2018 ACC Expert Consensus Decision Pathway on Novel Therapies for Cardiovascular Risk Reduction in Patients With Type 2 Diabetes and Atherosclerotic Cardiovascular Disease: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways

During the interactive table discussions, ACC consistently heard the following from participants: 1) there is a need for a paradigm shift from focusing on glycemic control alone to focusing more comprehensively on reducing CV risk and preventing CV death; and 2) there is a need to acknowledge that some of these emerging medical therapies have been proven to reduce CV death in patients with established or who are at high risk for CV disease, and that CV clinicians therefore have a role in prescribing them. [...]the ACC saw an opportunity to provide guidance to fill the current gap between CV clinicians and diabetes care providers who jointly manage patients with T2D and ASCVD. [...]given a diuretic and antihypertensive effect, SGLT2 inhibitors may increase the risk of volume depletion and hypotension; in large randomized control trials, this risk was slightly higher with canagliflozin than with placebo but was not increased with empagliflozin. Cost should also be considered, as insurance coverage for these agents can vary significantly. [...]data from ongoing clinical trials become available, patients at high risk for HF (and possibly those with established HF) may derive more benefit from an SGLT2 inhibitor with demonstrated CV benefit, whereas those with osteoporosis, prior amputations, severe peripheral artery disease, peripheral neuropathy, or active lower extremity soft tissue ulcers or infections may have a more favorable benefit/risk balance if initially treated with a GLP-1RA with demonstrated CV benefit rather than canagliflozin. Combination therapy with both an SGLT2 inhibitor and a GLP-1RA for glycemic management also accords with current T2D management guidelines (3). [...]it appears reasonable to use both an SGLT2 inhibitor and a GLP-1RA with demonstrated CV benefit concomitantly if clinically indicated, even though such combination therapy has not been studied for CVD risk reduction.5.4 What to Monitor When Prescribing an SGLT2 Inhibitor Patients starting an SGLT2 inhibitor should be informed about the higher risk of genital mycotic infections, and that this risk could be lowered with meticulous attention to personal hygiene.