To Cut CV Risk in Diabetes, Prescribe the Right Meds and Push for Lifestyle Changes

To reduce the risk of cardiovascular disease in adults with diabetes, the focus should be on appropriate lifestyle and pharmacological interventions—including aspirin, statins, and blood pressure-lowering medications—to adequately control risk factors, according to a new review from a group of primary care physicians and internal medicine specialists.

In patients with type 2 diabetes and atherosclerotic cardiovascular disease, antihyperglycemic therapy should include metformin and an additional agent proven to reduce the risk of major cardiovascular events and cardiovascular mortality, such as empagliflozin (Jardiance; Boehringer Ingelheim) or liraglutide (Victoza; Novo Nordisk), they note.

The recommendations, which aren’t new but based on the American Diabetes Association (ADA)’s Standards of Medical Care in Diabetes, were published April 3, 2018, in the Annals of Internal Medicine. They are meant to be disseminated to a broad range of frontline physicians who treat patients with type 1 and type 2 diabetes, but who may not be as familiar with the ADA standards.  

James Chamberlain, MD (St. Mark’s Hospital and St. Mark’s Diabetes Center, Salt Lake City, UT), the lead author of the new review and member of the ADA’s primary care advisory group, said the review’s purpose was to ensure that the current standards of care actually reach practicing physicians.

“We’ve been together for 8 to 10 years, and we’re all primary care diabetologists,” he told TCTMD. “We’re either [in] internal medicine or family medicine, or [are] midlevel providers such as a diabetes educator and a pharmacist. We were asked, when we were put on this committee years ago, to help get the standards of care in front of the providers in this country who are doing diabetes care. The majority of diabetes care is being done by primary care providers, not endocrinologists.”

Mirrors ADA Guidelines

The new review mirrors the ADA standards of care and provides direction for managing cardiovascular risk factors. For example, the group advises physicians measure blood pressure at every office visit and treat diabetic patients with hypertension to a systolic and diastolic blood pressure goal of less than 140/90 mm Hg (grade A recommendation). For patients at high risk for cardiovascular disease, a treatment target of less than 130/80 mm Hg is recommended if it can be achieved without “undue treatment burden” (grade C recommendation).

In addition to blood pressure control and treatment targets, the ADA makes several other recommendations, including but not limited to:   

• For patients with atherosclerotic cardiovascular disease, a high-intensity statin should be added to lifestyle therapy (grade A recommendation). For diabetic patients younger than 40 years with additional risk factors, a moderate-intensity statin can be considered (grade C recommendation);
• For patients with fasting triglyceride levels ≥ 500 mg/dL, physicians should evaluate for secondary causes of hypertriglyceridemia and consider medical therapy to reduce the risk of pancreatitis (grade C recommendation);
• Statin/fibrate and statin/niacin combination therapy is not recommended given the absence of cardiovascular benefit (grade A recommendation);
• Aspirin therapy is recommended in those with a history of atherosclerotic cardiovascular disease (grade A recommendation), but clopidogrel can be used for those with an aspirin allergy (grade B recommendation);
• Dual antiplatelet therapy with low-dose aspirin and a P2Y12 inhibitor is reasonable for 12 months after an ACS (grade A recommendation) and may have benefits beyond 1 year (grade B recommendation);
• In asymptomatic patients, routine screening for coronary artery disease is not recommended as long as risk factors are treated (grade A recommendation).

To TCTMD, Chamberlain said the ADA guidelines are always published in Diabetes Care and are available online, but “they’re not seen by most primary care physicians.”

He noted that the last several years have seen the emergence of several antihyperglycemic drugs that reduce the risk of cardiovascular outcomes, particularly empagliflozin in the EMPA-REG Outcome study and liraglutide in LEADER. “We felt it was important to note those,” said Chamberlain. “We really wanted to focus on drugs that had better cardiovascular data behind them.”