What is the management approach for type 2 diabetes mellitus (T2DM) in a patient with cardiovascular (CV) risk?

From the Guidelines

The management approach for type 2 diabetes mellitus (T2DM) in a patient with cardiovascular (CV) risk should prioritize the use of GLP-1 receptor agonists or SGLT-2 inhibitors, such as semaglutide or empagliflozin, to reduce CV events and mortality, as recommended by the most recent guidelines 1. The approach to managing T2DM in patients with CV risk involves a comprehensive strategy that targets both glycemic control and CV risk reduction. Key components of this approach include:

• Lifestyle modifications, such as weight loss, regular physical activity, and a heart-healthy diet
• First-line therapy with metformin, starting at 500 mg daily and increasing to 1000-2000 mg daily in divided doses
• Addition of a GLP-1 receptor agonist, such as semaglutide 0.25-1 mg weekly or dulaglutide 0.75-4.5 mg weekly, or an SGLT-2 inhibitor, such as empagliflozin 10-25 mg daily or dapagliflozin 5-10 mg daily, for patients with established CV disease or multiple risk factors, as these medications have proven CV benefits beyond glucose control 1
• Blood pressure control to <130/80 mmHg using ACE inhibitors or ARBs as first-line agents
• Statin therapy, typically atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily, regardless of baseline lipid levels
• Consideration of aspirin 81-100 mg daily for secondary prevention, particularly in patients with a history of CV disease 1 Regular monitoring of HbA1c, renal function, lipids, and blood pressure is essential to ensure that the treatment plan is effective and to make adjustments as needed. The goal of this approach is to prevent diabetes complications and reduce CV events, as diabetes and CV disease share common pathophysiological mechanisms, including inflammation, oxidative stress, and endothelial dysfunction. By prioritizing the use of GLP-1 receptor agonists or SGLT-2 inhibitors, healthcare providers can help reduce the risk of CV events and mortality in patients with T2DM and CV risk, as supported by the most recent guidelines 1.

From the FDA Drug Label

The effect of JARDIANCE on cardiovascular risk in adult patients with type 2 diabetes and established, stable, atherosclerotic cardiovascular disease was evaluated in the EMPA-REG OUTCOME study, a multicenter, multi-national, randomized, double-blind parallel group trial JARDIANCE significantly reduced the risk of first occurrence of primary composite endpoint of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke (HR: 0.86; 95% CI 0.74,0. 99)

The management approach for type 2 diabetes mellitus (T2DM) in a patient with cardiovascular (CV) risk is to use empagliflozin as an adjunct to diet and exercise to improve glycemic control and reduce the risk of cardiovascular death. The recommended dose is 10 mg once daily, which may be increased to 25 mg in patients tolerating the medication 2.

From the Research

Management Approach for Type 2 Diabetes Mellitus (T2DM) with Cardiovascular (CV) Risk

The management approach for T2DM in patients with CV risk involves a multifaceted strategy that includes:

• Behavioral modification to affect regular physical activity, healthy diet, weight loss, and smoking cessation 3
• Optimal glycemic control with HbA1c < 7% 3
• Aggressive management of hypertension (< 130/80 mmHg) and dyslipidemia 3
• Use of antiplatelet agents, blood pressure-lowering therapies, lipid-lowering therapies, and healthy lifestyle modifications 4
• Consideration of glucagon-like peptide 1 (GLP1) receptor agonists and sodium-glucose cotransporter 2 (SGLT2) inhibitors as first-line agents for both glycaemic control and CV risk reduction in patients with T2D and ASCVD 4, 5

Dietary Approaches

Different dietary approaches can be effective in managing T2DM and reducing CV risk, including:

• Low-carbohydrate diets 6
• Low-glycemic index (GI) diets 6
• Mediterranean diets 6
• High-protein diets 6 These diets can lead to improvements in glycemic control, weight loss, and lipid profiles, which can help reduce CV risk 6

Cardiovascular Risk Reduction

Cardiovascular risk reduction is a key part of clinical management in patients with T2DM, and can be achieved through:

• Optimal CV risk management (CVRM) 7
• Initiation of glucose-lowering agents with proven cardiovascular benefit, such as GLP-1 RAs and SGLT-2is 7
• Use of blood pressure-lowering medication, statins, and aspirin 7 The lifetime benefit from optimal CVRM and the addition of GLP-1 RAs and SGLT-2is can be significant, with a mean lifetime benefit of 3.9 years in patients with established CVD and 1.3 years in patients without established CVD 7