COMMENTARY

Lower CV Risk -- With a Diabetes Drug

Anne L. Peters, MD

Disclosures

April 01, 2016

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I want to share with you a fascinating case that I just saw in clinic. Usually, my cases in diabetes clinic are fascinating because of a blood glucose problem, but this patient was fascinating because of his cardiovascular risk and how I believe I was able to help reduce it.

The patient is a 52-year-old man with type 2 diabetes and cardiovascular disease. He was referred by his cardiologist so that I could treat his diabetes to lower his cardiovascular disease risk.

"Well, what's your A1c?" I asked.

"My A1c has been around 6%," he replied.

"Then your diabetes is well-controlled," I said.

"No," he said. "You have to do better. I just had another stent."

"Oh, that's too bad," I said. "How many stents have you had?"

"Eight. Every 4-6 months, I seem to need another stent in a different artery. They say that I'm going to need bypass surgery or worse if I don't fix this ongoing atherosclerotic process."

And I said, "Well, I'm not so sure that it's your diabetes. Your diabetes is well controlled."

But then I thought about it. He was on metformin and sitagliptin. His A1c level in my office was 6.4%. His blood pressure was incredibly well controlled, and he was on a maximal-dose statin. Despite all this, he was having accelerated atherosclerosis that was leading to chest pain, his need for stents, and his worsening cardiovascular situation.

 
This is the first time that I have so consciously said, "I'm going to use diabetes drugs to try to help reduce your cardiovascular risk."
 

I thought to myself about how, in the past 6 months, we've learned a great deal about diabetes medications and the fact that they may be able to help mitigate cardiovascular disease risk. I told the patient, "Okay, let's just switch your regimen. Let's stop the metformin, stop the sitagliptin, and I'm going to put you on two new medications. I want to put you on empagliflozin and pioglitazone because they will help maintain your blood glucose control, but both of those agents may also help reduce your cardiovascular risk."

I went on to explain about both agents. I told him about the EMPA-REG trial and how patients with known cardiovascular disease and type 2 diabetes had a 38% risk reduction in cardiovascular death.[1] He wanted to know how empagliflozin did this. I told him that I could give him some theories but that in fact, we didn't fully know how empagliflozin worked to help reduce cardiovascular risk—but suffice it to say that it did. And it might in him.

I told him that pioglitazone is a drug that we've had on the market for a long time, and that the newly released IRIS study showed that pioglitazone in patients with insulin resistance who didn't actually have type 2 diabetes but had insulin resistance and had had a prior stroke benefited from the use of pioglitazone compared with placebo.[2] The IRIS trial showed that over about 5 years, there was a 24% reduction in stroke or myocardial infarction in patients taking pioglitazone. I told him that we can stop the metformin and sitagliptin, add in pioglitazone and empagliflozin, and continue the statin, the blood pressure medications, et cetera.

This is the first time that I have so consciously said, "I'm going to use diabetes drugs to try to help reduce your cardiovascular risk." I often use diabetes drugs and know from recent trials that I may also be reducing cardiovascular risk, but this is the first time that a patient's chief complaint was, "Help me control my diabetes in order to reduce my cardiovascular disease risk."

In June, we're going to get updates on the liraglutide cardiovascular outcomes trial. There was a press release stating that the results are positive.[3] I look forward to learning more about the benefits of liraglutide in terms of cardiovascular outcomes. I'm excited that we have more diabetes drugs that have a dual benefit, reducing our high-risk patients' risk for diabetes complications as well as improving their cardiovascular outcomes risk.

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