Quantifying the Potential Impact of SGLT-2 Inhibitors in Heart Failure - Episode 18
Darren K. McGuire, MD, MHSc, remarks on his personal experience utilizing SGLT2 inhibitors to help patients achieve cardiovascular benefits and reacts to the reluctance by cardiologists to prescribe the class of drugs for appropriate patients.
Darren K. McGuire, MD, MHSc: We’ve taken this evidence into our clinical practice as quickly as we could. I am the medical director of the cardiology clinics at the Parkland Hospital and Health System in Dallas, Texas. That’s where most of our residents and their fellows train.
I oversee the fellows’ cardiology clinics, and we very quickly embrace applying the evidence from these cardiovascular outcomes trials. We were fortunate that this county hospital system actually brought an SGLT2 inhibitor and a GLP1 receptor agonist on board without restriction.
We have begun using these as routine cardiovascular medications in our cardiology clinics in the Parkland Health and Hospital System, very much as we use a statin. We identify diabetes and atherosclerosis or atherosclerotic vascular disease risk, and that triggers decision-making in our clinical space but has nothing at all to do with glucose. That’s how we’re applying SGLT2 inhibitor data. We’re prescribing these medications and teaching the patients about them. Patients need to redouble the urinary hygiene to avoid mycotic genital infections. They need to avoid the medicines on days they do not have a normal amount of oral intake. We apply sick-day rules.
We have systematic communication directly to the care provider who is managing the glucose. As cardiologists, we’ve started this medication to manage the cardiovascular issues, and we will continue to defer the glycemic management to you. That engages the coproviders in a team approach with an understanding that we’re not stepping on their toes and embarking on glucose management in their clinic, but we are using these medications for further cardiovascular benefit.
We’ve been able to rapidly apply. I’ve been involved in the development of all these drugs and most of these trials, and so I’m on the leading edge and pushing the envelope with my trainees. Then the question becomes, “How are cardiologists doing in general?” I would say, “Dismally.”Around the globe, cardiologists are very hesitant to prescribe these medications. That is largely driven by the fact that they don’t want to get involved in managing blood glucose. It’s not that we don’t think it’s important, but we have enough on our plate under our specialty domain that it simply gets beyond our expertise and beyond our purview.
It’s important that we disconnect the benefits of both the SGLT2 inhibitors and the GLP1 receptor agonists. The cardiovascular benefits that have been demonstrated are completely independent of glucose control. That’s now reflected in the EASD [European Association for the Study of Diabetes] and the ADA [American Diabetes Association] guidelines. We’re to consider these medications for the right patients. It doesn’t require need for more glucose control. You simply use the risk of the patient to prescribe the medication. It’s not that you’re forgetting the glucose control. That’s still going to be left up to the providers who’ve been managing it all along, but we’ll be adding these.
It’s important to understand that for patients who are on insulin or sulfonylureas, and may be very tightly controlled and even having occasional hypoglycemia, the addition of SGLT2 inhibitors or GLP1 receptor agonists can slightly increase the risk of hypoglycemia. In those tenuous patients who are very tightly controlled, we tend to negotiate with the primary care provider instead of prescribing the medicines ourselves. We encourage them to initiate the therapy while they may be backing off the sulfonylurea or dose reducing the insulin.
Otherwise, in the absence of background insulin or sulfonylurea, there’s really no risk of hypoglycemia with either of these classes of medications. We’re very comfortable prescribing them as cardiologists, but all while communicating with the people managing the blood glucose as we’re doing so.