CVD & DKD in T2D

True or false: there is little data to support that tight control reduces CVD

true

What did the UKPDS trial discuss?

MI benefit with metformin compared to diet alone or SU

What did the ADVANCE trial discuss?

Intense A1c control (6.5% or less) improves microvascular outcomes

What did the ACCORD trial discuss?

Intensive glycemic control (A1c less than 6%) increases mortality compared to the standard target of 7%

What did the VADT trial discuss?

Intensified glycemic control with rosiglitazone and insulin had no significant impact on CV or total mortality or macrovascular endpoints

modest reduction in albuminuria

A1c values of _____ are targeted in existing macro and micro vascular disease patients with T2D

7-8%

The ADA standards focus upon what kind of trials?

CVOT (CV outcome trials)

What does MACE stand for?

major adverse cardiovascular events

What are some of the outcome measures used in the CVOT?

• death from CV cause

• non-fatal acute MI

• non-fatal acute cerebrovascular event

• hospitalization for HF

• admission for unstable angina

Patients who have established ASCVD or CKD, what 2 classes of medications is recommended as part of the comprehensive CV risk reduction/glucose-lowering plans

• SGLT2 inhibitors

• GLP-1RA with demonstrated CVD benefit

What are examples of GLP1-RAs that have CVD benefits?

• semaglutide

• liraglutide

• dulaglutide

• tirzepatide

What is recommended for people with established ASCVD or multiple ASCVD risk factors or CKD?

• SGLT2-inhibitor

• GLP1-RA

• Combination

What is recommended for individuals with diabetes 55 or greater with established ASCVD or multiple ASCVD risk factors

ACEi or ARB therapy

In people with T2D with stable HF ____ may be continued for glucose lowering if eGFR remains >30mL/min

metformin

In people with T2D who are unstable or hospitalized, metformin (should/should not) be continued for glucose lowering if eGFR remains >30mL/min

should not

Which DPP4-inhibitor has a neutral effect on HF?

• sitagliptin

• linagliptin

Which DPP4-inhibitor should you use with caution in HF patients?

• saxagliptin

• alogliptin

Which class should you use with caution in any T2D with HF and avoid in NYHA class 3 and 4?

TZDs (specifically pioglitazone)

Pioglitazone my be considered in patients post_____

stroke

When should you begin a patient on pioglitazone post stroke

14 days after the event

What are the main indications for Canagliflozin?

• established CVD

• Diabetic nephropathy with albuminuria

Which oral GLP1 receives FDA approval for reduction in CV events and renal disease progression?

semaglutide

What are some of the CV effects of GLP1-RAs?

• anti-atherosclerotic effects

• risk factor modifications

• decreased infarct/injury size

• anti-inflammatory effects

• increased endothelial function

GLP1R agonists decrease the rate of hospitalization for _____

HF

Define DKD

persistent elevation of urinary albumin excretion

What are labs that should be screened to recognized or categorize DKD?

• eGFR

• proteinuria/albuminuria

When should you screen for CKD in T1D?

yearly starting 5 years after diagnosis

When should you screen for CKD in T2D?

Yearly starting at diagnosis

What defines CKD diagnosis?

• Persistent urine ACR greater or equal to 30 mg/g

• persistent eGFR less than 60mL/min and/or other evidence of kidney damage

What current therapeutic targets are known for inflammatory pathways?

• GLP1-Ras

• nonsteroidal MRA

What current therapeutic targets are known for glomerular hyperfiltration?

SGLT2 inhibitors

What current therapeutic targets are known for RAS activation?

ACEi and ARBs

What is 1st line therapy to initiate if eGFR is greater than or equal to 20

SGLT2i

What is 1st line therapy to initiate if eGFR is greater than or equal to 30

metformin

What is 1st line therapy to initiate if albuminuria and/or HTN

RAS inhibitor at max tolerated dose

What is an example of a nonsteroidal MRA

finerenone

In patients with established diabetic kidney disease, when should urinary albumin be monitored?

1-4 times per year

What should we aim to reduce urinary albumin by in people with CKD and albuminuria greater than/ equal to 300mg/g

30% or greater

True or false: you should withdraw SGLT2 inhibitor when there is an initial drop in eGFR?

false

What are some key risk mitigation strategies for GLP1-RAs and MRAs in T2D and CKD?

• eat protein first

• avoid high fat meals

• adjust antihyperglycemic agents as appropriate

• avoid food high in potassium

What are some key risk mitigation strategies for SGLT2 inhibitors in T2D and CKD?

• stress hygiene

• proactive dose reduction of diuretics (especially HF and CKD)

• be cautious with ketogenic diets or T1D

• foot exams

• adjustment of antihyperglycemic agents