Improving Outcomes—A Multidisciplinary Year in Review

Cardiology perspective

Dr. James L. Januzzi Jr., MD

This session focused on the recently published consensus report “Heart Failure: An Underappreciated Complication of Diabetes. A Consensus Report of the American Diabetes Association”.¹

The universal definition of heart failure (HF), a useful approach for staging HF, focuses on prevention, recognition of the early-stage disease, and intervention across all stages.²

Figure 1: Stepwise approach for screening and diagnosing across heart failure stages.¹

Diabetes is the prototypical form of stage A HF

Several epidemiological studies and surveys show that many individuals with diabetes have stage B HF. Exploring the mediators of the development of stage B HF and understanding the underlying structural heart disease is critical.¹

Stage B HF is also defined by the presence of heart muscle abnormalities and the presence of elevated natriuretic peptide (NP) levels or elevated cardiac troponin levels. An elevated NT pro-BNP can predict progressive HF and diabetes. Measurement of NP or high sensitivity troponin is recommended in patients with stages A or B HF and in those with abnormal measurements, referral for imaging is the next recommended step.¹

The consensus recommends prioritizing the use of sodium/glucose cotransporter-2 inhibitors (SGLT2i) in individuals with stage B HF. SGLT2i are an expected element of care in all eligible individuals with diabetes and symptomatic HF (stages C and D) including those with HF with preserved ejection fraction. Dipeptidyl peptidase-4 inhibitors or thiazolidinediones are not recommended for routine use in those with stages B to D HF. Insulin treatment could be added if additional glycaemic control is indicated.¹

Nephrology perspective

Tamara Isakova, MD, MMSc

By 2045, it's estimated that 784 million people across the world will have diabetes.³ Chronic kidney disease is one of the most severe complications of diabetes, reported in about 30% of cases with type one diabetes and about 40% of cases with type 2 diabetes. Chronic kidney disease also increases the risk of cardiovascular disease.^4,5

The cardio-renal benefits of SGLT2 inhibitors in patients with diabetes and CKD are well-established. The efficacy of SGLT2 inhibitors is uniform across patients with different degrees of kidney function. This has been proved in trials such as CREDENCE and DAPA-CKD that enrolled patients with low GFR.^6,7 Dr. Isakova adds, “the guideline will now state that you can go to a GFR of about 20 for SGLT2 inhibitors, which is sort of impressive”.

A multidisciplinary team is essential for the care of people with CKD and diabetes.

First-time prescriber rates for SGLT2i or GLP-1RA by clinical specialty in integrated health system clinics*

*Prescriptions were defined as first-time if it was the initial prescription for an SGLT2i or GLP-1RA identified in NM EDW

Gay HC, ... Ahmad FS. Submitted

Figure 2: First-time prescriber rates for SGLT2i or GLP1 RA by clinical speciality in integrated health system clinics.

According to data from the Northwestern Medicine, the number of total prescriptions of SGLT2 inhibitors has increased from 2013 to 2019, but the majority of prescribers are primary care doctors and endocrinologists, followed by cardiologists, and the medication is least prescribed by nephrologists. Similarly, there are gaps in the uptake of SGLT2 inhibitors across disease conditions and across groups of patients.

Diabetology Perspective

Neda Rasouli, MD

With the approval of novel medications and new evidence, the perspective of diabetes care has evolved tremendously. Traditionally the management of adults with type 2 diabetes was delivered in a single specialist setting with a focus on glycemic control.⁸ But now the treatment landscape has evolved to consider the need to prevent cardiovascular disease and microvascular complications. From 2015 onwards, in the “outcome era”, new glucose-lowering therapies such as empagliflozin demonstrated cardiovascular and renal benefits in addition to improving hyperglycemia.⁹

It's important to carry out vigorous screening and risk stratification to identify patients with a high risk for comorbidities or diabetes complications. The next step after risk stratification is the development of targeted individualized therapy. SGLT2 inhibitors and GLP-1RA are the preferred glucose-lowering medication for adults with type 2 diabetes and established atherosclerotic cardiovascular disease (ASCVD) or at high risk for ASCVD. For adults with type 2 diabetes and HF or CKD, SGLT2 inhibitors are the preferred glucose-lowering medication.

A multidisciplinary approach should be considered as a foundation of treatment.

References

1. Rodica Pop-Busui, James L. Januzzi, Dennis Bruemmer, et al. Heart Failure: An Underappreciated Complication of Diabetes. A Consensus Report of the American Diabetes Association. Diabetes Care. 2022; dci220014.

2. Bozkurt B, Coats AJ, Tsutsui H, et al. Universal Definition and Classification of Heart Failure: A Report of the Heart Failure Society of America, Heart Failure Association of the European Society of Cardiology, Japanese Heart Failure Society and Writing Committee of the Universal Definition of Heart Failure [published online ahead of print, 2021 Mar 1]. J Card Fail. 2021;S1071-9164(21)00050-6.

3. The IDF Diabetes Atlas Tenth edition 2021. Available at: https://www.idf.org/aboutdiabetes/what-is-diabetes/facts-figures.html#:~:text=In%202021%2C,and%20783%20million%20by%202045. Accessed on: 17 June 2021.

4. Saran R, Robinson B, Abbott KC, et al. US Renal Data System 2016 Annual Data Report: Epidemiology of Kidney Disease in the United States [published correction appears in Am J Kidney Dis. 2017 May;69(5):712]. Am J Kidney Dis. 2017;69(3 Suppl 1):A7-A8.

5. Reutens AT. Epidemiology of diabetic kidney disease. Med Clin North Am. 2013;97(1):1-18.

6. Bakris G, Oshima M, Mahaffey KW, et al. Effects of Canagliflozin in Patients with Baseline eGFR <30 ml/min per 1.73 m²: Subgroup Analysis of the Randomized CREDENCE Trial. Clin J Am Soc Nephrol. 2020;15(12):1705-1714.

7. Heerspink HJL, Stefánsson BV, Correa-Rotter R, et al. Dapagliflozin in Patients with Chronic Kidney Disease. N Engl J Med. 2020;383(15):1436-1446.

8. King P, Peacock I, Donnelly R. The UK prospective diabetes study (UKPDS): clinical and therapeutic implications for type 2 diabetes. Br J Clin Pharmacol. 1999;48(5):643-648.

9. Anker SD, Butler J, Filippatos G, et al. Effect of Empagliflozin on Cardiovascular and Renal Outcomes in Patients With Heart Failure by Baseline Diabetes Status: Results From the EMPEROR-Reduced Trial. Circulation. 2021;143(4):337-349.