Nihar Desai, MD, MPH, is an assistant professor of medicine in the Cardiovascular Medicine Section of the Yale School of Medicine and an investigator in the Center for Outcomes Research & Evaluation. His interests include the identification of opportunities to improve outcomes and the evaluation of the impact of novel care delivery systems on cost and quality. He has served in leadership positions in several organizations and is passionate about the need for strong physician leaders to advocate for patients and for the profession.
An editor from The American Journal of Managed Care® recently conducted a question-and-answer session with Desai to discuss strategies for improving cardiovascular outcomes among patients with type 2 diabetes.
The American Journal of Managed Care (AJMC®)
: What is the relationship between diabetes and cardiovascular (CV) disease? How does the presence of CV disease or CV risk factors affect the management of type 2 diabetes?
Nihar Desai, MD, MPH: A body of literature demonstrates that diabetes increases the risk of developing CV disease, including coronary heart disease and congestive heart failure. Although there has been some disagreement about whether diabetes is a coronary heart disease equivalent, it clearly is a risk factor for CV disease, and patients with both conditions face considerable morbidity and mortality. More recently, we have come to a more global management paradigm of CV risk factors among patients with diabetes. Because CV disease is a leading cause of morbidity and mortality, optimizing blood pressure, lipids, and the use of antithrombotic therapies and other medications that reduce CV risk plays a central role in the management of patients with type 2 diabetes.
: In your experience, who manages CV risk for patients with diabetes? Is it the endocrinologist, the cardiologist, or both? Is care provided efficiently?
Desai: Ideally, it is the entire care team. Sure, there is an endocrinologist and a cardiologist, but there is also the primary care physician, the advanced practice provider, the pharmacist, and the diabetes educator, among others. The patient expects and deserves the entire care team to be coordinated in their approach and unified in their goal—to improve the patient’s health. I think there is always room for improvement. The system is too often siloed and fragmented, uncoordinated and opaque. We desperately need more multidisciplinary team—based models of care for all our patients, in particular those with diabetes, given all the issues at play.
: In your experience, are community cardiologists knowledgeable about the management of diabetes, or do unmet educational needs still exist?
Desai: I think all cardiologists—regardless of practice setting, geographic area, or number of years in practice—can benefit from educational materials highlighting the optimal management of patients with diabetes and CV disease. Issues related to blood pressure control, antithrombotic therapy, lipid management, and use of other CV-risk reducing therapies are of such critical importance that they deserve to be highlighted and reemphasized. The use of more novel therapies, such as SGLT2 [sodium-glucose cotransporter 2] inhibitors and GLP-1 [glucagon-like peptide 1] receptor agonists, also needs focused educational outreach. These are agents that were historically deemed outside the purview of cardiologists, as they were traditionally thought of as diabetes medications. However, as evidence of their CV benefits continues to emerge, they are increasingly and appropriately viewed as CV risk—reducing medications just like statins. However, this is a paradigm shift, and therefore, education, feedback, and encouragement are required.
: Can you describe how the goal of treatment has shifted away from a focus on tight blood glucose control and toward evaluating and reducing overall CV risk?
Desai: This has been an incredibly important shift. Moving away from diabetes management that focused almost exclusively on glycemic control to a much broader and more patient-centered approach around reducing morbidity and mortality by addressing CV risk has happened over years and decades. I would say the clinical practice environment was [previously more] siloed and fragmented. Each provider had their sphere of influence, and for diabetes, that was glycemic control. However, results from epidemiologic and clinical research compelled a reevaluation. Analyses highlighting the CV risk of patients with diabetes and other [analyses] highlighting the importance of blood pressure, lipid, and antithrombotic therapy to address CV risk in this population helped catalyze a change in focus. More recently, the arrival of therapies that have only modest effects on HbA1c [glycated hemoglobin] levels, including SGLT2 inhibitors and GLP-1 receptor agonists, but have substantial benefits in terms of CV risk have further emphasized the need to look broadly at addressing CV risk.
: What have the results of clinical trials shown regarding the impact of various diabetes medications on CV comorbidities? For example, what have we seen in terms of reductions in major adverse cardiac events (MACE) and benefits in heart failure with the SGLT2 inhibitors, GLP-1 receptor agonists, and dipeptidyl-peptidase-4 (DPP-4) inhibitors?
