Researchers have welcomed recommendations for use of SGLT2 inhibitors in patients with type 2 diabetes, CVD risk, and insufficient glycaemic control despite metformin
The National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand have published two sets of new guidelines:
- Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018
- Australian Clinical Guidelines for the Diagnosis and Management of Atrial Fibrillation 2018
Among key recommendations for management of heart failure, the authors are advising use of sodium-glucose cotransporter 2 (SGLT2) inhibitors in patients with type 2 diabetes associated with cardiovascular disease (CVD) and insufficient glycaemic control despite metformin.
The aim of this recommendation is to decrease risk of cardiovascular events and hospitalisation for heart failure.
It marks the first time Australian heart failure guidelines have included a pharmacological recommendation specific to a sub-group of people with type 2 diabetes.
The strong recommendation, which is based on high-quality evidence, cites major trials that found the SGLT2 inhibitors empagliflozin and canagliflozin (the latter not available in Australia) reduced cardiovascular events and heart failure hospitalisation in people with type 2 diabetes who were at high cardiovascular risk (most with CVD).
This group had a raised HbA1c despite background therapy—including baseline prescription rates of 74–78% for metformin, 48–51% for insulin and 42–44% for sulfonylureas.
“It is rewarding when landmark clinical trial results are embraced in new treatment guidelines,” said Dr Petra Moroni-Zentgraf, Medical Director for Boehringer Ingelheim ANZ.
“Australian clinicians involved in the EMPA-REG OUTCOME trial deserve enormous recognition for their role in establishing a new paradigm for the protection of people with type 2 diabetes and established cardiovascular disease,” she said.
Blood pressure and lipid lowering according to published guidelines was also strongly recommended, to decrease the risk of cardiovascular events and the risk of developing heart failure.
Angiotensin-converting enzyme (ACE) inhibitors were recommended in patients with left ventricular systolic dysfunction, to decrease the risk of developing heart failure.
Changes in management as a result of the new atrial fibrillation (AF) guidelines include:
- Opportunistic screening in the clinic or community is recommended for patients over 65 years of age.
- The importance of deciding between a rate and rhythm control strategy at the time of diagnosis and periodically thereafter is highlighted. β-Blockers or non-dihydropyridine calcium channel antagonists remain the first line choice for acute and chronic rate control.
- The sexless CHA2DS2-VA score is recommended to assess stroke risk, which standardises thresholds across men and women.
- An integrated care approach should be adopted, delivered by multidisciplinary teams, including patient education and the use of eHealth tools and resources where available.
See the guideline summary for HF here
See the guidelines summary for AF here