Managing T2DM to Control CVD in Diabetic Patients

Currently, over 29 million people are living with diabetes in the US. This number is projected to rise to 55 million by the year 2030.

Type 2 diabetes mellitus (T2DM) is a major risk factor for cardiovascular disease (CVD), and nearly 70% of people over the age of 65 years with diabetes die of heart disease.

Jeffrey S. Freeman, DO, Chairman of the Division of Endocrinology and Metabolism at the Philadelphia College of Osteopathic Medicine, joined Penny Tenzer, MD, Professor of Clinical Family and Vice Chair of Academic Affairs at the University of Miami School of Medicine, and Richard E. Pratley, MD, Senior Investigator at the Translational Research Institute for Metabolism and Diabetes in Orlando, FL, onstage at PriMed West in a presentation at focused on improving outcomes for patients with both (T2DM) and cardiovascular disease (CVD).

Freeman began the session by breaking down the risks for patients with T2DM and CVD, telling his audience that T2DM alone significantly reduces life expectancy by 6.7 years.

“We also know that if we add a history of myocardial infarction (MI) to T2DM, life expectancy is reduced by 11.2 years, and 15.7 years when you have the metrics of T2DM and MI, and you add the history of stroke,” Freeman said.

Prately, the second speaker, focused on cardiovascular outcome trials (CVOTs) that began to be conducted following CVD risks detected with the diabetes drug Avandia in 2008. Pratley said that such trials have proven to be quite useful in developing better data for patient safety.

Prately also pointed out that while patients are not dying of hyperglycemia but rather macrovascular disease, that there is a 14% increase in fatal and nonfatal MI for every 1% increase in A1C level. Early initiation of glucose-lowering therapy can result in reduced macrovascular disease, and additional benefits are seen when A1C levels drop to 7% or less.

However, treatment of hyperglycemia alone will not eliminate CVD risk in patients with T2DM, Prately said, adding that comprehensive risk factor management is key to success in reducing CVD in this patient population. While a consideration of ethnic and cultural factors is required in evaluating diverse patient populations, comprehensive treatment must include lifestyle interventions that include improved diet, increased physical activity, weight loss, and stopping smoking.

Pratley characterized pharmacotherapy as a tool that can provide additional vascular protective measures, stating that progress in these areas “has brought us to the dawn of a new era in the management of T2DM with the added benefit that new antihyperglycemic agents not only lower A1C levels but also impact CVD outcomes.”

But as Pratley reviewed the 12 classes of medications currently available for treating diabetes, he commented, “The problem is not that we don’t have drugs, it’s trying to figure out which drugs to use, which combinations to use, and when to use them for which patient.”

Tenzer, the third speaker, focused on patient profiles and case examples of glycemic control in patients with T2DM and CVD to shed more light on how to select drugs and combinations of drugs for treatment. Tenzer also stressed the importance of a comprehensive evaluation of individual patient risk factors.

“As we get more and more anti-hyperglycemic agents, we have to consider all the factors with our patients,” Tenzer said. “These include whether they get hyperglycemic easily, whether weight is an issue, whether sleep apnea is an issue, their statins, all of those things. New data will continue to come in from CVOTs that must be considered.”

Tenzer emphasized the importance of tailoring treatments to individuals in her conclusion, advising her audience that the key word in diabetes management is individualization.

“We try to match the medication to the patient the best we can,” Tenzer said. “This how we achieve patient-centered care.”