Do we sufficiently implement the current ADA/EASD recommendations for treating patients with type 2 diabetes mellitus?

Overview

The main cause of morbidity and mortality in patients with type 2 diabetes mellitus (DM2T) are cardiovascular events and diseases (CVD⁺). Their occurrence is not only 2–5 times more frequent in DM2T than in non-DM2T peers, but it also has a more severe course, the treatment is more demanding and the prognosis is worse. The incidence of CVD⁺ is relatively high on average in Slovak DM2T patients (about 37%, which is more than 30% in Europe and 32.2% in the world). CVD⁺ is already significantly (22%) present at the time of diagnosis (22%), as well as in the first years of disease in patients not adequately controlled with metformin monotherapy (31%). The mortality of patients with DM2T and CVD⁺ is 3 times higher (35.3/1000 patients per year/PPY) than those with CVD^- (11.8/1000 PPY). While in Europe, mortality rates for DM2T patients range from 16 to 50 deaths per 1,000 PPY), according to the results of the Slovak NEFRITI-II study (2014–2018), this was 20.5/1,000 PPY. According to the latest recommendations of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) of 2018, one of the major considerations in the choice of treatment is whether the patient is suffering from atherosclerotic CVD⁺, including peripheral arterial disease, whether he has experienced a cardiovascular event (myocardial infarction, stroke), has heart failure, or has chronic kidney disease (CKD⁺). If the patient is in such a category, the recommended procedure is to add and prefer a drug with a confirmed cardiovascular, resp. a renal benefit that is currently demonstrated by SGLT2i or GLP1Ra. However, according to the results of the NEFRITI-II study, the use of cardioprotective groups of antidiabetic agents lags significantly behind the prevalence of CVD⁺ and is the same in patients with CVD⁺ and CVD-, suggesting that more glycemic than cardiovascular or renal indications are still being used to select these antidiabetic agents. It is therefore necessary to emphasize the importance of CVD⁺ in the work of diabetologists and to point out the benefits of SGLT2i and GLP1Ra in patients with CVD⁺. One of the key issues for the qualitative improvement of the medical treatment of our patients is also making SGLT2i available in a dual combination to metformin by modifying the indication limitations.

Keywords:

mortality – morbidity – cardiovascular – ADA/EASD recommendations 2018