[ad_1]
PARIS – The European Society of Cardiology (ESC), in collaboration with the European Association for the Study of Diabetes (EASD), has issued new guidelines for the management and prevention of cardiovascular disease in diabetic patients or pre-diabetic.
The recommendations in the document reflect recent positive findings from large-scale clinical trials on cardiovascular outcomes of new classes of diabetes medications and other recent developments.
The guideline updates the 2013 version: it not only provides advice on new classes of diabetes medicines based on revolutionary CVOTs, but it also removes metformin from its initial diabetes treatment status for all. They further stratify CV risk into medium, high and very high risk levels rather than primary prevention and secondary prevention.
The document testifies to "an unprecedented increase in the evidence base that health professionals can refer to in their daily consultations," write Francesco Cosentino, MD, PhD, Karolinska Institute, and Karolinska University Hospital. in Stockholm, Sweden, and Peter J. Grant, MD, University of Leeds, United Kingdom, respective co-chairs of the CES and EASD of the Drafting Working Group.
Cosentino and Grant presented the guiding principles here at the 2019 ESC Congress, and the document was published simultaneously online on August 31 in European Heart Journal and on the ESC site.
What's up?
"The last five years have been the most exciting period of diabetes research," said Cosentino, "because for the first time in the history of type 2 diabetes, we have data from several CVOTs indicating that the CV has benefits reduce drugs in patients with CVD or with a very high / high CV risk. "
The guidelines incorporate evidence from trials of sodium and glucose co-transporter 2 (SGLT2) inhibitors – EMPA-REG OUTCOME trial of empagliflozin (Jardiance, Boehringer Ingelheim / Lilly), the CANVAS trial of canagliflozin (InvokanaJanssen) and the DECLARETIMI 58 trial on dapagliflozin (Farxiga / Forxiga, AstraZeneca) and agonists of GLP-1 receptors (in particular glucagon-like): in particular the LEADER test on liraglutide (Victoza, Novo Nordisk), SUSTAIN-6 trial on semaglutide, Harmony Outcomes trial of albiglutide, REWIND trial on dulaglutide (Trulicity, Lilly), the PIONEER 6 trial on semaglutide and the CREDENCE trial on canagliflozin.
"A key starting point of our guidelines," said Cosentino, is the reclassification of CV risk in diabetic patients based on comorbidities and duration of illness, rather than simply considering them as requiring primary prevention or secondary CVD.
The guidelines classify diabetic patients as follows:
-
Average CV risk if they are young, have no other CV risk factors and have been diabetic for less than 10 years;
-
High CV risk if they have diabetes for more than 10 years and have at least one other risk factor, but no target organ damage; and
-
Very high CV risk if they have cardiovascular disease, target organ damage or type 1 diabetes for more than 20 years.
The clinical evidence strongly suggests that these new drugs should be recommended in patients with type 2 diabetes and cardiovascular disease prevalent or at very high / high cardiovascular risk, such as those with a target organ injury or several cardiovascular risk factors, whether they are treatment-naive or already under treatment. metformin.
"We are really facing a major paradigm shift" in the use of metformin, Cosentino said. For drug-naive patients with established type 2 diabetes and CVD, at very high risk, the recommendation recommends the immediate initiation of an SGLT-2 inhibitor or receptor agonist. GLP-1 or the addition of this treatment to treatment with metformin.
"This is important," said Grant theheart.org | Medscape Cardiology in an email, "because until now, all guidelines recommended metformin as a first-line treatment in all cases of type 2 diabetes. The strength of the evidence shows that it is no longer the right strategy. "
The guideline also indicates that the benefits observed with GLP-1 receptor agonists "most likely result from the reduction of events related to arteriosclerosis", whereas SGLT2 inhibitors appear to reduce endpoints related to heart failure.
"Huge changes in diabetes management over the past five years," Grant said, "is probably the biggest achievement since the discovery of insulin in 1924."
Grant drew attention to the following major updates of the iteration of the current directive:
-
"We should not talk about primary and secondary prevention," he said, but classify diabetic patients as presenting a moderate, high or very high risk of CVD.
-
A new CVOT aspirin (ASCEND) in moderate-risk diabetes has led them to not recommend aspirin in moderate-risk patients, but to use it individually in high-risk and very high-risk patients.
-
Two trials of proprotein-converting inhibitors subtilisin / kexin type 9 (PCSK9) – including one with a sub-study of diabetes – led them to recommend treatment with PCSK9 inhibitor in very high-risk patients presenting a high level of low density lipoprotein cholesterol persistently treatment with ezetimibe or intolerance to statins.
-
The COMPASS trial of rivaroxaban and aspirin in patients with stable coronary artery disease led to the recommendation of the use of this drug in antiplatelet biotherapy for the long-term prevention of CVD.
At the same time, "do not forget the glycemic control," Grant warned, because it helps prevent microvascular complications to the eyes, nerves and kidneys.
The guidelines recommend targeting a hemoglobin A1c of less than 7%, especially in young adults who have not been diabetic for a long time.
The document also recommends lipid targets of 2.5 mmol / L, 1.8 mmol / L and less than 1.4 mmol / L for diabetic patients with medium, high and very high risk of cardiovascular disease, respectively.
In addition, it is indicated that PCSK9 inhibitors are clearly needed in diabetic patients with a very high risk of cardiovascular events and that aspirin may be considered for these patients, but not for patients with moderate risk of cardiovascular events.
Interdisciplinary guidelines
Robert H. Eckel, MD, University of Colorado, Denver, former president of the American Heart Association (AHA, 2005-2006) and will soon co-chair the American Diabetes Association (ADA, January 2020). told theheart.org | Medscape Cardiology In an email that, in general, US health practitioners are turning to Standards of medical care ADA / EASD for advice on diabetes care and guidelines and statements from the AHA and the American College of Cardiology for advice on cardiology care.
This version of the ESC / EASD Guidelines for Diabetes and Cardiovascular Patients shows the importance of SGLT2 inhibitors and CVOT-based GLP-1 receptor agonists, he said, "including by placing them in as primary treatment versus metformin risk of CVD – which is a new way to categorize patients instead of classifying them as patients treated for primary prevention or secondary prevention of CVD. "
Relevant financial information is listed with the guidelines.
Congress of the European Society of Cardiology (ESC) 2019.
Eur Heart J. Posted online 31 August 2019. Full text
For more from theheart.org | Medscape Cardiology, follow us on Twitter and Facebook
[ad_2]
Source link