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ACC Pathway Finds Empagliflozin "Preferred" SGLT2 Therapy for Patients With Type 2 Diabetes, ASCVD

Mary Caffrey
The authors noted that until recently, medications to control blood glucose were not expected to offer any benefit in helping patients avoid cardiovascular events.
A new American College of Cardiology (ACC) Expert Consensus Decision Pathway states that empagliflozin is the preferred therapy among sodium glucose co-transporter 2 (SGLT2) inhibitors for patients with type 2 diabetes (T2D) and atherosclerotic cardiovascular disease (ASCVD).

The pathway document, which features a chart to guide cardiologists in clinical practice, was published this week in the Journal of the American College of Cardiology (JACC).1 The consensus document also finds that that liraglutide is the preferred treatment among a second novel class of T2D treatments, the glucagon-like peptide-1 (GLP-1) receptor agonists.

Empagliflozin is sold as Jardiance by Boehringer Ingelheim and Eli Lilly; liraglutide is sold as Victoza by Novo Nordisk.

Although cardiovascular disease remains the leading cause of morbidity and mortality in patients with T2D, the authors write that until recently medications to achieve glycemic control were not expected to offer any cardiovascular benefit. “The recent development of [2] novel classes of therapies—SGLT2 inhibitors and GLP-1 [receptor agonists]—has, for the first time, demonstrated that treatments developed for glucose lowering can directly improve outcomes,” wrote Writing Committee Co-Chairs Sandeep R. Das, MD, MPH, FACC;  Brendan M. Everett, MD, MPH, FACC; and their colleagues.

Having ACC weigh in on how cardiologists should treat T2D patients represents a paradigm shift in treating the disease, but one that is a natural evolution given developments since 2015 in research, treatment, and guidelines from major organizations engaged in diabetes care. On October 5, 2018, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes jointly updated their consensus statement on management of hyperglycemia to include SGLT2 inhibitors and GLP-1 receptor agonists.2

ADA endorsed the ACC pathway, and William T. Cefalu, MD, ADA’s chief scientific, medical and mission officer, served as an author on the JACC article.

Thomas Seck, MD, vice president of US Clinical Development and Medical Affairs, Primary Care, at Boehringer Ingelheim, shared the authors’ appreciation for the change in thinking about shared responsibilities of cardiologists and primary care physicians in diabetes care. “This is an important milestone—it underscores the important change we’ve seen in the last few years,” as guidelines have changed to reflect new evidence, he said in an interview with The American Journal of Managed Care®. “There are now multiple options for patients with type 2 diabetes and established cardiovascular disease, and that’s critically important.”

For ACC to put the cardiologist in charge of management of cardiovascular risk for the T2D patient is a major step forward, Seck said. “Before, diabetes was about managing glucose, and the cardiologist was much less involved in managing glucose,” he said.

The shift began in 2008, when the FDA began requiring that makers of T2D therapies conduct large cardiovascular outcomes trials (CVOTs) to demonstrate safety. (An FDA advisory panel held a 2-day hearing on the future of these trials in October.) Then in September 2015, investigators for the EMPA-REG OUTCOME trial stunned the diabetes community with results that showed a 38% reduction in cardiovascular death and a 32% reduction in death from any cause, compared with placebo.3

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