Compare Cardiovascular Benefits of SGLT2 Inhibitors for Type 2 Diabetes

SGLT2 inhibitors (Invokana, etc) are in the spotlight again.

The Company say Invokana (canagliflozin) is now approved to reduce the risk of major CV events in adults with type 2 diabetes and CV disease…while Jardiance (empagliflozin) is only approved to reduce CV death.

Explain Invokana’s approval is based on NONsignificant reductions in CV death, heart attack, or stroke…lumped into one composite outcome.

Point out Jardiance also reduces this combined risk in patients with type 2 diabetes and CV disease. Plus its evidence is more robust…and it’s the only flozin to significantly reduce CV death AND overall death.

Forxiga (dapagliflozin) is making waves too. A new trial suggests it lowers risk of heart failure hospitalizations…but not CV risk. This is mostly in diabetes patients withOUT CV disease, which may “dilute” its CV benefit in patients with CV disease.

Be aware, the overall evidence suggests CV risk reduction with SGLT2 inhibitors is mainly in those with type 2 diabetes AND CV disease. Plus flozins generally seem to reduce heart failure hospitalizations and slow progression of nephropathy…even in type 2s withOUT CV disease.

But weigh flozin downsides…including yeast infections, rare ketoacidosis, amputation concerns, and a cost of up to $90/month.

Continue to recommend metformin first in most patients with type 2 diabetes. Tailor add-ons based on A1C goals, cost, CV disease, etc.

Consider an SGLT2 inhibitor as an add-on option…especially if patients have CV disease AND heart failure or early kidney disease. See our algorithm, Stepwise Treatment of Type 2 Diabetes, for flozin renal function cutoffs.

Lean toward Jardiance as the flozin with mortality benefit.

Also think of GLP-1 agonists (Victoza, etc) for CV benefit. See how these and other meds stack up in our chart, Diabetes Meds and CV Impact.

For all patients with diabetes, emphasize strategies to lower CV risk…such as statins, BP control, and smoking cessation.