Control of Type 2 Diabetes Means More Than Simply Improving Blood Glucose Levels
Although lowering daily glucose readings and the hemoglobin A1C (a measure of overall glucose control over the past 2-3 months) is extremely important to reduce the risk of some long-term complications of diabetes, such as eye disease (retinopathy), kidney disease (nephropathy), and nerve damage (neuropathy), people with type 2 diabetes also have an increased risk of heart disease, stroke, and fatty liver disease. Reducing risk factors for each of these is also critically important in the management of type 2 diabetes, and is accomplished by actions such as losing weight (if needed), keeping blood pressure and cholesterol levels in healthy ranges, not smoking cigarettes, eating a healthy diet, and staying physically active.
We are fortunate to have many medications today that help improve glucose levels in people with type 2 diabetes, and we also have important medications that specifically help reduce the consequences of heart and kidney disease in people with these disorders. This brief article will focus on an important class of medications, the sodium-glucose cotransporter-2 inhibitors (SGLT2 inhibitors), and their effect on a lesser-known issue that is more common in people with diabetes called “heart failure” as well as the positive effect of SGLT-2 inhibitors in people with chronic kidney disease.
Heart Failure Risk and Management
Let’s begin with heart failure. What is it? How common is it? What are its symptoms? How is it diagnosed? And what can you do about it if you have it?
Heart failure is a condition in which the heart does not pump blood normally into the blood vessels or the heart muscle is too stiff and does not fill with blood normally. The risk of having heart failure is estimated to be 2 to 4-times higher in people with type 2 diabetes compared to individuals without diabetes. When the heart has difficulty pumping blood (or filling up with blood), the person with heart failure may have few or no symptoms initially, but if the condition worsens, symptoms such as fatigue, weakness, lightheadedness, rapid heartbeat, trouble breathing, needing to sleep on extra pillows at night to breath comfortably, and swelling of feet and ankles may occur.
If you or your healthcare provider suspect you may have heart failure, in addition to your symptoms and findings on a physical examination, there are blood tests and other exams, such as an echocardiogram (ultrasound of the heart that assesses the heart’s ability to pump blood), that can be done to determine if you have heart failure. The good news is that if you have heart failure there are many things that can be done to help with the symptoms and to help reverse it and/or prevent it from getting worse. These, of course, should all be discussed with your healthcare provider.
Some of the things that can be done include cutting down on salt intake, stopping smoking, limiting alcohol, being active (as directed by your healthcare provider), and losing weight. Medicines are also an important part of managing heart failure. What medicines your healthcare provider recommends will depend on the classification of your heart failure, whether you have what’s called heart failure with reduced ejection fraction (HFeEF), which means your heart is not pumping blood normally, or heart failure with preserved ejection fraction (HFpEF), which mean your heart muscle is stiff and your heart does not fill with blood normally. Medications you may be prescribed include diuretics (“water pills”), an angiotensin system blocker (such as an angiotensin converting enzyme [ACE] inhibitor… also commonly used to treat high blood pressure and diabetic kidney disease), and/or a beta-blocker.
The Benefits of SGLT2 Inhibitors for People with Heart Failure
Recently, there has been some very exciting news in the world of diabetes and cardiology. A class of diabetes medications known as SGLT2 inhibitors, which have been available to people with type 2 diabetes for improving glucose control for about eight years, have also been shown to significantly improve outcomes in patients with heart failure. Studies have shown that in people with or without type 2 diabetes who have heart failure, medications in the SGLT2 inhibitor class reduce the risk of dying from heart disease and also lower the risk of being hospitalized due to worsening of heart failure. In fact, the data have been so positive in some studies that the approved indication in the label for two of the SGLT2 inhibitors, dapagliflozin (FARXIGA®) and empagliflozin (JARDIANCE®) state in their Prescribing Information that they are indicated “to reduce the risk of cardiovascular death and hospitalization for heart failure in adults with heart failure with reduced ejection fraction.”
The Benefits of SGLT2 Inhibitors for People with Kidney Disease
It is also important to note that in addition to benefits in patients with heart failure, the SGLT2 inhibitor class of medications have proven benefits in patients with chronic kidney disease, a common complication of type 2 diabetes. Studies over the past few years have shown that in patients with or without type 2 diabetes who have chronic kidney disease, SGLT2 inhibitors can reduce the progression of kidney disease, lessen the risk of development of end-stage kidney disease (dialysis treatment), and reduce the risk of dying from heart disease and of hospitalization for heart failure. Based on these findings, two of the SGLT2 inhibitors, dapagliflozin (FARXIGA®) and canagliflozin (INVOKANA®) have language in their Prescribing Information stating that they are indicated to be used in people with type 2 diabetes and chronic kidney disease. Dapagliflozin is also indicated to be used in people without diabetes who have chronic kidney disease, based on clinical trial findings with this medication.
We are fortunate to have many medications today to treat type 2 diabetes. Beyond improving glucose levels, some of these medications, including the SGLT2 inhibitors, have effects on other disorders that are more common in people with type 2 diabetes. If you have heart failure and/or have chronic kidney disease, your healthcare provider may recommend an SGLT2 inhibitor for the management of your type 2 diabetes. These important medications have not only been shown to improve glucose levels (and can result in weight loss), but clinical trials continue to demonstrate additional potential benefits such as those described above in persons with type 2 diabetes and heart failure and/or diabetic kidney disease.
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