What medication should be added to a patient with Ischemic Heart Disease (IHD) and Diabetes Mellitus (DM)?

SGLT-2 Inhibitors Are Recommended for Patients with Ischemic Heart Disease and Diabetes Mellitus

SGLT-2 inhibitors (specifically empagliflozin, canagliflozin, or dapagliflozin) are strongly recommended as the medication of choice to add for patients with ischemic heart disease (IHD) and diabetes mellitus (DM). 1

Rationale for SGLT-2 Inhibitor Selection

SGLT-2 inhibitors provide multiple benefits that are particularly valuable for patients with both IHD and DM:

1. Cardiovascular Benefits:

   • Reduce risk of heart failure hospitalization by 35% 1
   • Reduce cardiovascular death by 38% in patients with peripheral artery disease 2
   • Reduce major adverse cardiovascular events (MACE) by 14% 2
   • Provide all-cause mortality reduction of 32% 2

2. Glycemic Control:

   • Reduce HbA1c by 0.7-1.0% 2
   • Empagliflozin provides significant reductions in HbA1c and fasting plasma glucose when used in combination with insulin 3

3. Additional Benefits:

   • Weight reduction (1.8-2.4% from baseline) 3
   • Blood pressure lowering effects 2
   • Renal protection 1

Clinical Decision Algorithm

1. First-line assessment:

   • Confirm diagnosis of both IHD and DM
   • Check baseline renal function (eGFR)
   • Review current diabetes medications

2. SGLT-2 inhibitor selection:

   • If eGFR ≥30 mL/min/1.73m²: Add empagliflozin 10mg daily (preferred due to strongest mortality benefit) 1, 2
   • If established cardiovascular disease: Empagliflozin has demonstrated 38% reduction in cardiovascular death 2

3. Monitoring:

   • Check renal function before initiation and periodically during treatment
   • Monitor for genital mycotic infections
   • Assess for symptoms of euglycemic diabetic ketoacidosis 2

Contraindications and Precautions

• Do not use if:

  • eGFR <30 mL/min/1.73m² (reduced efficacy) 3
  • Type 1 diabetes
  • History of diabetic ketoacidosis

• Use with caution in:

  • Elderly patients with volume depletion risk
  • Patients on diuretics (monitor for hypotension)

Alternative Options if SGLT-2 Inhibitors Contraindicated

If SGLT-2 inhibitors are contraindicated, consider these alternatives in order of preference:

1. GLP-1 receptor agonists (liraglutide, semaglutide, dulaglutide):

   • Have neutral effect on heart failure risk 1
   • Provide cardiovascular benefits including MACE reduction 2
   • May be considered for DM treatment in patients with heart failure (Class IIb recommendation) 1

2. DPP-4 inhibitors (sitagliptin, linagliptin only):

   • Have neutral effect on heart failure hospitalization 1
   • May be considered for DM treatment in patients with heart failure (Class IIb recommendation) 1
   • Important: Avoid saxagliptin due to increased risk of heart failure hospitalization 1

3. Insulin:

   • May be considered in patients with advanced systolic heart failure with reduced ejection fraction (Class IIb recommendation) 1

Medications to Avoid

• Thiazolidinediones (pioglitazone, rosiglitazone):

  • Associated with increased risk of heart failure in patients with DM 1
  • Not recommended for DM treatment in patients at risk of heart failure or with previous heart failure (Class III recommendation) 1

• Saxagliptin:

  • Associated with increased risk of heart failure hospitalization 1
  • Not recommended for DM treatment in patients at risk of heart failure (Class III recommendation) 1

Common Pitfalls to Avoid

1. Delaying SGLT-2 inhibitor initiation - These agents should be prioritized in patients with IHD and DM due to their cardiovascular mortality benefits

2. Ignoring renal function - While glycosuric effects diminish with declining renal function, cardiovascular and blood pressure benefits persist even with moderate renal impairment

3. Overlooking volume status - SGLT-2 inhibitors have diuretic effects that may require adjustment of other diuretic medications

4. Continuing medications with adverse cardiovascular profiles - Always discontinue thiazolidinediones and saxagliptin in these high-risk patients

By following these evidence-based recommendations, you can optimize outcomes for patients with both IHD and DM, reducing their risk of cardiovascular events, heart failure hospitalization, and mortality.