There are many factors involved in creating a personalized approach to treating patients with cardiovascular disease/type 2 diabetes. In this Ƶ video, , of Mount Sinai Hospital in New York City, discusses the many important variables to consider in devising an individualized approach.
Following is a transcript of her remarks:
As a cardiologist, I see many patients with diabetes. And importantly, recent studies have shown that only 13% of cardiologists actually test for diabetes in their patients. So when I look at an individualized approach, I say if I have a patient in my office who meets the criteria for risk for diabetes, then I'll check for diabetes. So if the waist circumference is more than 35 inches in a woman or more than 40 inches in a male, that's a risk for diabetes. If the patient is overweight and sedentary and has a family history of diabetes, those are all risk factors.
Importantly, for women, we ask if they've had gestational diabetes during pregnancies because that is known to markedly increase the risk of diabetes within 5 years of pregnancy. So on the one hand we'd take an individualized approach, even just screening of patients with diabetes.
Secondly, we know that diabetes affects both the microvasculature and the macrovasculature. It affects all parts of the body, causing blindness, kidney damage, peripheral vascular disease, heart attacks, and stroke. So when we look at how to treat a patient, we look at not just lowering the glucose, but what other effects can these drugs have on preventing untoward outcomes.
Importantly, in the last couple of years, two classes of medications have been shown now to reduce cardiovascular events. So cardiologists now are involved in the first-line treatment of patients with diabetes. The first group of medications, the SGLT inhibitors, are a group of medications shown to reduce cardiac events such as myocardial infarction, stroke, and death, and are shown to lower glucose levels. The second class of medications, the GLT-1 receptor antagonists, have also been shown to improve cardiovascular outcomes. The question is, when I see a patient in the office, what should I do?
So, the first-line therapy of any patient with newly diagnosed diabetes is Glucophage (metformin). The American College of Cardiology recently published 2018 guidelines of how to decide which is the next line of therapy. I would be remiss if I didn't talk about diet and exercise lifestyle changes, because of course that should be a primary concern for all doctors taking care of patients with diabetes. The discussion has to be around motivation to change, and long discussions about exercise, increasing mobility, and decreasing fat and sugar intake. Individualized therapy with nutrition is in line with treatment of all patients with diabetes.
The second class of medications that has been shown to reduce cardiovascular events in patients with diabetes are the GLP-1 receptor antagonists. This is an injectable medication that results in reducing glucagon and increasing insulin secretion. One of the secondary effects is weight loss. And it's an important drug for patients who are overweight and are interested in losing weight and have also used exercise and nutrition to the maximum possible ways. In patients with a history of pancreatitis or other abdominal complaints, a GLP-1 receptor antagonist might not be the best choice, since those side effects may be more prevalent.
From a public health perspective, we take a generalized approach to treating patients with diabetes -- our goal is always to reduce cardiovascular events. But as a clinician, a personalized approach is most appropriate. Each individual in the office has different risk factors for diabetes and different sequela of their diabetes. So for patients with renal disease, we might choose a separate line of therapy compared with those with gastrointestinal diseases. All in all, the goal is the same, to improve insulin and reduce glucose.