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SGLT2 Inhibitors as Standard of Care Throughout Cardiology


Cardiology experts provide insights on the recommended use of SGLT2 inhibitors as standard of care and the multidisciplinary approach to support it.


Neil Minkoff, MD: I want to follow up on that. I’m going to ask 1 follow-up question, and then I want to bring Dr Murillo in to talk about some of the pharmacoeconomics, as well. Steve and Dr Desai, you’re both well-known researchers and progressive in the field. Do you feel like the SGLT2 [sodium-glucose cotransporter-2] inhibitors becoming standard of care has become pervasive throughout the cardiology or CHF [congestive heart failure]-treating community? If not, what’s holding them back? It sounds as if we have all evaluated the data in the same way—provider, moderator, and payer. What’s holding them back from becoming more prevalent?

Steven Nissen, MD: I’ll comment first, if I may. We have a lot of trouble getting payers to pay for these drugs. The burdens and the barriers are very high, and making the case has been very difficult. I’ve met many patients with diabetes, reduced renal function, and some element of heart failure, where it’s clear that the benefits are impressive, and I just can’t get them on the drugs. I’ve had patients who have some economic means getting the drugs from Canada, which I don’t approve of. But I’ve had them doing that because they simply can’t get them paid for. It’s really a concern.

Nihar Desai, MD, MPH: Yes, I’ll echo that point that Steve made around access. That’s an important area for all of us to advocate and to say, “Evidence should be connected to coverage, and ultimately, to access.” That is an area where we can certainly do better. I also think that there are some historical silos that we need to break down between cardiologists and endocrinologists, or cardiologists and primary care providers. Who has jurisdiction, if you will, over prescribing a certain class of therapy? The patients deserve a lot better than that. What they want is to know that everyone who is caring for them, regardless of specialty or background, is thinking about optimizing their care at every opportunity. It’s on all of us as clinicians and members of the community to come together, engage with our colleagues, reimagine and rethink what care should be for these patients, and try to abandon some of the historical silos that have impeded progress in terms of adoption and implementation of this evidence in practice.

Steven Nissen, MD: Nihar, you make an incredibly important point. The siloization of care is a big problem. Diabetes and heart disease are overlapped syndromes. We have the diabetologist who is often writing the prescriptions, we have the cardiologist who is treating the complications of the disorder, and they’re not always talking to each other. We almost need a new specialty of cardiometabolic health. We recognize that, and in my section of preventive cardiology at Cleveland Clinic, we recently hired someone who is trained in both cardiology and endocrinology. He now sees patients in the prevention clinic at the Cleveland Clinic. That is an important discipline for the future. Not a lot of people are willing to go through fellowships in both disciplines. What we have to do is talk to each other and work together, because these patients do not belong to 1 specialty. They belong to multiple specialties. I might add that the nephrologists also have to have a seat at the table, given the morbidity and mortality from chronic renal disease.

Neil Minkoff, MD: I’m going to ask Dr Murillo, because I keep saying we’re going to get to him and we keep coming back around. There have been some discussions here about there being barriers to the usage. Some of those barriers are access related to payment and reimbursement or coverage. Some of them are the siloization and some of the other things we talked about. Is your organization getting a lot of requests to use SGLT2 inhibitors in nondiabetic patients and in earlier stages of heart failure?

Jaime Murillo, MD: The key word you used was nondiabetics. Those medications are part of the armamentarium that I mentioned to you. We’ve spent more than $100 million so far in that category alone. For the nondiabetic, that’s where we still have an opportunity. As I was mentioning to you, I was reviewing the agenda for our next meeting in July. There’s some information, but because it has not been approved yet, I have to keep the details out. But the bottom line is, that’s the direction we’re moving toward.

Neil Minkoff, MD: Will changes in the indication or the labels affect coverage, not just for you, but overall? Is that something that you would anticipate? Then, I’ll ask if the prescribers think that would make a difference, as well.

Will other SGLT2 inhibitors need a label change, or will the data in and of itself be sufficient to drive the change in coverage and request for coverage?

Jaime Murillo, MD: That’s a great question. So far, I can say that when you pull the different studies and you get close to 38,000 patients, the benefits are essentially across the board. We’re treating this as a class. We’re not taking this as 1 single medication does this, while the other SGLT2 inhibitor does that, and so on. We’re treating them as a class effect.

Neil Minkoff, MD: OK. Others?

Steven Nissen, MD: So far, what we’ve seen is that the effects do represent a class effect. I mentioned earlier, and I’ll say again, that it’s nice to have replication. We like to see replication. I’m going to be very eagerly awaiting the EMPEROR-HF trial, particularly in the preserved EF [ejection fraction] group. That’s a big reach. It would be extraordinarily exciting for cardiologists to have a drug for HFpEF [heart failure with preserved ejection fraction]. I don’t know what’s going to happen. I can’t predict it, but seeing replication in HFrEF [heart failure with reduced ejection fraction] will make me convinced that it is a class effect.

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