 2 diabetes. Improving the cardiovascular and kidney health of as many people as possible—reducing morbidity, mortality and health care expenditures—are the primary goals.”
Newer Type 2 diabetes medications have heart and kidney disease benefits, too. Dallas, TX: American Heart Association; September 28, 2020. eurekalert.org/pub_releases/2020-09/aha-nt2092320.php. Accessed September 29, 2020.