A 67-year-old woman attends your outpatient cardiology clinic this morning for routine follow up.
Background history includes the following:
Type 2 diabetes mellitus
Dyslipidemia
Hypertension
Coronary heart disease: NSTEMI 2012, percutaneous coronary intervention to left anterior descending artery, moderate right coronary artery disease.
Current medications are:
Metformin 1g twice daily
Glipizide ER 10mg once daily
Pioglitazone 15mg once daily
Lisinopril/HCT 20/12.5mg once daily
Atorvastatin 20mg once daily
Labs performed one month ago by her primary care physician include:
HbA1c 7.4%
eGFR 65mL/min/m2
LDL 105mg/dL; TG 175mg/dL
She has no new issues today and denies chest pain or exercise limitation. Examination reveals a blood pressure of 128/80 mmHg and a pulse rate of 68 beats per minute (regular). Calculated body mass index is 33kg/m2.
She has been coming to the clinic for almost 10 years and reports adherence to her medication profile. She is reluctant to make changes to her treatment regimen... 'if it ain't broke, don't fix it Doc?'
What change would be your first priority in reducing this patient's cardiovascular risk?
Show Answer
The correct answer is: C. Add empagliflozin 10mg once daily.
Atherosclerotic cardiovascular disease remains the single most common cause of death and disability for patients with type 2 diabetes mellitus. While this patient has been 'stable' for almost 10 years, her risk of future coronary events increases with age and every opportunity should be taken to optimize components of modifiable risk. This is likely to require some counseling to overcome the hesitancy for change.
Answers C and D are both reasonable and reflect the top priority: the inclusion of a glycemic agent with proven cardiovascular benefit.1 The addition of a sodium glucose co-transporter 2 inhibitor (SGLT-2i) will not only reduce her risk of future myocardial infarction (MI)/stroke and heart failure,2 but in the context of mild kidney dysfunction, may also slow the progression of her presumed diabetic nephropathy.3 Given her A1c is near to target, one could consider stopping or reducing the glipizide dose; however, as the SGLT-2i class only modestly reduces A1c (~0.5%), cautious addition is reasonable.3
Option D is an excellent alternative to C as she would still derive a similar MI/stroke risk reduction from the inclusion of a glucagon-like receptor-1 receptor agonist (GLP-1RA) in addition to weight loss in the context of her obesity (~3-5% expected weight loss).4 However, the nephroprotection provided by the SGLT-2i is preferable with her kidney dysfunction.
Answer A would also reduce her risk for future major adverse cardiovascular events (MACE) and should be done as soon as practical. Answer B would have only a modest effect and should be done only after optimizing statin dose. The benefits of SGLT-2i in the randomized trial data appear as early as 3 months so making this change early is a priority. Similarly, answer E will also reduce her risk for future MACE, although this could be considered once her LDL-lowering has been optimized.5
Educational grant support provided by: Boehringer Ingelheim Pharmaceuticals, Inc. and Lilly USA, LLC.
To visit the hub for the CV Risk in Diabetes: Emerging Science Grant, click here!
Del Olmo-Garcia MI, Merino-Torres JF. GLP-1 Receptor Agonists and Cardiovascular Disease in Patients with Type 2 Diabetes. J Diabetes Res 2018;2018:4020492.
Bhatt DL,, Steg PG, Miller M, et al. Cardiovascular Risk Reduction with Icosapent Ethyl for Hypertriglyceridemia. N Engl J Med 2019;380:11-22.
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