A panel of experts writing in The BMJ has recommended that sodium-glucose cotransporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists should be used in almost all adults with type 2 diabetes (T2D) who are at a high risk of cardiovascular and kidney complications. They also suggest that these medications should be used in most adults with a moderate risk of complications. However, for patients with a lower risk of complications, the panel advises against routinely prescribing these medications and instead suggests that health care providers discuss other available treatment options based on the patient’s preference and priorities.1,2
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Type 2 Diabetes and Cardiovascular Complications
T2D affects nearly half a billion individuals globally and is marked as the ninth leading cause of death internally, connected to multi-organ health issues. As this issue has become more prevalent, the central goal of diabetes management has shifted from controlling blood sugar to preventing cardiovascular and kidney complications. Previous findings have demonstrated that SGLT-2s and GLP-1s like finerenone (Kerendia; Bayer) and tirzepatide (Mounjaro, Zepbound; Eli Lilly and Company) have demonstrated protective benefits for the heart and kidney and achieve significant weight loss.1
Understanding SGLT-2 and GLP-1 Guidelines
Due to the rapidly evolving evidence around SGLT-2 inhibitors and GLP-1s for diabetes and cardiovascular treatment, the study authors noted that up-to-date guidelines are needed to help health care providers make decisions based on a risk-stratified approach and patient needs.1
The international panel included 2 patient partners, clinicians, and methodologists that created the guidelines by following standards for trustworthy recommendations. Using the GRADE approach, the panel considered the balance of benefits, harms, and burdens from the patient’s perspective, creating a living systemic review and network meta-analysis that evaluated treatments as of July 31, 2024. Additionally, the panel conducted systemic reviews that addressed risk prediction models and patient values, prioritizing therapeutics with sufficient randomized trial data and global relevance. Data for the recommendations included almost half a million individuals with T2D across 869 randomized controlled trials, involving 63 medications and 26 outcomes.1,2
Overview of Recommendations
Based on the evaluations, the panel announced 6 recommendations around SGLT-2 and GLP-1 use for T2D, cardiovascular and kidney complications.1,2
For adults at lower risk of cardiovascular and kidney complications, they suggest against SGLT-2 inhibitors or GLP-1s. The treatment effect estimates were informed by evidence from 110 trials involving 89,803 participants for SGLT-2 inhibitors and 109 trials involving 102,687 participants for GLP-1s. Next, for adults at moderate risk of cardiovascular and kidney complications, the panel suggests using GLP-1s and SGLT-2 inhibitors, based on similar trial data.1,2
For adults with chronic kidney disease (CKD) at moderate risk of cardiovascular and kidney complications, the researchers suggest against using finerenone. Based on evidence from 2 clinical trials with 13,026 participants, this weak recommendation was made based on finerenone’s limited and nonexistent benefits, a risk of harm, cost, access, and limited clinical experience.1,2
For adults at higher risk of cardiovascular and kidney complications, the panel recommends using SGLT-2 inhibitors or GLP-1s, based on evidence from 219 trials involving nearly 199,000 participants. In the studies, the treatments showed important, high-certainty benefits for overall survival, cardiovascular, and kidney health, which were considered to outweigh the risks and treatment burdens.1,2
For adults with CKD at the highest risk of cardiovascular and kidney complications, they suggest using finerenone. The weak recommendation was based on 2 trials, as treatment with finerenone demonstrated potential survival and kidney benefits that outweigh the risks.1,2
Lastly, for adults with obesity, the panel is in favor of using tirzepatide. However, they note that when choosing between different GLP-1s and tirzepatide, health care providers should weigh the higher certainty of cardiovascular and kidney benefits.1,2
The panel noted that in order to utilize the recommendations, health care providers must first assess an individual’s risk based on risk stratification and include patients in shared decision-making.1,2