Desai: A number of clinical trials [have evaluated] diabetes medications of varying mechanisms. The DPP-4 inhibitors have been shown to reduce HbA1c without increasing CV risk, though there may be a signal for increasing the risk of heart failure. More recently, [results of] clinical trials of SGLT2 inhibitors across patients of varying risk suggest that these [medications] can reduce the risk of MACE, particularly among patients with established CV disease. The data for GLP-1 receptor agonists are also consistent [in] showing a reduction in MACE. The newest data to emerge have been the dramatic reductions in the development of heart failure among patients with diabetes but no prior history of heart failure, as well as reductions in morbidity and mortality among patients with heart failure who receive SGLT2 inhibitors. Dapagliflozin has strong data in patients with heart failure, specifically patients with reduced ejection fraction heart failure, though clinical trials with several other SGLT2 inhibitors are ongoing. A very interesting aspect of the most recent data from DAPA-HF [NCT03036124] is that the benefit was consistent regardless of whether the patients had diabetes. Several other SGLT2 inhibitors, including empagliflozin, canagliflozin, and ertugliflozin, are also being studied in clinical trials of heart failure including for both heart failure with reduced and preserved ejection fraction. Secondary analyses of completed trials would suggest that the improvements in outcomes among patients with heart failure will be a class effect, but we eagerly await the results of the dedicated heart failure trials with these other agents.
: How have these clinical trial results affected your use of these classes of medications?
Desai: The emerging data have certainly [affected my] use of these medications. As a cardiologist, I am always looking for ways to improve outcomes for patients. As the evidence continues to come together, we have worked with our colleagues in endocrinology and pharmacy to develop care pathways and frameworks to more broadly use these agents [SGLT2 inhibitors and GLP-1 receptor agonists].
AJMC®: According to guidance from the American Diabetes Association (ADA) and the American College of Cardiology (ACC), what drug classes are recommended in patients with diabetes and established CV disease?
Desai: Among patients with diabetes and established CV disease, the recommendations are for the addition of an SGLT2 inhibitor or a GLP-1 receptor agonist that has demonstrated benefit in clinical trials. Among patients with heart failure, there is a preference for the SGLT2 inhibitors based on the data that we have seen thus far. In terms of which specific agent, I think the patient’s insurance provider/pharmacy benefit manager as well as the clinical situation influence that choice. Many plans have a preferred agent and we are certainly guided by that. In addition, if the clinical use is for heart failure specifically, I would favor dapagliflozin, given the clear and strong evidence of benefit.
: Are cardiologists aware of current guidance from the ADA and ACC, and are they applying this guidance in their day-to-day practice? If not, what can be done to improve awareness of current guidance and help cardiologists incorporate up-to-date guidance into their everyday clinical practice?
Desai: I think cardiologists are aware of the current guidance, but given how recent it is, many are still working through its implementation in their local practice environment. There is always a role for educational initiatives and outreach efforts. In addition, timely and accurate reports and performance data can help providers improve care. Finally, cardiologists need to hear from endocrinologists that they are supportive of cardiologists’ initiating these therapies, and [cardiologists should work together with] other healthcare professionals, including diabetes educators and pharmacists, who are available to help in the care of these patients.
: What steps can clinicians take to employ a more holistic approach to the management of type 2 diabetes and CV risk? What could cardiologists do better or differently to improve CV risk management in patients with diabetes?
Desai: It starts with having a good understanding of the CV risk that patients with diabetes have and then working deliberately to assess the risk factors and modify them. Patients desire and deserve to have every provider they see working together to optimize their health and improve outcomes. Cardiologists need to engage more with primary care physicians, endocrinologists, and other healthcare professionals to help facilitate multidisciplinary care that is coordinated and patient centered.
In your clinical practice, what types of support have you received from health plans or health systems—for example, case management programs? Have these programs helped improve patient outcomes? If yes, what has been helpful? If no, what more can be done?
Desai: We have seen myriad programs and services, from diabetes educators to navigators to disease management programs. The most helpful aspect of all these programs is that they engage providers, educate them, and provide much-needed help to care for patients with diabetes. I think these programs are most impactful when they are holistic and patient centered. They are not exclusively focused on medications, but they offer a portfolio of options and engage patients in their own care. We need a lot of this, and I think providers and plans are linked in their desire to improve outcomes for patients and members.
: What are your thoughts on the future of diabetes care? Are you optimistic? What can we look forward to in the next 5 to 10 years?
Desai: I am both concerned and optimistic. We see that rates of obesity and metabolic syndrome continue to increase and accelerate in our country and around the world. Therefore, the epidemic of diabetes and diabetes-related complications will be with us for the foreseeable future. That said, I am quite optimistic, as the innovation in this space has been admirable. [Given the innovations ranging] from new therapies to new models of care to new technologies and digital interventions to improve awareness, empower patients, and optimize care, I believe very strongly that we are poised to meet the needs of our patients and communities.