Contributor: Frank Lavernia, MD
Heart disease is the leading cause of death in the US. Hopefully, most people with diabetes know about the tight connection between diabetes and heart disease, but what they may not know is that kidney and heart disease are also interconnected. What do they have in common? Hypertension. Blood glucose, blood pressure, and cholesterol are three values that are important to monitor and manage with various treatments. Yet only approximately 17% of people with diabetes are able to keep all three values within their desired range consistently.
Many health care clinicians (HCC) and the patients they see have become extremely focused on blood glucose results. Many feel that if the patients get their A1C level to below 7%, they have successfully reduced their diabetes risks. The American Diabetes Association guidelines also stress that patients 40 or older should be on a statin even if they have not had a cardiac event, stroke, or peripheral vascular disease. The particular statin type and dose will depend on various factors such as LDL-C level (bad cholesterol) and past cardiovascular events. If tolerated well, statins should be taken forever. Goals for LDL-C value have been steadily declining, but unfortunately, many patients do not reach those goals. Clinicians are not convincing patients to either increase the dose, change to a more potent lowering statin, or add another agent, even for patients older than 75 years of age.
In December 2019, the FDA approved the use of Vascepa for people with diabetes. This drug is given when there are two additional risk factors and high triglycerides (>150 mg/dL). This will help with residual risks that exist even while taking a statin. Vascepa is the first FDA-approved drug (not an omega-3 oil tablet) to reduce cardiovascular risk among patients with elevated triglyceride levels as an add-on to maximally tolerated statin therapy (REDUCE-IT Trial). Omega-3-acid ethyl esters should not be substituted for Vascepa. Vascepa contains only eicosapentaenoic acid (EPA); the others do not. Other omega-3 oil tablets contain long-chain fatty acids docosahexaenoic acid (DHA), which produce substantial triglyceride reduction and other beneficial effects on atherogenic lipid and inflammation-related parameters, blood pressure, and heart rate variability, but products that contain DHA may raise low-density lipoprotein-cholesterol (LDL-C). High levels of triglycerides can play a role in the hardening of arteries or thickening of the artery wall, which can increase the risk of a heart attack or stroke; however, the mechanisms of action that contribute to reduced cardiovascular events among patients taking Vascepa are not completely understood.
Hypertension levels should be managed by the HCC and patient. As people with diabetes monitor their blood glucose, they can also monitor blood pressure at home and share that critical information with their HCC. There are multiple ACE and/or ARB drugs that are indicated for people with diabetes because of the kidney protection they offer. If the maximum dose is not successful at lowering blood pressure into range (generally <140/90 mm Hg), a second or third agent may be needed. Some patients have significant kidney disease, and they would benefit from lowering BP down to <130/80 mm Hg. We now have a newer group of drugs that have virtually changed how we protect the kidneys further and prevent end-stage renal disease.
Since 2008 the FDA has mandated CVOT (Cardiovascular Outcome Trials) on all new antihyperglycemic drugs before they are approved for safety and efficacy. Many individual drugs in two classes (GLP-1 RA and SGLT-2i) have shown added efficacy, and all have shown safety. Because of these findings, HCC must ask themselves if their patients with diabetes qualify for one of these newer medications to reduce cardio-renal events.
Dr. Lavernia has been a practicing diabetologist in South Florida for more than 35 years. He was the founder and director of the North Broward Diabetes Center in Florida. He is an adjunct faculty member of the National Diabetes Education Initiative (NDEI), Vascular Biology Working Group (VBWG), and for the Coalition for the Advancement of Cardiovascular Health (COACH). He is also a member of the American Diabetes Association, American Association of Clinical Endocrinology, European Association for the Study of Diabetes, and the National Hispanic Medical Association. He is a member of the DiabetesSisters Board of Directors.