Dr. Cosentino and colleagues are to be congratulated on the thoughtful and thorough guidelines on diabetes and cardiovascular diseases developed by the European Society of Cardiology (EAS) in collaboration with the European Association for the Study of Diabetes (EASD) (1). With regards to medication management for drug-naïve patients with type 2 diabetes (T2DM), the authors have recommended the use of either a sodium-glucose cotransporter 2 (SGLT2) inhibitor or a glucagon-like peptide 1 receptor agonist (GLP-1 RA) as a first-line treatment for drug-naïve T2DM patients with established cardiovascular disease (CVD) or with high/very high cardiovascular risk. Conversely, the use of metformin is recommended as first-line treatment only in drug-naïve T2DM patients at low/moderate cardiovascular risk (1). This recommendation is new and different from that reported in the 2018 Consensus report by the American Diabetes Association and the EASD where the use of metformin is recommended as a first-line treatment for all T2DM patients whereas SGLT2-inhibitors or GLP-1 RAs should be added as preferred second agents to metformin in T2DM patients with established CVD, heart failure or renal diseases (2). We assume that this new ESC-EASD treatment algorithm in drug-naïve T2DM patients largely derives from the interpretation of the results of cardiovascular outcomes trials (CVOT) that evaluated the cardiovascular safety of SGLT2-inhibitors or GPL1RAs. However, most of these CVOTs enrolled T2DM patients with a long duration of disease and who had established CVD or multiple cardiovascular risk factors. Thus, it is important to underline that drug-naïve patients with T2DM were poorly or not all represented in these CVOTs and that SGLT2-inhibitors or GPL1RAs were generally added as add-on treatment to metformin. For this reason, we consider that the strength of current evidence for recommending SGLT2-inhibitors or GPL1RAs as first-line treatment in drug-naïve T2DM patients is low, based on their effects on cardiovascular risk. Furthermore, given that most T2DM patients are also insulin resistant, it is not clear why the few currently available anti-hyperglycemic agents that have been shown to be able to improve this metabolic abnormality, have a low cost and may also have cardiovascular benefits (i.e., metformin and pioglitazone) are now recommended only as second- or third-line treatment options in drug-naïve patients with T2DM.

Treatment algorithm in patients with type 2 diabetes and atherosclerotic cardiovascular disease or high/very high cardiovascular risk

Targher, Giovanni
Writing – Original Draft Preparation
;
2020-01-01

Abstract

Dr. Cosentino and colleagues are to be congratulated on the thoughtful and thorough guidelines on diabetes and cardiovascular diseases developed by the European Society of Cardiology (EAS) in collaboration with the European Association for the Study of Diabetes (EASD) (1). With regards to medication management for drug-naïve patients with type 2 diabetes (T2DM), the authors have recommended the use of either a sodium-glucose cotransporter 2 (SGLT2) inhibitor or a glucagon-like peptide 1 receptor agonist (GLP-1 RA) as a first-line treatment for drug-naïve T2DM patients with established cardiovascular disease (CVD) or with high/very high cardiovascular risk. Conversely, the use of metformin is recommended as first-line treatment only in drug-naïve T2DM patients at low/moderate cardiovascular risk (1). This recommendation is new and different from that reported in the 2018 Consensus report by the American Diabetes Association and the EASD where the use of metformin is recommended as a first-line treatment for all T2DM patients whereas SGLT2-inhibitors or GLP-1 RAs should be added as preferred second agents to metformin in T2DM patients with established CVD, heart failure or renal diseases (2). We assume that this new ESC-EASD treatment algorithm in drug-naïve T2DM patients largely derives from the interpretation of the results of cardiovascular outcomes trials (CVOT) that evaluated the cardiovascular safety of SGLT2-inhibitors or GPL1RAs. However, most of these CVOTs enrolled T2DM patients with a long duration of disease and who had established CVD or multiple cardiovascular risk factors. Thus, it is important to underline that drug-naïve patients with T2DM were poorly or not all represented in these CVOTs and that SGLT2-inhibitors or GPL1RAs were generally added as add-on treatment to metformin. For this reason, we consider that the strength of current evidence for recommending SGLT2-inhibitors or GPL1RAs as first-line treatment in drug-naïve T2DM patients is low, based on their effects on cardiovascular risk. Furthermore, given that most T2DM patients are also insulin resistant, it is not clear why the few currently available anti-hyperglycemic agents that have been shown to be able to improve this metabolic abnormality, have a low cost and may also have cardiovascular benefits (i.e., metformin and pioglitazone) are now recommended only as second- or third-line treatment options in drug-naïve patients with T2DM.
2020
Treatment algorithm; type 2 diabetes; cardiovascular disease
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Utilizza questo identificativo per citare o creare un link a questo documento: https://hdl.handle.net/11562/1009037
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