By Marti Webb Slay
“When it comes to diabetes and cardiovascular risk factors in general, it takes a village to dial people in so they will avoid my cath lab in 10 or 15 or 20 years,” said Jason Thompson MD, PhD, cardiologist at Birmingham Heart Clinic.
Thompson says new diabetes medications offer promise for cardiac care as well as diabetes, and he encourages physicians across specialties to communicate better and work together for the benefit of their patients.
“The reality is, we don’t have enough endocrinologists to take care of a population that’s getting older with an increased prevalence of diabetes,” he said. “So I don’t think initiation of these drugs falls just to endocrinology or just to primary care or cardiology. We should all be thinking about them. Sometimes doctors say they don’t want to step on the primary care providers’ toes, but I don’t think that applies here because, at the end of the day, we want people to have great care. Today, it’s easy to shoot a text or call your patient’s general physician and say, ‘I’m thinking about this for your patient.’ We should all be thinking about it.
“While the field of cardiology has been dynamic, the risk factors haven’t changed: smoking cessation, blood pressure control, cholesterol control and diabetes. But the exciting thing is our tools have improved.
“We are in the golden age of diabetes therapies. In the last five to seven years, we’ve seen several different classes of diabetes medicines come on the market. They not only improve glycemic control, but they offer direct cardiovascular benefits as well, independent of the glucose-lowering effects. That’s particularly exciting for us, for a couple of reasons: first, there is an epidemic of type 2 diabetes in this country right now, and we are in a better position to deal with that. And second, diabetes, perhaps outside of smoking, is the single greatest risk factor driving coronary disease in this country. So having these two new tools is a wonderful thing.”
Thompson explained how the two primary classes of new diabetes medicines offer different benefits for cardiac patients.
SGLT2 inhibitors, including Jardiance®
“These lower the threshold in the kidney for excreting glucose,” he said. “In lowering that threshold, we excrete sugar, and that lowers our blood sugar. That particular class of medication has been shown to be beneficial to patients with heart failure.
“There are other benefits. It’s a good diabetic medicine, and because you are losing sugar in your urine, there is a weight loss benefit. But independent of those things, it has also been shown to reduce heart failure readmissions. I can’t think of a new heart failure medication that has hit the market and taken it by storm in more than a decade.”
Since these medicines increase glucose in the urine, it’s important to watch for UTIs, particularly fungal infections.
GLP-1 receptor agonists, including Ozempic®
“This group of medicines has been shown to decrease cardiovascular events,” he said. “These are more ischemic-type events like nonfatal myocardial infarction, stroke, death from a cardiovascular event.
“In particular, the stroke reduction is huge. Nothing scares me more than a stroke in one of my patients, because they tend to be so final. There’s nothing we really can do other than speech therapy and physical therapy and occupational therapy. Now we have a group of medicines that can lower cardiovascular events, particularly stroke. I think that’s very exciting.”
Nausea is the most significant side effect of this class of medicine. “There’s some dietary things you can do to offset that,” he said. “It slows down your digestion so food stays in your stomach longer. It decreases appetite. If you overeat, you are going to have nausea, so you’ll need to eat smaller meals.”
Thompson says the side effects are minor compared to the cardiac protections these medicines provide, and he encourages physicians to consider whether their patients will have preventive benefits from them.
“Sometimes as cardiologists, we get so focused on the fix, that we lose sight of the prevent,” he said. “There are so many things we can do now that we couldn’t tackle even ten years ago for more complex coronary disease, peripheral disease and all these things. The single most important thing we can offer patients is prevention.”