Metabolism in diseases: the revolution
In recent years, sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists have revolutionized the treatment of type 2 diabetes, offering not only improved glycemic control but also important cardiovascular benefits. Large clinical trials have shown that these drugs reduce the risk of major adverse cardiovascular events and improve outcomes for specific groups of patients with diabetes and pre-existing or high-risk cardiovascular disease. There are also prppfs that SGLT2 inhibitors acute administration to congestive/chronic heart failure patients is able to suddenly improve the cardiac ejection fraction, compared to regular anti-congestitial drugs.
Cardiovascular benefits of SGLT2 inhibitors
SGLT2 inhibitors, such as empagliflozin, dapagliflozin, and canagliflozin, work by blocking the reabsorption of glucose in the kidneys, promoting its urinary excretion, and improving metabolic control. Studies such as EMPA-REG OUTCOME and DAPA-HF have shown that these drugs significantly reduce the risk of hospitalization for heart failure and cardiovascular mortality in patients with heart failure, regardless of the presence of diabetes. In addition, SGLT2s show protective effects on renal function, contributing to a lower progression of chronic kidney disease, a significant risk factor for cardiovascular events.
Cardiovascular benefits of GLP-1 agonists
GLP-1 receptor agonists, such as liraglutide, semaglutide and dulaglutide, mimic the action of endogenous GLP-1, improving insulin secretion, slowing gastric emptying and reducing appetite. Studies such as LEADER and REWIND have shown that these drugs reduce the risk of myocardial infarction, stroke and cardiovascular mortality, particularly in patients with type 2 diabetes and pre-existing cardiovascular disease. Additionally, GLP-1s appear to offer benefits in reducing blood pressure and body weight, factors that further contribute to cardiovascular protection.
Which patients benefit most?
The cardiovascular benefits of these drugs are most pronounced in patients with:
- type 2 diabetes and established cardiovascular disease: Patients with a history of heart attack, stroke, or heart failure benefit significantly from the use of SGLT2 and GLP-1.
- heart failure and chronic kidney disease: SGLT2 inhibitors have shown significant effects in reducing the progression of kidney disease and preventing hospitalizations for heart failure.
- high cardiovascular risk: Even in the absence of a prior diagnosis of cardiovascular disease, GLP-1 has been shown to reduce the risk of adverse events in patients with multiple risk factors (hypertension, obesity, dyslipidemia).
Summary
SGLT2 and GLP-1 drugs represent a significant advance in the management of type 2 diabetes, with cardiovascular benefits that go beyond simple glycemic control. The choice between these two classes of drugs should be guided by the clinical characteristics of the patient, with particular attention to the presence of cardiovascular disease, heart failure or renal risk. Emerging evidence suggests that the integration of these drugs into the treatment guidelines for diabetes can significantly reduce cardiovascular morbidity and mortality in high-risk patients.
- Edited by Dr. Gianfrancesco Cormaci, PhD, specialist in Clinical Biochemistry.
Scientific references
Gerstein HC, Colhoun HM et al. The Lancet 2019; 394(10193):121-130.
Neal B, Perkovic B et al. New Engl J Med. 2017; 377(7):644-657.
Marso SP et al. New Engl J Med. 2016; 375(4):311-322.
Zinman B et al. New Engl J Med. 2015; 373(22):2117-2128.
