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Cardio Diabetes Medicine 2017 473

GLP-1RA: Conclusion :
At present, only the Evaluation of Lixisenatide Due to a high prevalence of cardiovascular
in Acute coronary syndrome [ELIXA] study is complete. morbidity and mortality in T2DM, the optimal
The cardiovascular safety is non inferior although approach to the reduction of cardiovascular risk
not superior to placebo. Placebo controlled trials, should focus on aggressive management of the
have demonstrated that patients treated with GLP-1 standard cardiovascular risk factors rather than
RA have a lower incidence of MACE, cardiovasculor purely on intensive glycemic control. As can be seen
mortality and all cause morality.6 from the various trials reviewed here, favourable
glycemic efficacy does not necessarily translate to
Several ongoing randomized large scale trials will be
important to consolidate the results obtained so far. favourable cardiovascular outcomes. Clinicians must
therefore make careful informed decisions based
SGLT -2I : on the cardiovascular effects of the various anti-
diabetic drugs when prescribing . Based on current
The recently published EMPA-REG outcome study
presented exciting cardiovascular results, with evidence, metformin should remain the first-line
empagliflozin. Overall this drug displayed on 38% drug of choice in T2DM, being the most extensively
reduction in cardiovascular death and a 32% reduction studied and demonstrating excellent cardiovascular
in all cause Morality.7 safety even with long term use. Although evidence
for the cardiovascular safety of sulfonylureas are
DECLARE TIMI 58 study the effect of Dapagliflozin inconsistent, the first-generation agents are probably
on cardiovascular outcome expected to be finished associated with net harm and should be avoided.
in 2019.(CANVAS) The Canagliflozin cardiovascular Newer generation sulfonylureas have a comparatively
assessment study expected to complete data more favourable cardiovascular profile, but weight
collection in 2017. gain remains a concern. The meglitinides and AGIs

Study on Ertugliflozion to assess cardiovascular lack cardiovascular safety data in T2DM and should
safety is expected to be completed in 2021. therefore be reserved in favour of other second-
line agents. Among the TZDs, rosiglitazone may
Insulin : Evidence From Studies: be associated with an increased risk of MI, while
pioglitazone may have beneficial cardiovascular
Several studies have reported an increase in effects. Both are however contraindicated in heart
cardiovascular risk and higher mortality, whereas failure. The incretin-based drugs have been at the
others have demonstrated a reduction in forefront of this era of cardiovascular safety trials
cardiovascular events, apart of their raise in the and have been extensively studied. Current evidence
incidence of hypoglycaemia. An observational study suggests that the gliptins have neutral overall
of patients on insulin plus metformin reported a higher cardiovascular effect, but may increase risk of heart
risk of composite effect of non fatal cardiovascular failure, particularly saxagliptin. Among the GLP-1
and all cause mortality among insulin therapy users agonists, liraglutide may have beneficial effects on
compared to those administered sulfonylureas as cardiovascular outcomes, but this requires further
an add on therapy. A recently published ACCORD validation. Similarly, the SGLT-2 inhibitors have
trial suggests that insulin dose did not play a role shown promising results with empagliflozin and may
in the greater cardiovascular mortality in patients potentially confer cardiovascular benefits, although
randomized to intensive glycemic control.8 In the SU/ additional data is needed to substantiate this.
insulin arm of the UKPDS, There was no association With results of several large ongoing randomized
between the use of insulin and CVD incidents, even trials expected in the coming years, the body of
after 10 yrs of follow up. The ORIGIN trial and the evidence will continue to expand and help guide
legacy effects (ORIGINALE) study continued that clinicians in making the best decision in reducing the
glargine had neutral effects on cardiovascular health. cardiovascular risk of their diabetic patients.
HEART 2D trial found no differences in respect of
cardiovascular events between prandial vs basal High Lights :
strategies.9
1.Overall, Metformin appears to have the best benefit
Insulin Degludec DEVOTE trial was designed to to risk profile, which is consistant with its place
test its safety and efficiency in subjects with T2DM as First line therapy in clinical practice guideline
at high risk of cardiovascular events. Due to the recommendations.
satisfactory preliminary results, this trial has recently
been approved by the FDA. 2.Agarbose doesn’t appear to increase the risk of

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