Contributor: Dr. Staci-Marie Norman, PharmD, DCES
With all the focus on love and Valentine’s Day hearts, February is the perfect time to talk about our own hearts. When people think or talk about diabetes, the focus is typically on blood glucose. Blood sugar management is very important, but there are other organs in our body that diabetes can profoundly affect. Our heart is one of these organs, as cardiovascular disease is the number one cause of death in people with diabetes. If you are a man with diabetes, your risk of cardiovascular disease is twice that of someone without diabetes. For women, the risk of cardiovascular disease is up to four times more likely, according to the American College of Cardiology. So, let’s talk about how we can reduce these risks.
Diabetes management is multi-faceted. You can't just focus on blood glucose and not worry about blood pressure or cholesterol. You can't just eat healthy but not exercise or take your medications. It all works together. A nutritious diet, exercise, smoking cessation, and taking your medication are all essential in diabetes management and cardiovascular risk reduction. But this month, we'll focus on some medications proving to be highly beneficial for glycemic management and reducing cardiovascular risk.
Glucagon-Like Peptide-1 Receptor Agonists (GLP1-RA) - These medications were introduced in 2005 with Byetta, a twice-daily injection. In the past 18 years, we have moved from twice daily injections to daily (Victoza) and weekly injections (Trulicity, Ozempic, Adlyxin) and an oral dosage form (Rybelsus). These medications mimic an intestinal hormone we produce naturally in response to the presence of food. When Byetta was first introduced, we knew that these hormones stimulated insulin secretion from the pancreas when we eat. They also help to regulate how fast the food moves through the stomach and empties into the intestine. This motility rate is part of the difference between feeling full or hungry. Over the years, we have learned so much more about the GLP1-RAs. They have a substantial glucose-lowering ability, much more than any other class of medications other than insulin. They can also help in weight reduction, with clinical trials showing an average decrease of 12-15 kg (approximately 25-30lb). Further clinical studies have found that they play a significant role in cardiovascular protection and have some renal protection. In clinical trials, it has been found that the risk of another cardiovascular event has been lowered significantly for people with established cardiovascular disease (CVD). The FDA has added an indication for cardiovascular risk reduction in patients with known cardiovascular disease for Victoza and Ozempic. The clinical trials for Trulicity looked at patients with CVD and those at high risk for CVD. The findings were so significant that the FDA added an indication for use in patients with risk factors for CVD. These were the first medications we have for diabetes that can also be helpful in the fight against heart disease.
Sodium-Glucose Cotransporter 2 inhibitors (SGLT-2i) - These medications work in the kidneys to flush excess glucose out of the body through the urine. Our kidneys have a normal "safety valve" that starts dumping excess glucose into the urine when the blood glucose reaches about 180mg/dL. An SGLT-2i lowers this "safety valve" to about 130mg/dL, allowing more glucose to be eliminated from the body. The first SGLT-2i, Invokana, was brought to market in 2013. Farxiga, Jardiance, and Steglatro followed it. It has been found that when the kidney "dumps" glucose into the urine, sodium is also eliminated, which has a beneficial effect on blood pressure. The elimination of extra glucose is also an elimination of excess calories that are not stored as fat. This gives us the beneficial effect of weight loss. These are all super benefits we want from our diabetes medications, and more benefits are being found in further studies. Because of the decrease in blood pressure and the volume of fluids in the body, these medications are helpful in heart disease, especially heart failure. Farxiga and Jardiance have been given FDA indications for use in heart failure in patients with or without heart disease. Another significant step forward in having more medications that can not only decrease blood glucose but also protect our hearts! And they have also been found to protect our kidneys.
Due to all this clinical data, the American Diabetes Association changed its treatment algorithm to reflect the cardiovascular and renal protective properties. The algorithm now suggests that for people with or at high risk for CVD who take metformin, either a GLP1-RA or SGLT-2i be started. As a pharmacist and diabetes educator, I can’t tell you how exciting it is to have many medications that can provide many benefits.
So do your heart a favor - if you need to optimize your blood glucose management, talk to your doctor about the best option for you, your blood glucose, and your heart.
Dr. Staci-Marie Norman, PharmD, DCES received her bachelors from Purdue University (’94) and her Doctor of Pharmacy from the University of Oklahoma (’96). In 2000 Dr. Norman added to her credentials by becoming a Certified Diabetes Care and Education Specialist. She is currently the Clinical Coordinator and staff pharmacist for Martin’s Pharmacy. Dr. Norman is a national faculty member for the American Pharmacist Association, teaching certificate programs in both diabetes and cardiovascular disease. She serves on the advisory board that oversees development and revision of these programs. Along with teaching and development responsibilities for APhA, Dr. Norman serves as a peer reviewer for research grants and publication submission. Dr. Norman has also spoken for Abbott, Bayer, Lilly, Mannkind, and Lifescan as a diabetes specialist.