Dr Javed Butler Discusses Cardiologists' Roles in T2D Management

If you change the narrative and package SGLT-2 inhibitors as a form of cardiovascular risk modulation, cardiologists may be more likely to get involved in diabetes management, said Javed Butler, MD, MPH, MBA, chairman for the Department of Medicine at the University of Mississippi.

Transcript:

The American Journal of Managed Care® (AJMC®): Do you agree SGLT-2 inhibitors should become foundational treatments for those with type 2 diabetes (T2D) with comorbid cardiovascular disease (CVD), alongside or in place of metformin, as the drug class helps to avoid long term complications?

Dr. Butler: If you look at the full cardiovascular outcomes trial, and they have had a whole host of other patient populations that were enrolled either with atherosclerotic cardiovascular disease or multiple risk factors, we can argue whether it's a class effect or not, whether there's a major adverse cardio events (MACE) difference or mortality difference between this drug, that drug. At least the renal benefit and the heart failure benefit seems to be pretty consistent across all trials. I think it's pretty reasonable to say that for people who mimic the criteria for cardiovascular outcomes trials, SGLT-2 inhibitors should be given as standard for disease modification.

AJMC®: Can you discuss the importance of improved quality of life exhibited by patients in DAPA-HF and what it will mean if empagliflozin has similar effects?

Dr. Butler: I mean, I don't think we can say that we can ignore side effects because there are benefits. So I think that these are sort of two separate constructs and regardless of how good the benefits are, we still have to worry about the side effects and try to do whatever we can to minimize the side effects. Now our patients want to live longer and healthier. So quality of life is a pretty important domain and pretty important goal of our management strategies. Any therapy that reduces the risk of mortality and hospitalization but also improves quality of life becomes a sort of incrementally more attractive therapy. If something improves survival, but does not improve quality of life scores, well, survival is pretty important and you need to give it and vice versa. If something improves quality of life, it's safe, but doesn't improve mortality, that doesn't mean that you don't use that drug. So I think mortality, quality of life and side effects are all sort of three independent domains and you have to take them as such.

AJMC®: Does empagliflozin show potential diabetes prevention effects in patients with prediabetes? Can you discuss the debate around preventing T2D with a drug?

Dr. Butler: I don't know the answer to your question, whether empagliflozin data will show that or not because remember, up until now, all the input trials were done in patients with diabetes. The first data that will come out in patients who don't have diabetes is actually with EMPEROR Reduce. Nobody knows those data. Having said that, you know, Metformin and prevention of diabetes is something that physicians embrace. DAPA-HF has presented those data and they look interesting. I would say, one trial, one drug, secondary endpoint, all of these replications will be good. So let's see what EMPEROR shows. But let's also not forget that the best way to prevent diabetes is eat right, lose weight, and exercise. All of these things are in conjunction too, but not necessarily give the message that you don't need to do lifestyle modification and just take a pill to reduce your risk of diabetes. But I think that's one of the very interesting secondary analyses that we will all wait to see from the EMPEROR Reduce trial.

AJMC®: Empagliflozin has been added to the Los Angeles County formulary to keep patients out of the hospital for HF. Do you anticipate greater uptake should the drug receive additional indications, or if results show it is superior to dapagliflozin?

Dr. Butler: I mean, I think inferior or superior, I don't know about that. In general, all of these drugs tend to at least have heart failure and renal benefit and some benefit is great. And usually between the regulatory indication, guidelines recommendation, and then getting on insurance formularies and then hospital algorithms. These are sort of three or four different leavers that, eventually when all pulled together, really increases the use of life saving medication. So, hopefully, yes.

AJMC®: As endocrinologists and cardiologists tend to treat the sickest, most costly patients in the US health system, how can cardiologists become more involved in diabetes care?

Dr. Butler: Well, I mean, I don't think that the issue is cardiologists getting involved in diabetes care. What we learned from DAPA-HF is that the benefit of dapagliflozin is actually in both patients with and without diabetes. So I think it's a little bit of a mind shift. I think if you go to a cardiologist and say that you have to treat diabetes, I don't think there'll be a lot of takers, especially when you start to, you know, discuss about the use of insulin and modulation of insulin and all that kind of stuff. I think if you change the narrative, and if empagliflozin also shows benefit in non-diabetes patients, and we really solidify this position that the benefit is cardiovascular benefit that extends beyond diabetes, then I think for cardiovascular risk modulation, using these drugs and cardiologists getting involved is a better proposition than to say to get involved in the care of diabetes per se.