The ACC's new 2018 Expert Consensus Decision Pathway on Novel Therapies for Cardiovascular Risk Reduction in Patients with Type 2 Diabetes and Atherosclerotic Cardiovascular Disease addresses the changing paradigm in how cardiovascular specialists should approach care of T2D patients.

The Pathway, which is endorsed by the American Diabetes Association and published in the Journal of the American College of Cardiology, identifies three key areas where cardiovascular professionals are uniquely positioned to assist with the management of T2D patients: 1) screening for T2D in patients with or at high risk of cardiovascular disease; 2) aggressively treating cardiovascular risk factors; and 3) incorporating data for newer antihyperglycemic agents into routine practice.

"Previously, [cardiovascular] care in patients with diabetes was centered around risk factor optimization, and the medications used for glycemic control were not expected to demonstrate direct [cardiovascular] benefit," wrote Writing Committee Co-Chairs Sandeep R. Das, MD, MPH, FACC, and Brendan M. Everett, MD, MPH, FACC, and colleagues. "The recent development of two novel classes of therapies – SGLT2 inhibitors and GLP-1RAs – has, for the first time, demonstrated that treatments developed for glucose lowering can directly improve [cardiovascular] outcomes."

The Pathway provides practical guidance on when and how to incorporate the use of SGLT2 inhibitors and GLP-1Ras in the treatment of patients with T2D and ASCVD with the express goal of reducing cardiovascular risk and optimizing outcomes. Authors note a number of circumstances in which clinicians might consider starting one of these agents, including at the time of diagnosis of clinical ASCVD in a patient with T2D on a drug regimen that does not include a GLP1-RA or SGLT2 inhibitor;  at the time of diagnosis of T2D in a patient with clinical ASCVD; and at hospital discharge after admission for an ASCVD- or diabetes-related clinical event.

In addition to identifying "a need for a collaborative, interprofessional and multidisciplinary approach to managing" T2D patients at high-risk of cardiovascular disease, the Pathway also strongly encourages patient discussions that review of risks, potential benefits, and different treatment options. "Specifically, potential side effects, drug-drug interactions, and safety issues should be explained clearly, patient preference and other concerns elicited, and cost discussed, since SGLT2 inhibitors and GLP1-RA are expensive, and out-of-pocket cost could be considerable for many patients," they said. A pathway chart outlining when to use an SGLT2 inhibitor or a GLP-1RA first based on clinician and patient priorities is included in the document. The chart also helps to identify when alternative agents should be considered based on symptoms and medical history.

"On behalf of the more than 30 million Americans living with diabetes, we are pleased to align with and endorse the ACC's decision pathway on novel therapies for people with type 2 diabetes and cardiovascular disease," said William T. Cefalu, MD, Chief Scientific, Medical and Mission Officer of the American Diabetes Association. "Diabetes is not just a condition of abnormal glucose metabolism; it is also significantly associated with cardiovascular disease. Comprehensive data obtained from multiple major clinical trials over the recent past have demonstrated significant reductions in major adverse cardiac events with two classes of diabetes medications, the GLP-1 receptor agonists and SGLT-2 inhibitors. Reducing the impact of cardiovascular disease for people with type 2 diabetes is essential to improving quality and length of life."

This is the latest Expert Consensus Pathway document, part of ACC's ongoing Clinical Pathway efforts to provide cardiovascular professionals practical guidance, particularly in areas of emerging science where evidence is limited. The Clinical Pathway process includes bringing together stakeholders as part of Heart House Roundtables to explore areas of concern and steps forward; the development of an Expert Consensus Decision Pathway (ECDP) document; and ultimately educational tools and decision aids.

Keywords: Hypoglycemic Agents, Diabetes Mellitus, Type 2, Risk Factors, Glucose, Critical Pathways, Patient Preference, Consensus, Blood Glucose, Risk Assessment, Atherosclerosis, Risk Reduction Behavior, Drug Interactions, Decision Support Techniques

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