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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
- 3. How to we choose treatments / prescribe ?
- 4. • 1. Anti-platelet drugs – Clopidogrel , Ticagrelor • 2. Statins • 3. Beta-blocker • 4. ACE Inhibitors /ARB • 5. MRAs • 6. ARNI ( Valsartan-Sacubitril) • 7. GLP1 agonists and SGLT2 Inhibitors
- 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
- 9. Cardiac Benefits of Newer Anti-Diabetic Drugs
- 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.
- 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
Editor's Notes
- Cost of GLP 1 Agonists - $ 50-100 / Month SGLT2 Inhibitors - $ 500 / month
- 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