In part 5 of this Exclusive Interview, Aaron Vinik talks with Diabetes in Control Publisher Steve Freed during the AACE 2018 convention in Boston, MA about the best patients to whom to prescribe SGLT-2s or other medication with the use of the correct risk calculator.
Aaron Vinik MD, PhD, FCP, MACP, FACE is the Director of Research at Eastern Virginia Medical School in Norfolk, VA.
Transcript of this video segment:
Freed: Getting back to cardiovascular risk, if you go back, it was always about A1C blood sugars and that was because we didn’t have anything to treat the cardiovascular except for hypertension. But for MACE, we didn’t have any drugs. Now we have the SGLT2 inhibitors that are playing a major role. How do you use those when it comes into your practice? What type of patient do you provide SGLT2 that you think is absolutely important?
Vinik: I think that patients who have high risk. But remember now, everybody was using the wrong risk calculator. Wilson’s paper actually, that came out & that we spoke about a year ago, showed that their calculations of risk using standardized measures was fallacious so you needed new risk calculation. If you go and look at the numbers that I just gave you, in terms of exercise, all Wilson’s calculations relate to one thing: heart rate. So if you put that into your new calculation, and then say, can I identify the person at risk that I should give an SGLT2 inhibitor or an incretin, it’s very easy; any one of my patients have a resting heart rate above 78 beats per minute who’s going to do poorly in terms of control is going to be a candidate for me to put either on a SGLT2 inhibitor or an incretin or a cycloset. So, that’s my choice. Now is there anything we should be learning from the results? Yes. What is the percent reduction in macrovascular events if I put you on a SGLT2 inhibitor, I can get 38 percent? With the EMPA-REG study. But, if I take you across the line and I give you an incretin like liraglutide with which I can get 13 percent. Do you know what the difference between those two is? Empa and Cana will drop your blood pressure and they will not increase your heart rate, no increase in heart rate. Lira will drop your blood pressure and increase your heart rate. So, there are swings and roundabouts. Lira would have it all if they could stop that increase. And then I’ll tell you next year because we’ll be finishing our study in September. It’s that exact question. So, I know I am naughty to start speculating [on] the differences in the autonomic nervous system between those drugs but I have no doubt. There’s another paper out right now that Lira can actually affect the autonomic nervous system negatively.
Freed: So, the chances of that drug getting approval?
Vinik: I think that drug will get approved. If there is a 13 percent change, people will grab it. Do you want to know what the number is for cycloset? Fifty percent. But nobody wants to believe that.
Freed: It’s amazing that the information, for whatever reason, isn’t getting out there and I guess it has a lot to do with the FDA and how they are allowed to market the drug.
Vinik: Well, with the FDA, but also, the history. The history of this drug is it came from trying to shut down pituitary tumors. And that’s what people think. Endocrinologists only think about that.