Consensus recommendations for management of patients with type 2 diabetes mellitus and cardiovascular diseases

Abstract

The recent American Diabetes Association and the European Association for the Study of Diabetes guideline mentioned glycaemia management in type 2 diabetes mellitus (T2DM) patients with cardiovascular diseases (CVDs); however, it did not cover the treatment approaches for patients with T2DM having a high risk of CVD, and treatment and screening approaches for CVDs in patients with concomitant T2DM. This consensus guideline undertakes the data obtained from all the cardiovascular outcome trials (CVOTs) to propose approaches for the T2DM management in presence of CV comorbidities. For patients at high risk of CVD, metformin is the drug of choice to manage the T2DM to achieve a patient specific HbA1c target. In case of established CVD, a combination of glucagon-like peptide-1 receptor agonist with proven CV benefits is recommended along with metformin, while for chronic kidney disease or heart failure, a sodium-glucose transporter proteins-2 inhibitor with proven benefit is advised. This document also summarises various screening and investigational approaches for the major CV events with their accuracy and specificity along with the treatment guidance to assist the healthcare professionals in selecting the best management strategies for every individual. Since lifestyle modification and management plays an important role in maintaining the effectiveness of the pharmacological therapies, authors of this consensus recommendation have also briefed on the patient-centric non-pharmacological management of T2DM and CVD.

Keywords: CVDs; CVOTs; Consensus; HF; T2DM.

Fig. 1

Evidence-based algorithm for the management of patients with T2DM and high risk of CVD. CVD cardiovascular disease, GLP-1 glucagon-like peptide-1, SGLT2 sodium–glucose transporter proteins-2, TZD thiazolidinedione, DPP4 dipeptidylpeptidase-4. ^aProven CVD benefits means the agent has a label indication of reducing the CVD events. For SGLT2 inhibitors evidence based preference is empagliflozin > canagliflozin. SGLT2 inhibitors vary in regards to eGFR pre-requisites for a continued use. ^bFor GLP-1 agonist evidence based preference is Semaglutide > Liraglutide > Dulaglutide > Exenatide > Lixenatide. Caution to be exercised in case of end-stage renal disease. ^cDegludec and insulin Glargine (U100) have shown CVD safety, ^dDapagliflozin: preferred option for patients with eGFR > 60 mL/min/1.73 m², ^eLow dose TZDs are better tolerated. ^fChoose later generation SU to minimize the risk of hypoglycaemia

Fig. 2

Evidence-based algorithm for the management of patients with T2DM and established ASCVD. ASCVD atherosclerotic cardiovascular disease, GLP-1 glucagon-like peptide-1, SGLT2 sodium–glucose transporter proteins-2, TZD thiazolidinedione, DPP4 dipeptidylpeptidase-4. ^aProven CVD benefits means the agent has a label indication of reducing the CVD events. For GLP-1 agonist evidence based preference is Liraglutide > Semaglutide > Exenatide > Lixenatide. Caution to be exercised in case of end-stage renal disease. ^bFor SGLT2 inhibitors evidence based preference is Empagliflozin > Canagliflozin. ^cLow dose TZDs are better tolerated. To be cautiously added to the patients with no history of heart failure and active surveillance to be maintained throughout the treatment. ^dChoose later generation SU to minimize the risk of hypoglycaemia. ^eDegludec and insulin Glargine (U100) have shown CVD safety

Fig. 3

Evidence-based algorithm for the management of patients with T2DM and HF or HF + ASCVD. ASCVD atherosclerotic cardiovascular disease, HF heart failure, GLP-1 glucagon-like peptide-1, SGLT2 sodium–glucose transporter proteins-2, DPP4 dipeptidylpeptidase-4. ^aboth empagliflozin and canagliflozin have shown reduction in HF in CVOT trials. ^bFor GLP-1 agonist evidence based preference is Liraglutide > Semaglutide > Exenatide > Lixenatide. Caution to be exercised in case of end-stage renal disease. ^cProven CVD benefits means the agent has a label indication of reducing the CVD events. ^dChoose later generation SU to minimize the risk of hypoglycaemia. ^eDegludec and insulin Glargine (U100) have shown CVD safety. Avoid thiazolidinediones, saxagliptin or Alogliptin in patients with ASCVD and HF

Fig. 4

Screening approach for the T2DM patients with suspected heart failure. BNP brain natriuretic peptide, ECG electrocardiogram, NT-proBNP N-terminal pro-brain natriuretic peptide, ULN upper limit of normal