Physician’s Weekly co-hosted another installment of the #PWChat series on Monday, Nov. 27 to address diabetes management in the Cardiovascular Outcome Trial Era.

Joined by former AACE president, Yehuda Handelsman, MD, FACP, FACE, FNLA, topics discussed included how heart disease presents in people with type 2 diabetes, what contributes to the development of heart and vascular disease in diabetes, current treatment recommendations to reduce cardiovascular disease in people with diabetes, and much more.

You can view our upcoming schedule, or read our other #PWChat recaps here.

Below are the highlights from the chat. You can read the full transcript here.

 

 

Question 1

Q1: How does #heartdisease present in people with type 2 Diabetes? #PWChat

— Physician’s Weekly (@physicianswkly) November 27, 2017

A1: Diabetes patients face high burden of #CardiovascularDisease, #CongestiveHeartFailure & chronic #KidneyDisease resulting in death from ischemic heart, arrhythmia & #stroke. They also have #PeripheralArterialDisease w/ high rates of amputation, #dialysis & #blindness #PWChat

— Yehuda Handelsman (@yhandelsmanmd) November 27, 2017

A1. Often can be asymptomatic. #PWchat https://t.co/wnBx6eMIRC

— Linda Girgis, MD (@DrLindaMD) November 27, 2017

 


Question 2

Q2: What contributes to the development of heart and vascular disease in patients with diabetes?#PWChat

— Physician’s Weekly (@physicianswkly) November 27, 2017

A2: Obesity w/ associated fat & inflammation; insulin resistance effect on endothelial dysfunction & association with dyslipidemia – high TGL; low HDL & increased small dense LDL; #hypertension; increased coagulation & autonomic #neuropathy #PWChat

— Yehuda Handelsman (@yhandelsmanmd) November 27, 2017

What’s the underlying mechanism for increased CVD, CHF, and stroke in T2D? Is it the higher BP, risk of plaque breaking loose, …? #pwchat

— Matthew Loxton (@mloxton) November 27, 2017

So see my A2 reply, in Short- Yes yes and Yes Insulin Resistance BP Dyslipidemia & Inflammation are key

— Yehuda Handelsman (@yhandelsmanmd) November 27, 2017

 


Question 3

Q3: What are the current treatment recommendations for reducing #CardiovascularDisease in people with #diabetes #PWChat

— Physician’s Weekly (@physicianswkly) November 27, 2017

A3: @TheAACE #DiabetesMellitus guidelines also recommend incorporating lifestyle changes w/ #weightloss, #statins therapy, antiplatelets & no smoking. @AmDiabetesAssn has similar suggestions but looser targets (2/2)#PWChat

— Yehuda Handelsman (@yhandelsmanmd) November 27, 2017

With the differing targets between @AmDiabetesAssn & @TheAACE guidelines, which recommendations do you recommend other clinicians follow?#PWChat

— Physician’s Weekly (@physicianswkly) November 27, 2017

Although I’m a member of both societies Being that I chaired the AACE GLs and am still Chair of DM & Lipid Scientific committees I prefer the @TheAACE targets #PWChat

— Yehuda Handelsman (@yhandelsmanmd) November 27, 2017

 


Question 4

Q4: What makes comprehensive management of patients w/ diabetes & heart disease particularly challenging? #PWChat

— Physician’s Weekly (@physicianswkly) November 27, 2017

A4: These patients typically require multiple medications to achieve control of multiple contributing factors, which increases cost, is a burden to the patients, and reduces adherence #PWChat

— Yehuda Handelsman (@yhandelsmanmd) November 27, 2017

 


Question 5

Q5: How can these obstacles be overcome? What works & how can adherence be improved? #PWChat

— Physician’s Weekly (@physicianswkly) November 27, 2017

A5: Tough, Keep educating Clinicians and patients. Important to utilize combination medications and provide a simple & clear management plan, especially giving it in writing #PWChat

— Yehuda Handelsman (@yhandelsmanmd) November 27, 2017

 


Question 6

Q6: What topics surrounding glucose, lipid, & cardiovascular risk management are controversial in managing patients with #diabetes & #heartdisease? #PWChat

— Physician’s Weekly (@physicianswkly) November 27, 2017

A6: Whether treating glucose is really important is debated; do medications for #diabetes cause harm, even death, making selection controversial; whether intensive lipid treatment is needed in people w/ diabetes, since they have “low” LDL.. (1/2)#PWChat

