Do Beta-Blockers Increase the Risk of Hypoglycemia in Patients with Diabetes and Atherosclerosis?
Given that a large portion of patients with diabetes have proven cardiovascular disease, several clinical studies or their subsequent analyses address the effects of beta-blockers in these patients. One such analysis was the post-hoc analysis of the TECOS study, which among other things, attempted to evaluate the connection between the use of beta-blockers in type 2 diabetics with proven atherosclerotic cardiovascular disease and the incidence of hypoglycemic episodes.
Treatment with Beta-Blockers and Diabetes Mellitus
Beta-blockers are a cornerstone in the treatment of various cardiovascular diseases such as arterial hypertension, angina pectoris, or heart failure. They represent a heterogeneous group of drugs that differ significantly in their pharmacokinetic and pharmacodynamic properties (e.g., lipophilicity and hydrophilicity, duration of action, or intrinsic sympathomimetic activity). Nevertheless, the whole group has proven positive effects on cardiovascular morbidity and mortality. However, there are sometimes concerns about their use in diabetics due to potential adverse metabolic effects – worsening insulin resistance, increased propensity for dyslipidemia, and masking symptoms of hypoglycemia.
Analysis of Data from the TECOS Study
The primary goal of the TECOS study was to gather data on the effect of sitagliptin on cardiovascular events, enrolling 14,671 patients. At the onset of the study, 9322 (64%) of them were using beta-blockers, and these patients had a more frequent history of myocardial infarction or heart failure.
Beta-blocker use was not associated with a higher risk of severe hypoglycemic episodes during the monitoring period (median duration of 3 years) (hazard ratio [HR] 1.14; 95% confidence interval [CI] 0.88–1.48).
Regarding the composite cardiovascular outcome (defined as death from cardiovascular cause, non-fatal myocardial infarction, non-fatal stroke, or hospitalization for unstable angina pectoris), patients using beta-blockers had a higher risk than those not receiving this treatment (4.5 vs. 3.4 events/100 patient-years; HR 1.17; 95% CI 1.05–1.29), independent of whether they had a history of myocardial infarction or heart failure.
Conclusion
Regarding the risk of hypoglycemia, the findings from this analysis are consistent with previous studies and support the current belief that modern beta-blockers, especially β1-selective ones, have a neutral metabolic effect and thus minimal impact on the occurrence or worsening of hypoglycemia. They should be prescribed whenever their use is appropriate and their benefit outweighs the risk, including in indicated patients with diabetes mellitus.
Beta-blockers were not associated with a reduction in cardiovascular risk in this study, suggesting the need for a randomized trial evaluating chronic beta-blocker therapy in a group of diabetic patients with known atherosclerotic cardiovascular disease.
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Source: Shavadia J. S., Zheng Y., Green J. B. et al. Associations between beta-blocker therapy and cardiovascular outcomes in patients with diabetes and established cardiovascular disease. Am Heart J 2019; 218: 92–99, doi: 10.1016/j.ahj.2019.09.013.
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