Optimal Management of Diabetes: Expert Nurse Practitioner Perspectives - Episode 3
Davida Kruger, MSN, APN-BC, BC-ADM: What patient factors do you consider when selecting the best treatment approach for individual patients? In other words, how does the presence of a comorbidity influence some of your choices?
I think we would all say that the biggest risk for our patients is cardiovascular disease. The standards of care would say, if your patient has known cardiovascular disease, go over to the GLP-1 [glucagon-like peptide-1] receptor agonists, and if they have heart failure or kidney disease, then we’re going to go over to the SGLT2 [sodium-glucose cotransporter-2] inhibitors. What are the other things? In my mind, that’s pretty well the big difference in how we use GLP-1 receptor agonists and SGLT2 inhibitors with those comorbidities. Would you agree?
Lucia Novak, MSN, ANP-BC, BC-ADM, CDTC: Yes, definitely. That’s why the cardiovascular outcome trials were meant to show that all drugs that were coming to market for the indication of the treatment of type 2 diabetes did not increase the risk for a major adverse cardiovascular event, and they had to be proven to be at least safe in the patient population that is already 4- to 6-fold more at risk for having an adverse event.
In addition, all of the medications have shown safety. All of the drugs we have now have shown that they do not increase the risk for harm, but the benefit of these trials is that they have shown that some drugs, especially those in the GLP-1 receptor agonist class as well as in the SGLT2 inhibitor class, have actual benefit.
To your point, the GLP-1 receptor agonists reduce that atherosclerotic type of ischemic event, and then the SGLT2 inhibitors protect against hospitalizations for heart failure, reducing that risk even in patients without type 2 diabetes as some of these drugs have shown, and then there is also protection for the kidneys.
Davida Kruger, MSN, APN-BC, BC-ADM: What I find is interesting is, I was an investigator in many of the cardiovascular outcome trials. In 2008 when they were mandated by the FDA, I thought, “Oh good, these will be 3-to-5-year trials. I could feed my family of researchers here.” Never did I think we were going to make history. When you think about these data, yes we want to use statins and we want to use ACE [angiotensin-converting enzyme] inhibitors for all our patients. But when you look at the data for all of these cardiovascular trials, the separation of the benefit, whether the patient had no cardiovascular disease or if they had an event, within the first 4 to 6 weeks, they start to get a decreased risk of cardiovascular disease, death, MI [myocardial infarction], and stroke. So to me, why are we not using more of these? The data turned out to be phenomenal beyond anybody else’s wildest dreams.
The other thing is that we know the greatest risk to our patients is cardiovascular disease. I then think of women. Women are understudied, as always, in a lot of these trials. If you don’t have diabetes, we know that your risk of cardiovascular disease is less than that of men, but if you have type 2 diabetes, then your risk is the same as a man’s risk. When you enter this whole arena of diabetes, whether you’re a man or a woman, your decreased life expectancy is somewhere around 5 to 7 years just because you have diabetes and cardiovascular risk. If a patient has had 1 MI or if they’ve had a stroke, their life expectancy if they have diabetes is decreased by about 19 years.
The other thing that is interesting too is that, if you’ve had 1 MI and you have diabetes, then you have a huge risk of having a second MI. It’s in something like 5 to 10 years in which you will likely have a second MI. Anything we could do that lowers that patient’s risk of either having a cardiovascular event or having a second event pays off 10-fold for our patients. Any comments?
Lucia Novak, MSN, ANP-BC, BC-ADM, CDTC: Yes. Due to the fact that women are aren’t studied and that we also don’t present with classic symptoms, I do believe that heart disease in women is underappreciated. What we as clinicians need to understand is that heart disease impacts women of all age groups. When women experience a cardiac event, they do worse than men at any comparable age.
Women who are 45 to 65 years of age are more likely to die within the first year. Women over the age of 65, compared to men of the same age, are more likely to die within a few weeks. When women have their first event, they also tend to be about 10 years older than men because we have some protective mechanism in place with the estrogen. For women 25 to 44 years of age, cardiovascular disease is still the third most common cause of death in that age group. In the later years when menopause hits and we no longer have that benefit of estrogen, about 1 in 4 women are going to die from that event.
Again, women tend to be under-reported, understudied, and misunderstood oftentimes. I agree with you.
Davida Kruger, MSN, APN-BC, BC-ADM: I want to thank the audience for watching this HCPLive® Peers & Perspectives®. If you enjoyed the content, please subscribe to our e-newsletter to receive upcoming Peers & Perspectives® and other great content right in your inbox. Thank you all for joining us today.
Transcript Edited for Clarity