Guidelines Regarding Use of SGLT2s for Patients With Diabetes and HF

An expert panel of cardiologists reviews the ACC/AHA/ADA treatment guidelines regarding the use of SGLT2s for patients with diabetes and HF.


Neil Minkoff, MD: One of the things that we talk about a lot in population management and across implementation of different disease states is the use of the guidelines. Where are we with those, and how do you think they’re reflecting practice? HHHHow do you think they’ll be improved to improve practice? Dr Desai?

Nihar Desai, MD, MPH: It’s always hard to know where the guidelines are going to go. We’ve gotten some glimmers, at least on the cardiovascular side, with ACC [American College of Cardiology], AHA [American Heart Association], and other professional societies beginning to integrate this evidence. They are also increasingly advocating for the SGLT2 [sodium-glucose cotransporter-2] inhibitors, particularly in terms of the patients with atherosclerotic cardiovascular disease and diabetes. That’s where the first 3 or 4 trials came out. That’s really where the SGLT2 inhibitors first made their splash, to Dr Nissen’s point. In terms of the DAPA-HF trial data, and how the professional societies will then integrate those and synthesize them into a guideline, I’m eagerly awaiting what that document is going to look like. The clinical community would benefit from the professional societies coming forward and trying to make a statement about what they think best medical therapy is. In addition, and we were talking about this before with Dr Nissen, because you have such a broad number of therapies in the heart failure arena, how can one rationally use the therapies that are available? The last thing that our patients want to hear is, “Mr. Smith, we have yet another pill to add onto the 240 pills,” as in Steve’s example, that they’re already taking on a weekly basis. For us to be able to then think about the patients first and have the guidelines embody what clinical care should look like for them would be very beneficial for the clinical community. If one looks at the evidence on the heart failure side, and again, more will emerge, an impartial view of that would be…the standard background therapy, β-blockers, ACE [angiotensin-converting enzyme] inhibitors, and MRAs [magnetic resonance angiographies], because the data are so compelling.

Steven Nissen, MD: Let me say something a bit controversial here.

Neil Minkoff, MD: Not you!

Steven Nissen, MD: As the evidence emerged around the cardiovascular benefits of some of the newer diabetes drugs, I was frustrated that the ADA [American Diabetes Association] was abit slow on the trigger. There was a guideline early on that basically said to give metformin and then give whatever you want for the next step. Now, they’re gradually getting a bit better. There was sort of a political correctness and hesitation to offend the makers of any of the drugs by not showing any preferences. I get it. I understand that none of us want to do that. But we have to go where the evidence is. I find it very hard to advocate for certain classes, and I mentioned this before. I’m going to say it again. I find it hard to see patients get metformin and then get a DPP-4 [dipeptidyl-peptidase-4] inhibitor, particularly people who are at high risk for heart failure, when we know that at least 1 of the DPP-4 inhibitors seemed to increase the risk of heart failure. We have to move a little faster on the diabetes side. I would give the same criticism to the ACC/AHA guidelines. They’ve been historically conservative and perhaps unwilling to move as fast as the science moves, and it’s an area of frustration. Even I, as a past president of the ACC, have been a bit frustrated with my organization not being more proactive. Clinicians and academicians need to push these societies to get with the program and move a bit faster on the guidelines.

Nihar Desai, MD, MPH: Neil, if I could make one comment building on that.

Neil Minkoff, MD: Of course.

Nihar Desai, MD, MPH: That point is incredibly well-said and well-taken. Today, across the country, there are going to be thousands and thousands of visits of patients who have diabetes and heart disease. Chances are, the numbers would suggest to you that they are much more likely to walk out of that office with a prescription for a sulfonylurea or a DPP-4 inhibitor than they are an SGLT2 inhibitor. That’s what the numbers would suggest. That is a symptom of a diseased system that is not delivering the best quality and best value of care to our patients. Everyone has a role to play in that—professional societies, individuals, payers, patient advocacy groups. Everyone has a role to play, because people deserve better. What they deserve is that their providers are practicing evidence-based medicine, and there are too many instances where that’s just not happening.

Neil Minkoff, MD: Let me ask the question to Dr Murillo.

Jaime Murillo, MD: Thank you. I wanted to reinforce a point that is critical for us in general as the payers. Guidelines are very important to us when we design medical policies because we base them on those guidelines. If we don’t have them, it ties our hands in terms of how we move forward with it and not having practitioners say, “That’s because your company wants this.” It really isn’t about what our company wants. It is about what the guidelines say. It’s extremely important that we have the ability to fall back onto those guidelines to design a medical policy.

The other point is, to stress the points that your panelists have made, we cannot wait 5 years to update guidelines. We’re no longer in that space. We need to be more dynamic, and sometimes we have to be bolder in moving forward and making sure that things are done on behalf of patients. We cannot wait 5 or 10 years for that. To your point, Nihar, the last comment is so important. We cannot also depend on the good doctors, and accept that only those who go to Dr Nissen and Dr Desai would benefit from the knowledge of many others. Everyone should have access to the same care, or at least close to it. That’s why having guideline-based protocol designs gives everyone the opportunity to benefit from what we today believe, that SGLT2 inhibitors have a major part to play in this population, and everyone should have access to them.

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