{"id":323054,"date":"2020-06-24T15:45:24","date_gmt":"2020-06-24T13:45:24","guid":{"rendered":"https:\/\/medizinonline.com\/cardio-renal-protection-as-an-important-goal-in-type-2-diabetes\/"},"modified":"2020-06-24T15:45:24","modified_gmt":"2020-06-24T13:45:24","slug":"cardio-renal-protection-as-an-important-goal-in-type-2-diabetes","status":"publish","type":"post","link":"https:\/\/medizinonline.com\/en\/cardio-renal-protection-as-an-important-goal-in-type-2-diabetes\/","title":{"rendered":"Cardio-renal protection as an important goal in type 2 diabetes."},"content":{"rendered":"

Cardio-renal protection is one of the most important goals in the management of type 2 diabetes mellitus. Therefore, SGED\/SSED recommendations for the treatment of type 2 diabetes mellitus include a more rapid escalation of therapy when glucose control is inadequate and the use of agents with proven cardioprotective properties [1].<\/strong><\/p>\n

<\/p>\n

The goal of diabetes therapy is to delay or, at best, prevent the occurrence of complications without compromising quality of life [2]. This requires sustained glycemic control and effective management of cardiovascular risks. To achieve this, individual wishes and objectives should be defined during the patient’s follow-up in order to promote therapy adherence and motivation for accompanying measures. The consideration of the patient’s wishes and an individual goal setting as well as treatment strategy are central factors [2]. The choice of appropriate drug therapy can be complicated by the heterogeneity of type 2 diabetes mellitus (T2DM) and comorbidities present. The recently adapted Swiss recommendations for the treatment of T2DM guide general practitioners through the prescribing process, taking into account the latest scientific evidence [1].<\/p>\n

Adjusted cardiovascular risk categories.<\/strong><\/p>\n

In line with the 2019 update of the European Society of Cardiology (ESC) and European Association for the Study of Diabetes (EASD) guidelines, the Swiss Society of Endocrinology and Diabetology (SGED\/SSED) recommendation for the management of type 2 diabetes mellitus (2020) also adjusted the cardiovascular risk categories, which take into account the duration of diabetes and comorbidities [1,3]. In addition to patients with existing cardiovascular disease, patients with three or more additional risk factors are now assigned to the highest risk category [1]. These criteria are often met in T2DM patients or in the presence of microvascular complications (nephropathy, retinopathy, or neuropathy).<\/p>\n

Role of SGLT-2 inhibitors in the management of T2DM.<\/strong><\/p>\n

Cardiovascular outcome studies are available for the SGLT-2 inhibitors canagliflozin, dapagliflozin, and empagliflozin and the GLP-1 receptor agonists lixisenatide, exenatide, liraglutide, semaglutide, and dulaglutide, which show a significant reduction in cardiovascular events and mortality [4\u201312]. Therefore, in the Swiss recommendations, at an estimated glomerular filtration rate (eGFR) >30 ml\/min, early combination therapy consisting of metformin and an SGLT-2 inhibitor or GLP-1 receptor agonist is recommended (Fig. 1)<\/strong>. If the set HbA1c target values are not reached, the other drug class (SGLT-2 inhibitor or GLP-1 receptor agonist) can be added in the next step (Fig. 2)<\/strong> [1].<\/p>\n

In the presence of heart failure, early combination of metformin with an SGLT-2 inhibitor is recommended, as no benefit has been shown for GLP-1 receptor agonists in the context of heart failure [1].<\/p>\n

In addition to cardiovascular considerations, renal risk factors must also be taken into account when treating T2DM. In patients with chronic kidney disease, SGLT-2 inhibitors can be used at an eGFR \u226545 ml\/min (except ertugliflozin only at eGFR >60 ml\/min), according to the SmPC [1]. However, study data are available for canagliflozin and empagliflozin showing safety up to an eGFR >30 ml\/min [1].* Although the glucose-lowering effect of canagliflozin and empagliflozin decreases with decreasing eGFR, the benefit of cardio-renal protection remains even at low eGFR [1, 5, 7].<\/p>\n

Conclusion<\/strong><\/p>\n

The adapted SGED\/SSED recommendations for the management of type 2 diabetes focus on cardio-renal protection and serve as a guide for general practitioners on the optimal management of type 2 diabetes patients. By redefining cardiovascular risk groups based on the latest scientific evidence and early use of metformin in combination with SGLT-2 inhibitors or GLP-1 receptor agonists, cardio-renal prevention can be markedly improved [1].<\/p>\n

* SGLT-2 inhibitors are not currently approved for renal protection. You can find the current drug information on www.swissmedicinfo.ch<\/a><\/p>\n

\"\"<\/p>\n

Figure 1:<\/strong> Updated Swiss recommendations. Adapted from [1].<\/p>\n

\"\"<\/p>\n

Figure 2:<\/strong> Key recommendations for general practitioners. Adapted from [1].<\/p>\n

Literature:<\/p>\n

    \n
  1. Lehmann, R., et al: Recommendations of the Swiss Society of Endocrinology and Diabetology (SGED\/SSED) for the treatment of type 2 diabetes mellitus (2020). Swiss Society of Endocrinology and Diabetology (SGED\/SSED). https:\/\/www.sgedssed.ch\/diabetologie\/sged-empfehlungen-diabetologie Last access 24.04.2020, 2020.<\/li>\n
  2. Davies MJ, et al: Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care, 2018. 41(12): 2669-2701.<\/li>\n
  3. Cosentino, F., et al, 2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD. Eur Heart J, 2020. 41(2): p. 255-323.<\/li>\n
  4. Neal B, et al: Canagliflozin and Cardiovascular and Renal Events in Type 2 Diabetes. N Engl J Med, 2017. 377(7): 644-657.<\/li>\n
  5. Perkovic V, et al: Canagliflozin and Renal Outcomes in Type 2 Diabetes and Nephropathy. N Engl J Med, 2019. 380(24): 2295-2306.<\/li>\n
  6. Wiviott SD, et al: Dapagliflozin and Cardiovascular Outcomes in Type 2 Diabetes. N Engl J Med, 2019. 380(4): 347-357.<\/li>\n
  7. Zinman B, et al: Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes. N Engl J Med, 2015. 373(22): 2117-2128.<\/li>\n
  8. Pfeffer MA, et al: Lixisenatide in Patients with Type 2 Diabetes and Acute Coronary Syndrome. N Engl J Med, 2015. 373(23): 2247-2257.<\/li>\n
  9. Holman RR, et al: Effects of Once-Weekly Exenatide on Cardiovascular Outcomes in Type 2 Diabetes. N Engl J Med, 2017. 377(13): 1228-1239.<\/li>\n
  10. Marso SP, et al: Liraglutide and Cardiovascular Outcomes in Type 2 Diabetes. N Engl J Med, 2016. 375(4): 311-322.<\/li>\n
  11. Marso SP, et al: Semaglutide and Cardiovascular Outcomes in Patients with Type 2 Diabetes. N Engl J Med, 2016. 375(19): 1834-1844.<\/li>\n
  12. Gerstein HC, et al: Dulaglutide and cardiovascular outcomes in type 2 diabetes (REWIND): a double-blind, randomised placebo-controlled trial. Lancet, 2019. 394(10193): 121-130.<\/li>\n<\/ol>\n

    Responsible for content and financed by Mundipharma Medical Company, Basel Branch.<\/em><\/p>\n

    PR202007<\/em><\/p>\n

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