April 06, 2020
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Novel antihyperglycemic agents, multidisciplinary care model impact cardiorenal outcomes

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Janani Rangaswami

SCOTTSDALE, Arizona — There is an important unmet need for multidisciplinary care models to utilize the novel antihyperglycemic agents to lower cardiorenal outcomes in patients, according to an expert at the Cardio Renal Metabolic Conference.

“When you look at the field of cardiorenal medicine, as well as of the field of metabolic control in diabetes, they both share a rich and long history, but somehow these two fields have always seemed to go in parallel with each other,” Janani Rangaswami, MD, FACP, FCRS, FAHA, the associate chair (research) at the department of medicine (nephrology) at Einstein Medical Center, Philadelphia, clinical associate professor at Thomas Jefferson University in Philadelphia and vice president of the Cardio Renal Society of America, said in her presentation. “Right now with the explosion of data of the cardiovascular benefits of the novel antihyperglycemic agents, there is actually a great opportunity for these fields not to function in parallel, but to converge in a meaningful way that impacts the triple threat of diabetes, cardiovascular disease and kidney disease.”

The SGLT-2 inhibitors and GLP-1 receptor agonists reduce the burden of cardiovascular disease and kidney disease, Rangaswami said. Several high quality randomized controlled trials have shown benefits with respect to lowering mortality (for some agents), reducing cardiovascular disease burden (more benefits with heart failure with the SGLT2 inhibitors and for atherosclerotic cardiovascular disease with the GLP-1 RAs), she said, reducing worsening of kidney disease and need for dialysis.

Kluger and colleagues showed patients enrolled in the SGLT-2 inhibitor cardiovascular trials had differing baseline cardiorenal risk profiles, which need to be factored in when choosing these agents. Event rates in these SGLT-2 inhibitor trials mirrored the established cardiovascular rates and baseline risks by low eGFR and/or high urine albumin-to-creatinine ratios. These agents showed benefits across eGFR strata and across baseline urine albumin-to-creatinine.

For cardiorenal outcomes in the SGLT-2 inhibitor trials, post hoc analyses by Neuen and colleagues, Wanner and colleagues and Rangaswami’s group showed these therapies are effective in patients with impaired GFR, such as patients with kidney disease.

Lack of utilization of SGLT-2 inhibitors and GLP-1 receptor agonists occur due to a disparity in specialty resources, cost factors, reluctance to change culture and a lack of a central role for an internist, according to Rangaswami.

Disparities within specialties are a barrier in implementation of these agents. Rangaswami discussed the ratio range of health care provider to newly diagnosed patient with diabetes, noting it was 30:1 to 154:1 in cardiology and is 371:1 to 267:1 in endocrinology. She said that nephrologists in Washington D.C. have a patient to provider ratio of 46:1 compared to 2,000:1 in Wyoming. These data were reported from an analysis led by Ravi Patel, MD and Muthiah Vaduganathan, MD.

Rangaswami discussed the concept of a multidisciplinary cardiorenal metabolic program where it is important to create a bridge between endocrinology, nephrology and cardiology, identify a role for internists, identify a care navigator, create institutional support, invest in outreach measures to identify high-risk patients and involve fellows and residents.

“The most important thing [is] we have made this mistake before where we have had data on life saving drugs and the uptake of these important therapies is always behind,” Rangaswami said. “If we don’t learn from some of our prior mistakes, we will continue to make the same mistakes even with these amazing new agents.” – by Erin T. Welsh

References:

Kluger A, et al. Cardiovasc Diabetol. 2019;doi:10.1186/s12933-019-0903-4.

Neuen BL, et al. Circulation. 2018;doi:10.1161/CIRCULATIONAHA.118.035901.

Rangaswami J. Cardiorenal outcomes with the novel antihyperglycemic agents and multidisciplinary care models. Presented at: Cardio Renal Metabolic Conference; March 6-7, 2020; Scottsdale, Arizona.

Sarnak M, et al. N Engl J Med. 2018;doi:10.1056/NEJMoa1800256.

Wanner C, et al. Circulation. 2018;doi:10.1161/CIRCULATIONAHA.117.028268.

Disclosure: Rangaswami reports no relevant financial disclosures.