SGLT2is and GLP-1 RAs Show Best Cardiovascular Results when Initiated Sooner

The case for why SGLT2is or GLP-1 receptor agonists should be initiated early in diabetes treatment, regardless of whether the patient is on insulin therapy. 

Researchers analyzed 8 different studies for 3 differing classes of diabetes medications for results. Upon completing this analysis, researchers determined that patients who used insulin in conjunction with other diabetes drugs were at a greater risk of having an adverse cardiovascular event than those taking diabetes medications without insulin. Even with the outcome of the results, it is still advised that SGLT2 inhibitors and GLP-1 receptor agonists be prescribed as soon as possible to reap the most heart benefits from them. Major adverse cardiovascular events were assessed by researchers from multiple trials for cardiovascular outcomes. The drugs used in these trials were DPP-IV inhibitors, SGLT2 inhibitors, and GLP-1 receptor agonists. 

Researchers between two groups of patients made comparisons. The first group of patients was prescribed insulin at baseline before starting any other medications. The second group of patients has been prescribed insulin at baseline. In addition to the two groups mentioned above, two different placebo groups were given a placebo in place of drug therapy. Upon comparison, results showed that patients receiving drug therapy with no baseline insulin saw greater cardiovascular benefits than those who received placebo with no insulin. Patients who were given the drug regimen while on baseline insulin also saw significant cardiovascular benefits.  

Patients in both groups receiving baseline insulin experienced adverse cardiovascular effects. From these study results, one can gather that diabetes patients should all be on an SGLT2 inhibitor or GLP-1 receptor agonist regardless of whether they are on insulin therapy. Although the studies showed that patients on insulin and other drug therapy had adverse cardiovascular events, there is still a more significant cardiovascular benefit than insulin alone. In cases like these, the physician must weigh the risk versus the benefits. For example, suppose a patient with diabetes, who is on insulin, went to their doctor with no other risk factors for developing cardiovascular disease. In that case, the doctor may be justified in not prescribing an SGLT2 inhibitor or GLP-1 receptor agonist. On the other hand, suppose a similar patient shows up but has risk factors for cardiovascular disease. In that case, the doctor might want to prescribe them one of the two drug classes to help decrease their risks of having a cardiovascular event.  

Practice Pearls: 

• Patients see a more significant benefit when prescribed an SGLT2 (sodium-glucose co-transporter-2) inhibitor or GLP-1 (glucagon-like peptide 1) receptor agonist during cardiovascular issues. 
• Although patients on baseline insulin are at higher risks of experiencing adverse cardiovascular events, adding an SGLT2 inhibitor or GLP-1 receptor agonist is still beneficial for their heart health.
• Physicians should weigh the risks versus the benefits when considering prescribing SGLT2 inhibitors and GLP-1 receptor agonists to patients who are already on baseline insulin.  

Regina Schaffer, Prescribe SGLT2 inhibitors, GLP-1 receptor agonists ‘as early as possible’ for CV benefit. Healio, 26 February 2021. 

Joanna E Khatib, Yixue Shao, The Association Between Baseline Insulin Treatment and Cardiovascular Events: A Meta-Analysis. Journal of the Endocrine Society, 31 December 2020.  

Oluwatayo Ishola, PharmD. Candidate, South College, School of Pharmacy 

See more about SGLT2 inhibitors in our Therapy center.