Title
The Pancreas vs. The Heart; Why Not Treat Both?: A Quality Improvement Initiative to Increase the Use of GLP-1 Agonists and SGLT2-Inhibitors within a Resident-Run Clinic
Authors
Jenna Campbell D.O., Bishrut Nepal D.O., Zehra Hussain M.D.
Introduction
Heart Disease is the leading cause of death for men, women, and individuals of most racial and ethnic groups in the United States. One person dies every 34 seconds in the United States from cardiovascular disease. Cardiovascular disease continues to be a burden on the healthcare system and costs $229 billion each year according to the CDC. More than 37 million Americans are diagnosed with type 2 diabetes mellitus (T2DM) and 32% will be affected by cardiovascular disease. The ramifications of poorly treated cardiovascular disease are devastating including cardiomyopathy, myocardial infarction and cerebral vascular disease. As of recent there has been a shift of using diabetic medications to not only assist in glycemic control but also reduce major adverse cardiovascular events (MACE) in T2DM. A meta-analysis involving the use of sodium-glucose contransporter-2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP1-RA) in patients with T2DM and cardiovascular disease have individually proven to reduce not only MACE, but also cardiovascular mortality and all-cause mortality at a median 3-year follow-up.
Methods
We randomly screened patients with T2DM and cardiovascular disease in Wilmington Adult Medicine clinic and found 102 patients who met inclusion criteria of A1C>7 and GFR>45. We then developed a survey asking resident providers about their knowledge and comfortability with these agents, it was open from April 1, 2023 to April 7, 2023. The questions centered around contraindications to both agents and provider comfortability in prescribing them.
Results
In our patient population, 23.5% (24/102) of those patients were already previously managed on an SGLT2i or GLP1-RA.Of the 24 patients already managed with either agent, 50% would benefit from a repeat HbA1C and BMP to consider addition of a second agent or further up-titration of initial agent. Of the 78 patients not on either agent, 34 (43.5%) patients met inclusion criteria to be started on either agent. Based on the survey that was sent to the 47 providers whose patients were determined to need an agent, 20 (42.5%) responded to our survey. Only 60% of responding providers were aware that both SGLT2i and GLP1-RA both reduced with similar efficacy MACE. 50% of responding providers reported to be somewhat confident in prescribing either of these agents to their patients with a 70% preference in prescribing an SGLT2i over a GLP1-RA.
Conclusion
The aim of our study was to identify patients within our resident-run clinic who are diagnosed with both T2DM and cardiovascular disease. Our aim was to increase the use of GLP1-RA and SGLT2i in patients who met specific qualifications and understand provider hesitancy in doing so. Future work could focus on improving provider confidence by implementing directed didactic sessions focused on the benefits of both GLP1-RA and SGLT2i.
References
Center for Disease Control. Type 2 Diabetes. 2022 31 Dec. https://www.cdc.gov/diabetes/basics/type2.html (4) Cheng. Why Choose Between SGLT2 Inhibitors and GLP1-RA When You Can Use Both?. Circulation. 2021 Feb;143:780–782 (1) Goncalves E, Bell DSH. Combination Treatment of SGLT2 Inhibitors and GLP-1 Receptor Agonists: Symbiotic Effects on Metabolism and Cardiorenal Risk. Diabetes Ther. 2018 Jun;9(3):919-926. doi: 10.1007/s13300-018-0420-6. Epub 2018 Apr 5. PMID: 29623594; PMCID: PMC5984923. (2) Sabouret P, Bocchino PP, Angelini F, D'Ascenzo F, Galati G, Fysekidis M, DE Ferrari GM, Fischman DL, Bhatt DL, Biondi-Zoccai G. Comparing benefits from sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists in randomized clinical trials: a network meta-analysis. Minerva Cardiol Angiol. 2023 Apr;71(2):199-207. doi: 10.23736/S2724-5683.22.05900-2. Epub 2022 Feb 23. PMID: 35195376. (3)