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ACC Provides Guidance to Cardiologists on Using SGLT2 Inhibitors and GLP-1RAs

Key findings

  • The American College of Cardiology (ACC) now urges cardiologists to consider sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists for patients with type 2 diabetes who have atherosclerotic cardiovascular disease
  • A new Expert Consensus Decision Pathway on this topic includes an algorithm for managing these patients
  • Cardiologists should watch for emerging evidence in this rapidly changing area of medicine

There has been a paradigm shift in the care of patients with type 2 diabetes: new classes of diabetes drugs present opportunities to prevent associated major adverse cardiovascular (CV) events.

Clinical trials of sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide 1 receptor agonists (GLP-1RAs) have shown that these agents reduce rates of cardiovascular events. In the case of GLP1-RAs, lower rates of vascular complications such as acute myocardial infarction or stroke were seen, while trials of SGLT2 inhibitors showed an impact on cardiovascular death and hospitalizations related to heart failure. These benefits are independent of the drugs' direct glucose-lowering effects.

New Responsibilities for Cardiologists

The traditional role of the cardiovascular disease (CVD) specialist needs to be reexamined, according to a new Expert Consensus Decision Pathway from the American College of Cardiology (ACC), published in the Journal of the American College of Cardiology.

The document calls for cardiologists to adopt a more active role in prescribing SGLT2 inhibitors and GLP-1RAs for patients with type 2 diabetes who also have atherosclerotic CVD, and to adopt a collaborative, interprofessional and multidisciplinary approach to caring for this high-risk group.

James L. Januzzi, Jr, MD, FACC, is chair of the ACC Task Force on Expert Consensus Decision Pathways and was part of the writing committee. He explains in a preface that ACC Expert Consensus Decision Pathways provide guidance in areas in which evidence is new and evolving.

Practice Recommendations

The Expert Consensus Decision Pathway is a practical guide for initiating and monitoring SGLT2 inhibitors and GLP-1RAs with the express goal of reducing CV risk. It summarizes key elements from emerging studies and discusses the mechanisms, benefits and safety risks of the novel therapies.

As its title suggests, the heart of the document is a decision pathway that gives step-by-step guidance to clinicians. The paper also covers issues such as:

  • How to choose between an SGLT2 inhibitor and a GLP-1RA for an individual patient
  • Whether patients need to be on metformin before initiating an SGLT2 inhibitor or GLP-1RA
  • Whether SGLT2 inhibitors and GLP-1RAs should be used concomitantly
  • How to monitor patients when prescribing an SGLT2 inhibitor or GLP-1RA

Expect Change

Dr. Januzzi and his colleagues note that this area of medicine is likely to continue to evolve rapidly because additional CV outcomes trials of SGLT2 inhibitors and GLP-1RAs are ongoing or recently completed. They encourage CVD specialists to watch for the decision pathway to change as new evidence emerges.

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