In a series of presentations at ACC.21, the virtual meeting of the American College of Cardiology, researchers delivered data to confirm two observations about cardiovascular outcomes in heart failure patients with or without type 2 diabetes (T2D) and/or chronic kidney disease (CDK). First, the use of SGLT2 inhibitors is associated with reduced risk of cardiovascular death, worsening heart failure, and/or hospitalization for heart failure, and second, SGLT2i agents are woefully underused.
In a presentation titled, “Just Go With the Flo(zin): SGLT2i Should Be Added to A Few, Some, Most, All HFrEF Patients?”, Glenn Herrington, PharmD, Ambulatory Care Cardiology Pharmacist at New Hanover Regional Medical Center in Wilmington, North Carolina, reviewed findings from EMPA-REG OUTCOME, CANVAS PROGRAM, DECLARE-TIMI 58, VERTIS CV, DAPA-HF, and EMPEROR-REDUCED to assess benefits and safety.
He concluded that SGLT2i treatment offered significant benefit for patients with reduced ejection fraction heart failure (HFrEF) with or without T2D or CKD, so they should be considered in all HFrEF patients. But he also emphasized that it is necessary for patients to first be assessed for contraindications, which include type 1 diabetes, dialysis, pregnancy, and possibly lactation, as well as history of previous SGLT2i allergy.
In a moderated poster session titled “Cardiologist to Diabetologist,” researchers assessed both SGLT2i benefit and use in a pair of posters.
Johns Hopkins University School of Medicine student Rishav Adhikai and Hopkins Associate Professor of Medicine and Endocrinology Michael J. Blaha, MD, MPH, looked at cardiologist prescribing of SGLT2i and GLP-1 receptor agonists since the publication of favorable outcomes for the agents.
“Major clinical guidelines, including those by the American College of Cardiology and the American Diabetes Association, now strongly recommend these drugs,” Adhikai said.
Although it’s estimated that more than a third of diabetes patients also have cardiovascular disease, “all available evidence suggests that very few of these patients are receiving SGLT2i drugs,” he added.
In clinical practice, Adhikai and Blaha hypothesized that cardiologists “may be especially well-positioned to deploy the drugs.” To test that hypothesis, they analyzed data from IQVIA’s National Prescription Audit, a database that captures more than 90% of retail prescription dispensing in the U.S.
They analyzed monthly prescriptions, prescriber specialty, and molecules used from January 2015 through December 2020.
“We evaluated whether there were any statistically significant inflection points or time series data for publication,” they reported.
In 2015, there were 7,234,124 SGLT2i prescriptions dispensed, and just over 35,000 were written by cardiologists. In the same year, there were 5,687,478 GLP1-RA prescriptions and 27,897 were cardiologist prescribed.
The 2015-2020 total SGLT2i prescriptions dispensed were 63,206,920, a six-year cumulative increase of 101%, while total GLP1-RA scripts were 63,411,892, a 207% increase, again for all six years.
Among cardiologists, year-over-year rate of SGLT2i prescribing increased by 39% from 2015-2016, 27% 2016-2017, 42% 2017-2018, 54% 2018-2019, and 64% 2019-2020. The total growth in SGLT2i scripts written by cardiologists over six years was “five-fold greater than the national rate of growth.”
Cardiologists also increased prescribing of GLP1-RA, but the rate of increase was more modest: average 18% year-over-year and 160% total increase over the six-year period.
But when the prescriptions dispensed by cardiologists are compared to those dispensed by endocrinologists—who write the majority of prescriptions in both classes—and primary care providers, cardiologists “represent a small percent of the prescriptions dispensed… although the rate of prescribing does increase as favorable data are reported.”
The Hopkins researchers concluded that “despite large absolute increases in use of cardioprotective SGLT2i and GLP-1RA medications by cardiologists, adaption remains markedly low and accounts for less than 2% of national use. “
To remedy the situation, they recommended a “focused and coordinated effort across all the medical specialties that manage patients with diabetes, including an enhanced role for the cardiologist.”
The EMPRISE East Asia Study “evaluated the impact of empagliflozin on health resource utilization in clinical practice” in Japan, South Korea, and Taiwan by analyzing medical record databases in each country.
Wayne Huey-Herng Sheu, MS, MD, PhD, superintendent of the Taichung Veterans General Hospital in Taiwan, and colleagues identified patients with T2D who initiated empagliflozin or a DPP-4 inhibitor between 2015 and 2018. They used propensity scoring to match 28,712 patients 1:1 at baseline.
“We evaluated their rates of all-cause hospitalization, emergency room visits, and outpatient visits,” Sheu said.
“The risk for any hospitalization was significantly lower in patients receiving empagliflozin than in those receiving DPP-4 inhibitors, with an overall relative risk reduction of 27%,” he said. Likewise, the risk was of an emergency department visit was lower—12% relative risk reduction—and outpatient visits were modestly lower (4%).
The risk of first hospitalization was significantly lower—overall HR 0.77 (95% CI 0.73-0.81)—and once hospitalized, the empagliflozin patients had shorter stays, although the difference was not statistically significant.
Of note, Sheu said the empagliflozin benefit was observed in patients with diabetes “with and without cardiovascular disease and was evident soon after treatment was initiated.”
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Low uptake of SGLT2is and GLP1-RAs among cardiologists may be contributing to undertreatment of patients.
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SGLT2i therapy should be considered for all patients with HFrEF.
Peggy Peck, Editor-in-Chief, BreakingMED™
Harrington had no disclosures.
Blaha has received grants from the NIH/NHLBI, FDA, American Heart Association, Aetna Foundation, and Amgen Foundation and has served on Advisory Boards for Amgen, Sanofi, Regeneron, Novartis, Akcea, Novo Nordisk, Bayer, and 89Bio.
The EMPRISE East Asia trial was funded by the Boehringer Ingelheim & Eli Lilly and Company Diabetes Alliance.
Sheu and Qian had no disclosures.
Cat ID: 103
Topic ID: 74,103,730,103,3,446,12,13,187,127,411,192,669,918,925,168