— Yehuda Handelsman (@yhandelsmanmd) November 27, 2017

A6: the facts that #statins can cause #diabetes; the belief that #hypertension goals should be higher than >140/90 in this population; the fact that diabetes patients are acetylsalicylic acid-resistant; & diabetes not being a #CoronaryArteryDisease equivalent (2/2)#PWChat

— Yehuda Handelsman (@yhandelsmanmd) November 27, 2017

To Make it clear my response to Q6 highlights, controversies, myth and wild assertions. These contribute to non adherence A lot has improved recently i.e the new AHA/ACC HTN Guidelines #PWChat

— Yehuda Handelsman (@yhandelsmanmd) November 27, 2017

 


Question 7

Q7: What is the current status of the safety of medications for #hyperglycemia? Should clinicians stop using them? #PWChat

— Physician’s Weekly (@physicianswkly) November 27, 2017

A7: Because of safety concerns, @US_FDA has required new DM meds to undergo CV outcome/safety clinical trials since 2008. 13 trials have been completed, more ongoing. All showed DM drugs to be safe. A few even showed improved CV outcomes, including reduced mortality #PWChat

— Yehuda Handelsman (@yhandelsmanmd) November 27, 2017

 


Question 8

Q8: Which key outcome trials may impact guidelines and clinical practice in #diabetes & #CardiovascularDisease? #PWChat

— Physician’s Weekly (@physicianswkly) November 27, 2017

A8: Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients–Removing Excess Glucose study showed empagliflozin reduced CV death in DM & CVD by 37%, total death, CHF hospitalization, & improved kidney function (1/3)#PWChat

— Yehuda Handelsman (@yhandelsmanmd) November 27, 2017

A8: The Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results–A Long Term Evaluation trial showed liraglutide reduces CV & total death & improves kidney function. (2/3)#PWChat

— Yehuda Handelsman (@yhandelsmanmd) November 27, 2017

A8: The Canagliflozin Cardiovascular Assessment Study showed canagliflozin reduces MACE- major adverse cardiovascular events, a combination of #MyocardialInfarction– non fatal (#HeartAttack), #cardiovascular-associated death, & non fatal strokes (3/3)#PWChat

— Yehuda Handelsman (@yhandelsmanmd) November 27, 2017

The names of the trials were spelled out in the answer they are referred to as: A8 1 EMPA-Reg A8 2 LEADER A8 3 CANVAS #PWChat

— Yehuda Handelsman (@yhandelsmanmd) November 27, 2017

 


Question 9

Q9: How should #Diabetes be managed in this Cardiovascular Outcome Trial Era?#PWChat

— Physician’s Weekly (@physicianswkly) November 27, 2017

A9: There’s quite a bit of confusion; empagliflozin & liraglutide got an @US_FDA indication for #diabetes w/ #CardiovascularDisease, empagliflozin to reduce #cardiovascular death, liraglutide to reduce MACE (1/2)#PWChat

— Yehuda Handelsman (@yhandelsmanmd) November 27, 2017

A9: canagliflozin may get such indications. The role of these meds in patients with no #CardiovascularDisease is not clear. @TheAACE recommends them as 1st line drugs, while @AmDiabetesAssn recommends them as earlier choices in patients with #diabetes & CVD (2/2)#PWChat

— Yehuda Handelsman (@yhandelsmanmd) November 27, 2017

 


Question 10

Q10: How can clinicians learn more about the outcomes of the CV trials and their impact on managing patients with diabetes & heart disease? #PWChat

— Physician’s Weekly (@physicianswkly) November 27, 2017

A10: Courses & Live conferences like the 15th annual World Congress on Insulin Resistance, #Diabetes & #CardiovascularDisease (#15WCIRDC), which I will chair later THIS WEEK (11/30-12/2) at @HiltonUniversal in Los Angeles. Learn more at https://t.co/TEwk5pcPRi!#PWChat

— Yehuda Handelsman (@yhandelsmanmd) November 27, 2017

 


Question 11

Q11: Why is it important to have a special conference dedicated to diabetes, obesity, insulin resistance and #CVD?
#PWChat

— Physician’s Weekly (@physicianswkly) November 27, 2017

A11: There’s a need to address the relationships between metabolic conditions: #obesity, lipids, #hypertension, #diabetes, fatty liver disease, inflammation, chronic #KidneyDisease & #CardiovascularDisease (1/2)#PWChat

— Yehuda Handelsman (@yhandelsmanmd) November 27, 2017

A11: There’s also a need to bring research to practice by convening general clinicians, researchers, cardiologists, endocrinologists & nephrologists & Primary care professionals who can translate the impact of #cardiovascular trials on daily practice (2/2)#PWChat

— Yehuda Handelsman (@yhandelsmanmd) November 27, 2017