Cardiovascular Disease Guidelines for Diabetes Medications

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: Dr. Vaduganathan, as we talk about the ACC [American College of Cardiology] guidelines, I’d love your perspective on a couple other things in addition to the guidelines. Do you think we’re doing enough? I know sometimes we joke around in saying at least on the receiving end of it, I sometimes hear from my patients and saying, “Oh, the cardiologist recommended it.” It cuts off 8 minutes of my visit, so I really appreciate it. But do you see the adoption of the SGLT-2s, the GLP-1s, and how has that been from the cardiology community? Obviously, you see it incorporated within the guidelines. I would love that perspective, in addition, kind of where we are from an ACC standpoint.

Muthiah Vaduganathan, MD, MPH: Absolutely. It’s a great question. The ACCH, a formal guideline, updates every few years, so it lags behind the more rapid real-time updates of the ADA [American Diabetes Association], and I think we’re envious of our colleagues. The ESC [European Society of Cardiology], on the other hand, has had an interval update, and was actually one of the first sets of guidelines in 2019 in conjunction with the EASD [European Association for the Study of Diabetes], to actually propose first-line use of SGLT-2 inhibitors and GLP-1 receptor agonists ahead of metformin or even in metformin-naïve patients, recognizing no or limited heterogeneity in treatment effects across all study populations, with the caveat being that the proportion of metformin-naïve patients was low, but still represented thousands of patients across these trials.

I think the other elements that are worth mentioning, the ACC has a more practical guidance that they put forward called an expert consensus decision pathway, that discusses more of the nuances and practicalities of initiating some of these drugs for a practicing cardiologist. Those are quite helpful in terms of adjustment of concomitant medications, whether that be cardiovascular or antihyperglycemic therapies. It’s quite helpful.

In terms of your question about the uptake, I’d say it was modest to low until we started to see clinical benefit in nondiabetic cohorts. The 3 clinical trials, DAPA-Heart Failure, DAPA-CKD, and EMPEROR-Reduced, that showed benefits in large groups of people, actually the majorities of the trials, without diabetes, I think firmly established that this, of course, is not just a diabetes drug, and that is something that cardiologists had shied away from until then. Seeing the remarkable safety profile, especially in nondiabetic patients, where really all the glycemic adverse effects are not seen at all, I think allowed greater comfort of cardiologists to embrace these therapies in practice.

Transcript edited for clarity.