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Cardiovascular disease leads to a new algorithm for diabetes treatment

  • Author Footnotes
    1 These authors contributed equally to this article.
    Valentina Rodriguez
    Footnotes
    1 These authors contributed equally to this article.
    Affiliations
    Division of Endocrinology, Diabetes, and Metabolism, New York University School of Medicine, New York, NY, USA
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  • Author Footnotes
    1 These authors contributed equally to this article.
    Matthew C. Weiss
    Footnotes
    1 These authors contributed equally to this article.
    Affiliations
    Center for Prevention of Cardiovascular Disease, New York University School of Medicine, New York, NY, USA
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  • Howard Weintraub
    Affiliations
    Center for Prevention of Cardiovascular Disease, New York University School of Medicine, New York, NY, USA
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  • Ira J. Goldberg
    Affiliations
    Division of Endocrinology, Diabetes, and Metabolism, New York University School of Medicine, New York, NY, USA

    Center for Prevention of Cardiovascular Disease, New York University School of Medicine, New York, NY, USA
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  • Arthur Schwartzbard
    Correspondence
    Corresponding author. Center for Prevention of Cardiovascular Disease, New York University School of Medicine, 530 First Avenue, HCC 4F, New York, NY 10016, USA.
    Affiliations
    Center for Prevention of Cardiovascular Disease, New York University School of Medicine, New York, NY, USA
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  • Author Footnotes
    1 These authors contributed equally to this article.

      Highlights

      • Cardiovascular disease (CVD) is a primary cause of morbidity and mortality in type II diabetes mellitus.
      • CVD prevention/treatment is not used to select antihyperglycemic medications.
      • A new treatment algorithm based on the presence or risk of CVD and/or heart failure is needed.
      • Newer antihyperglycemic therapies can reduce CVD events.

      Abstract

      Patients with diabetes mellitus have increased rates of atherosclerotic cardiovascular disease (CVD) and heart failure (HF). This increase occurs despite optimal lipid-lowering therapies. We reviewed clinical trials of diabetes treatments and their effects on circulating plasma lipoproteins and CVD. Several earlier studies failed to demonstrate clear CVD benefit from diabetes therapies. In addition, triglyceride-reducing agents did not reduce overall CVD in large clinical trials although these trials were not conducted in cohorts selected as hypertriglyceridemic. Specific classes such as the thiazolidinediones increased HF. After Food and Drug Administration mandates for more rigorous safety data, recent studies have not only demonstrated CVD safety for many diabetes mellitus agents, but have also shown that certain newer medications such as empagliflozin, canagliflozin, liraglutide, and semaglutide reduce CVD. Moreover, pioglitazone use in insulin-resistant patients has resulted in decreased cerebrovascular and cardiovascular events, suggesting a protective vascular effect of this agent. Benefits from these newer classes of medications are unlikely to be because of improved lipoprotein profiles. These disparities in diabetes medication effects on CVD are likely attributable to each drug or drug class' cardiometabolic effects. Selecting medications based solely on their potential to lower hemoglobin A1C is an outdated therapeutic approach. We propose a new algorithm for treatment of patients with type II diabetes such that medication selection is based on the presence or risk of coronary artery disease and/or HF.

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