SUN-149 Cardiologist vs. Endocrinologist Encounters in Patients with T2D and CVD: Potential Implications for Glucose-Lowering Therapy Use and Education

Correlates of SGLT-2-inhibitiors use among patients with atherosclerotic cardiovascular disease and type 2 diabetes mellitus: Insights from the department of veterans affairs

This study using data from the Veterans Affairs (VA) administrative and clinical dataset examined determinants of sodium-glucose cotransporter-2 inhibitors (SGLT-2i) use among patients with concomitant atherosclerotic cardiovascular disease (ASCVD) and diabetes mellitus. The aim of the present analysis was to identify barriers and facilitators associated with SGLT-2i in a real-world contemporary patient population in order to improve utilization of these guideline-directed agents.

Implementation of Cardiometabolic Centers and Training Programs

PURPOSE OF REVIEW

Type 2 diabetes is frequently accompanied by obesity, nonalcoholic fatty liver disease, chronic kidney disease, and cardiovascular disease, which collectively contribute to the high burden of cardiometabolic disease. This review discusses cardiometabolic disease management, strategies to implement cardiometabolic centers to deliver care, and dedicated programs to train the next generation of cardiometabolic experts.

RECENT FINDINGS

Sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide 1 receptor agonists, and a nonsteroidal mineralocorticoid receptor antagonist have demonstrated beneficial effects across cardiometabolic conditions. However, utilization of effective pharmacotherapies is low in clinical practice, in part due to clinical inertia and traditional sharp delineation in clinical responsibilities of specialists. Multidisciplinary clinics and population-health models can provide comprehensive care but require investment in physical and information technology infrastructure as well as in training and accreditation. Post-internal medicine residency cardiometabolic health training programs have been proposed. Implementing cardiometabolic centers in health systems involves reshaping current practices. Training programs focused on cardiometabolic health are needed to address the growing burden of disease and specific training needs in this ever-expanding area.

Cardiometabolic medicine: a review of the current proposed approaches to revamped training in the United States

Cardiovascular disease (CVD) remains the leading cause of mortality in the United States, and the population of patients with cardiometabolic conditions, including obesity, metabolic syndrome and diabetes mellitus, continues to grow. There is a need for physicians with specific training in cardiometabolic medicine to provide a ‘medical home’ for patients with cardiometabolic disease, rather than the fractured care that currently exists in the United States. Cardiometabolic specialists will head multidisciplinary clinics, develop practice guidelines, and lead through research. Proposals for US training in cardiometabolic medicine include: maintain the current training model, a dedicated 2–3 year fellowship following internal medicine residency, a 1-year fellowship following either internal medicine residency or fellowship in cardiology or endocrinology, and certification available to any interested clinician. This review discusses the pros and cons of these approaches. The authors believe that a dedicated cardiometabolic training fellowship has significant advantages over the other options.

Trends in Clinical Characteristics and Prescribing Preferences for SGLT2 Inhibitors and GLP-1 Receptor Agonists, 2013-2018

OBJECTIVE

There is a paucity of data evaluating recent changes in clinical and prescriber characteristics of patients initiating sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1RA).

RESEARCH DESIGN AND METHODS

U.S.-based administrative claims data (July 2013 to June 2018) were used to identify initiators of SGLT2i and GLP-1RA.

RESULTS

Over 5 years, empagliflozin initiation (as a proportion of SGLT2i) increased by 57.1% (P < 0.001 for trend), while canagliflozin initiation declined by 75.1% (P < 0.001). Empagliflozin was the only agent within SGLT2i with an increase in the proportion of patients with myocardial infarction, stroke, or heart failure (collectively called CVD-HF) (P < 0.001). Liraglutide initiation (as a proportion of total GLP-1RA) declined by 32.1% (P < 0.001), and dulaglutide initiation increased by 34.1% (P < 0.001); the proportion of patients with CVD-HF increased the most in liraglutide initiators (5.1% increase; P < 0.001). Most prescribers were internists or endocrinologists; cardiologist prescribing remained low (<1%).

CONCLUSIONS

For SGLT2i, shifts in preference for empagliflozin followed changes in drug labels and guidelines, while for GLP-1RA, other factors such as price or ease of administration may have led to a preference for dulaglutide over liraglutide.

The elephant in the room: Why cardiologists should stop ignoring type 2 diabetes

Type 2 Diabetes (T2D) is a growing public health threat that is evolving into a global pandemic with debilitating, expensive and often lethal complications. Even when hemoglobin A1c (HbA1C) levels are well controlled, and concomitant cardiovascular (CV) risk factors are effectively treated, two out of every three patients with T2D are destined to die from CV complications. Several large randomized controlled trials (RCT) indicate that two classes of glucose-lowering medications, oral sodium-glucose cotransporter type 2 inhibitors (SGLT2-i) and injectable glucagon-like peptide-1 receptor agonists (GLP-1RA), confer significant CV benefits, including reductions in: hospitalizations for heart failure (HF), progression of diabetic kidney disease, atherosclerotic CV events, and (with some agents) CV death. These CV benefits appear to be independent of the glucose-lowering effects of these agents. These compelling findings are triggering a fundamental paradigm shift in T2D management whereby the focus is no longer on HbA1c alone, but instead on implementing a comprehensive CV risk reduction strategy prioritizing the use of these evidence-based therapies (along with other evidence-based treatment strategies) with the objective of reducing the risk of morbid complications, and improving the quantity and quality of life of patients with T2D. Cardiologists are uniquely positioned to become more involved in the management of T2D and established CV disease, which at this time should include initiation (either by prescribing or by making recommendations) of agents proven to reduce CV risk. Specifically, SGLT2-is and/or GLP-1RA have now been shown to have a favorable risk-benefit balance, and are being increasingly emphasized by the practice guidelines as preferable treatment options in vulnerable patients with T2D. The cardiology community should collaborate with other care providers to ensure that when and where appropriate these new T2D therapies are used along with other evidence-based therapies to improve patient outcomes.