A new Expert Consensus Decision Pathway issued by the American College of Cardiology (ACC) summarizes key elements from emerging studies, to provide succinct, practical guidance on the use of novel, specific glucose-lowering agents for reducing CV risk in patients with T2D and clinical atherosclerotic cardiovascular disease (ASCVD).

The opportunity for CV disease prevention in patients with T2D has recently expanded. Certain sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide 1 receptor agonists (GLP-1RAs) have shown significant reductions in the risk of major adverse cardiovascular events (MACE). Although the exact mechanisms of CV benefit remain uncertain, they appear to be unrelated to the direct glucose-lowering effects of these agents.

Specific recommendations on use of novel glucose-lowering agents include a list of circumstances in which clinicians might consider starting one of these agents with demonstrated CV benefit. Clinicians should consider initiating a clinician-patient discussion about the use of either a GLP-1RA or SGLT2 inhibitor at the time of a clinical follow-up visit for patients with T2D and clinical ASCVD. Similarly, a new diagnosis of T2D in a patient with clinical ASCVD or a new diagnosis of clinical ASCVD in patient with T2D also offers the opportunity to begin a clinician-patient discussion about starting one of these therapies demonstrated to improve CV outcomes. Patient preferences and medical history can help guide the decision on which agent is considered most appropriate.

Among the SGLT2 inhibitors, empagliflozin is currently the preferred agent based on the available evidence and overall benefit-risk balance. Among the GLP-1RAs with demonstrated CV benefit, the most convincing data for CV benefit are for liraglutide, which should currently be the preferred member of this class for CV event reduction until additional information becomes available.

The document provides a flow chart that can help in deciding which agent to prescribe, and a list of relevant considerations for drug initiation and monitoring of patients who newly start one of these agents. Moreover, the document discusses outstanding questions on the use of these drug classes.

The arrival of these new agents proven to reduce adverse CV outcomes in patients with T2D has triggered a major paradigm shift beyond glucose control, to a broader strategy of comprehensive CV risk reduction. The potential of these new compounds has also stimulated re-examination of the traditional roles of various medical specialties in the management of T2D, compelling CV disease specialists to adopt a more active role in prescribing drugs that may previously have been seen primarily as glucose-modifying therapies and creating a need for a collaborative, interprofessional, and multidisciplinary approach to managing this high-risk patient group.

Expert Consensus Documents have now been rebranded to “Expert Consensus Decision Pathways.”

Although Decision Pathways have a new format, they maintain the same goal of Expert Consensus Documents: to develop clinical policy based on expert opinion in areas in which important clinical decisions are not adequately addressed by existing trials. Expert Consensus Decision Pathways are designed to complement the guidelines and bridge remaining gaps in clinical guidance.

Find the 2018 ACC Expert Consensus Decision Pathway