Are the newer anti-diabetic medications being prescribed after assessment of cardiovascular risk ?
Current practice in light of evidence and guidelines . What do the trial data tell us ?
Cardiac Output, Venous Return, and Their Regulation
Underuse and Misuse of Newer Anti diabetic Medications in Patients at Risk and Established Cardiovascular Disease
1. Underuse and Misuse of Newer Antidiabetic
Medications in Patients at Risk and
Established Cardiovascular Disease
Dr Syed Raza
MD, MRCP, FRCP, CCT, FACC, FESC
Consultant Cardiologist & Physician
Awali Hospital, Bahrain
2. Objectives
1. How do we choose treatments for our patients?
2. Evidence for newer anti-diabetic medications - CVOT trials
3. Limitations on use and misuse
4. Ways to improve prescription
5. Misuse of Medication Prescription (GLP 1
Agonists and SGLT2 Inhibitors )
• 1. Contraindicated
severe renal impairment
Dehydration
Current UTI
Hypotension
Pancreatic disease
High risk of DKA
2. Off label use - Type 1 DM
3. Use in patients with very low BMI
4. Use for weight loss alone in Non Diabetics
6. Reasons for Poor Usage of Newer Anti-Diabetic
Medications
• 1. Lack of awareness of current guidelines based on
evidence of CV and renal benefit from trials.
• 2. Inertia in starting a treatment
• 3. Local restrictions and supply
• 4. Lack of MDT approach to a patient
• 5. Affordability
• 6. Patient education - confidence and medication adherence
14. CANVAS: Canagliflozin Cardiovascular Assessment Study
A close look at the study design
Diabetes
Diabetes
with CV
risk factors
Diabetes
with
established
CAD
40% of study
population
60% of
study
population
Am Heart J. 2013 Aug;166(2):217-223.e11.
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34. • 1. Physicians need to update themselves of the current
guidelines
• 2. Bringing the guidelines into practice
• 3. Keen to prescribe as a non Diabetologist and dose
modification as needed.
• 4. Role of Pharmacy and Therapeutic Committee
• 5. Subsidize and reduce cost of medicines
• 6. Patient education
It is known for several years and it was published in Diabetes Care journal that Diabetes increases CV mortality or CV mortality is high in individuals who have Diabetes than those who don’t have diabetes . . The mortality is higher if no of CV risk factors are added up
Here are the anti diabetic medications that have shown to decrease CVD risk and have proven positive outcome in terms of CV outcome. Except DPP4 Sitagliptic has shown favorable CV outcome and the evidence comes from the TECOS trial . Reduced non fatal MI and Stroke as well as hospitalization due to unstable angina. Metaanalysis of 9 trials , 12000 patients showed that Pioglitazone was associated with reduced risk of MACE in people with insulin resistance, pre-diabetes and diabetes mellitus. However, the risks of heart failure, bone fracture, oedema and weight gain were increased. There remains uncertainty about whether metformin reduces risk of cardiovascular disease among patients with type 2 diabetes, for whom it is the recommended first-line drug. Although this is mainly due to absence of evidence
This slide shows the timelines of the outcome trials with the antidiabetic medications between 2013 and 2018 . In blue are the trials with DPP4 inhibitors , in RED are trials with GLP agonists while more recent trials using SGLT2 inhibitors are in Green. The results of Declare TIMI 58 which I shall be discussing is expected in April next year.
60 % of study population had established CAD while 40% had risk factors for CAD
Canvas and Canvas R were merged together to form CANVAS program . About half received Canagliflozin while the rest received placebo. Almost 96% in both arms completed the staudy
