New medicines decrease heart disease in diabetes

Cardiovascular disease is the leading cause of death and disabilities in persons with diabetes. Diabetes increases the risk of heart attacks two to fourfold in men and five to eight fold in women. Women with diabetes experience cardiovascular events at the same rate as men with diabetes. In nondiabetic populations, women usually have only 25% the risk of men prior to menopause and 50% of the risk of men after menopause. In nondiabetic populations the rate in women does not become equal to men until after age 65 years. Each year $37.3 billion is spent treating cardiovascular disease in persons with diabetes. Cardiovascular disease has become an important focus in the overall treatment of persons with diabetes. Preventing heart attacks and strokes in diabetes is as important as preventing blindness, kidney failure and amputations in diabetes.

Beginning in 2008 the Food and Drug Administration (FDA) issued guidelines requiring that all new diabetes medications demonstrate that they do not increase the risk of cardiovascular disease. This directive was issued after a new medication — rosiglitazone — was suggested to increase cardiovascular risk. Historically the class of drugs known as sulphonylurea drugs (currently available agents: glyburide, glipizide and glimepiride) had been shown to increase risk. They were not taken off the market because at that time there were no other oral agents available.

Medicines that should be avoided in diabetes include the following. Glimepiride: because it doubles the risk of stroke. Rosiglitazone: Causes a 28% increase in the rate of heart attacks and 72% increase in heart failure. Pioglitazone: causes a 40% increase in the occurrence of heart failure.

Several new classes of diabetes medications have been shown not only to lack harmful effects, but to actually lower the risk of heart attacks strokes and heart failure.

Pioglitazone: While noted above as increasing the risk of heart failure, pioglitazone also has a beneficial effect on decreasing heart attacks by 20% and strokes by 21 %. Therefore, your provider may consider using this medicine for these beneficial effects while monitoring closely for the development of any signs of heart failure.

SGLT-2 Medicines (Canagliflozin, Dapagliflozin and Empagliflozin): This class of medicines helps to eliminate glucose from the body by removing it through the urine. As a class they decrease cardiovascular death by 18%; they decrease heart attacks by 14% and decrease heart failure by 32%. Empagliflozin (Jardiance) has the greatest benefit as it lowers cardiovascular deaths 38% and reduces heart failure by 36%. This class has also been shown to have significant effects in preventing the worsening of kidney disease in diabetes.

GLP-1 Medicines Dulaglutide, Liraglutide, Exenatide and Semaglutide): This class of agents are analogs of the naturally occurring hormone known as GLP-1. An analog is a substance that is very similar to but not an exact replica of a natural substance. They decrease Cardiovascular death by 13%; Heart attacks by 8%, stroke by 16% and heart failure by 10%.

Ask your health care providers which, if any of the medicines might be appropriate to add to your treatment regimen.

Dr. Samuel Abbate is a physician practicing in Wasilla.