More T2D patients should be taking novel drugs

Too many Australians are missing out on novel diabetes drugs, leading to hundreds of unnecessary life-threatening health problems each year, according to modelling from the Baker Heart and Diabetes Institute

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Too many Australians are missing out on novel diabetes drugs, leading to hundreds of unnecessary life-threatening health problems each year, according to modelling from the Baker Heart and Diabetes Institute.

If SGLT2 inhibitors were given to 75% of patients with type 2 diabetes and a history of cardiovascular disease, we would see 680 fewer major cardiovascular events, 511 fewer hospital admissions for heart failure, and 78 fewer people developing end-stage kidney disease each year, according to the report.

Likewise, if doctors were treating the same population with GLP-1 receptor agonists, a similar number of major cardiovascular events could be prevented.

“We have now got overwhelming evidence, certainly for people with diabetes and established cardiovascular disease, that SGLT2 inhibitors and GLP-1 agonists are effective in preventing myocardial infarction and stroke,” Professor Jonathan Shaw, diabetes expert and deputy director of the Institute, said.

SGLT2 inhibitors, in particular, are also effective at preventing episodes of heart failure, with a 2017 study finding a 33% reduction in hospitalisations in patients taking canagliflozin, compared with those taking a placebo.

This is important, because patients with type 2 diabetes account for more than one in three acute admissions to hospital for heart failure, a 2016 MJA study found.

Diabetes experts now recognise that heart failure is a leading cause of death among patients with type 2 diabetes, and often comes without any prior cardiac disease.

The strength of these new diabetes drugs was that patients started seeing the heart benefits within a few weeks, Dr Ian Arthur, a GP and specialist member of the Australian Diabetes Society, said.

“I think SGLT2 inhibitors should be second-line therapy for all patients with pre-existing CVD and an eGFR above 45,” he said.

“GLP-1 agonists have similar benefits but are less well tolerated and many patients prefer not to use an injectable therapy,” Dr Arthur, a contributor to the RACGP’s General Practice Management of Type 2 Diabetes 2016-18 handbook, said.

Dr Arthur noted that while SGLT2 inhibitors increased the risk of thrush, most patients didn’t find the thrush recurred once it has been treated.

While PBS funding demands that patients have an HbA1C of 7% or greater, emerging research has found cardiovascular and renal benefits among patients with well-controlled blood glucose  and even among patients without diabetes.

At least two studies indicate the drugs protect the heart, even among patients with no history of cardiovascular disease, suggesting the drugs benefit a broad group of people.

As well as the hundreds of life-threatening events prevented each year, the effects of wider uptake of these novel diabetes drugs “would clearly be significantly magnified over time”, Professor Shaw wrote.

The Dark Shadow of Type 2 Diabetes report also found that a 20% increase in statins and either ACE inhibitors or angiotensin II receptor blockers (ARB) would save more than 300 people dying from cardiovascular problems each year.

Yet despite diabetes guidelines recommending the routine use of these drugs in patients with cardiovascular disease, many patients are still missing out.

A study of two Australian diabetes clinics found that at least one in three patients were not prescribed an ACE inhibitor or an ARB, and a similar proportion were not prescribed a statin.

The report, which was funded with an unrestricted educational grant from Boehringer Ingelheim and Eli Lilly, also highlighted the lesser known complications from type 2 diabetes.

Patients are at an increased risk of many cancers, including a two-fold increase in liver cancer and endometrial cancer and up to a three-fold increase in pancreatic cancer.

This emphasised the importance of adhering to cancer-screening programs, Professor Shaw said.

In addition, the chances of developing dementia are 60% greater in people with type 2 diabetes, and are elevated not only for vascular dementia, but for Alzheimer’s disease as well.

Liver disease, depression, hearing impairment, eye problems and periodontal disease are also more common in these patients.

The Dark Shadow of Type 2 Diabetes, published 25 May, 2020