Endocrinologist Hopkins Medicine publishes first clinical practice review on diabetes management

New drugs for people with diabetes seem to be popping up all the time. Drugs that help the body break down carbohydrates, drugs that increase the excretion of glucose in the urine, drugs that help muscles respond to insulin, and drugs that stimulate the pancreas to produce it -; the list of pharmaceutical options for treating diabetes is growing.

The downside to this plethora of treatment options is that it can be difficult for healthcare providers to keep up with the latest research and standards of care. Which drug is best for which patients? And what are the best drugs to prescribe to lower blood sugar and reduce the risk of cardiovascular disease?

Endocrinologist and Johns Hopkins Medicine Associate Professor Rita Rastogi Kalyani, MD, wrote a clinical practice review article in the April 1 edition of the New England Journal of Medicine (NEJM) which distills the results of the most recent trials and guidelines into a systematic approach to the treatment of patients with diabetes and at risk for cardiovascular disease. Kalyani’s article is the first clinical practice review published by the journal on the management of diabetes in nearly a decade.

Different from research studies, clinical practice reviews present a common clinical problem and evidence to support various treatment strategies, followed by a review of the author’s clinical guidelines and recommendations to optimize patient care. patients.

People with type 2 diabetes are twice as likely to develop atherosclerotic cardiovascular disease and heart failure than people without it. the NEJM This article presents an up-to-date approach for healthcare providers when choosing hypoglycemic therapies for their diabetic patients, particularly for reducing the risk of cardiovascular disease.

We have seen a major shift in diabetes care over the past few years. We now have tools to better understand how to reduce microvascular and macrovascular complications in people with type 2 diabetes. “

Rita Rastogi Kalyani, MD, Johns Hopkins Associate Professor and Endocrinologist of Medicine

The article examines the cardiovascular benefits and risks of the most commonly used drugs for diabetes that are currently available in the US market.

Kalyani lists the specific agents of two new classes of drugs as being beneficial for diabetic patients who already have signs of heart or vascular disease.

Glucagon-like peptide 1 (GLP-1) receptor agonists, liraglutide, injectable semaglutide and dulaglutide, increase the body’s production of insulin, especially after meals.

The sodium glucose cotransporter 2 (SGLT2) inhibitors, empagliflozin and canagliflozin, reduce the amount of glucose that the body reabsorbs through urine.

All of them are effective in helping patients reduce the risk of having a major cardiovascular event, such as a heart attack or stroke. The SGLT2 inhibitor, dapagliflozin, is effective in helping to reduce the risk of hospitalization for heart failure.

“After metformin, which is widely regarded as the initial drug treatment for type 2 diabetes, drugs specific to the GLP-1 receptor agonist and SGLT2 inhibitor classes with demonstrated cardiovascular benefit should be considered as additional drugs for patients. already suffering from cardiovascular disease. regardless of whether their A1C level is on target to reduce the risk of future cardiovascular events, ”says Kalyani, referring to the hemaglobin A1C test, which measures a patient’s average blood sugar over three months.

Sugar attaches to a protein in red blood cells that carries oxygen to organs and tissues and carries carbon dioxide to the lungs. The A1C test measures the average percentage of glucose in a person’s hemoglobin over a period of several months. Healthy A1C levels are below 5.7%. Usually, A1C levels above 6.5% indicate diabetes.

Kalyani notes that newer drugs tend to be more expensive and long-term effects are unknown. Prior to 2008, the US Food and Drug Administration -; the agency that regulates the pharmaceutical industry -; did not require large outcome trials for the drugs after they were introduced to the market. As a result, Kalyani says, the cardiovascular effects of older drugs are less certain.

the NEJM The article details specific drugs that provide additional benefits for patients with diabetes who have conditions such as multiple risk factors for cardiovascular disease, heart failure, and chronic kidney disease.

“Certain agents such as dulaglutide and dapagliflozin have also shown cardiovascular benefits in patients with multiple cardiovascular risk factors,” says Kalyani.

In addition, specific SGLT2 inhibitors may be beneficial for patients with heart failure with reduced ejection fraction -; a condition in which the heart muscle does not pump blood efficiently -; as well as for patients with chronic renal failure.

The article includes comprehensive medication tables that include factors to consider in clinical practice when choosing a hypoglycemic medication for patients with type 2 diabetes, including the effectiveness of reducing blood sugar. A1C, route and frequency of administration, cost, effects on weight, risk of hypoglycemia. , side effects and clinical benefits.

“Primary care, endocrinology, cardiology and nephrology health care providers are now prescribing these new hypoglycemic drugs to their patients,” Kalyani says. “Diabetes care will need to be increasingly collaborative in the future and, fundamentally, remain patient-centered.”

Kalyani was previously chair of the professional practice committee of the American Diabetes Association, which annually updates the Standards of Medical Care in Diabetes, the organization’s clinical practice guidelines. She has also co-authored clinical guidelines published by the Endocrine Society and the American College of Cardiology.