The Dual Challenge: Diabetes, Heart Disease, and Kidney Disease

For millions of Americans living with type 2 diabetes, the risk of heart disease and kidney disease looms large. According to the Centers for Disease Control and Prevention (CDC), adults with diabetes are two to four times more likely to die from heart disease than adults without diabetes.Furthermore,diabetes is a leading cause of chronic kidney disease (CKD) and kidney failure.

The debate, aptly titled “Moonshine vs Tennessee Wine: Debate on Controversies in Diabetes,” featured Heather Roth, BSPharm, and Heather Johnson, PharmD, BCACP, who presented compelling arguments for each drug class. The core question: which offers the most comprehensive protection for the heart and kidneys?

Round 1: The Case for GLP-1 Receptor Agonists

Heather Roth, a clinical pharmacy specialist, championed GLP-1 receptor agonists, highlighting their remarkable track record in reducing major adverse cardiovascular events (MACE).these events include heart attack, stroke, and cardiovascular death.

GLP-1s work through several mechanisms:

• Increasing insulin secretion in response to glucose.
• Decreasing inappropriate glucagon secretion (a hormone that raises blood sugar).
• Slowing gastric emptying, which can definitely help control appetite.
• Reducing food intake, leading to weight loss.

These actions collectively contribute to lower blood pressure, improved cholesterol levels, and better blood glucose control. Roth emphasized the shift in american Diabetes Association (ADA) guidelines, which now prioritize CV and renal health alongside A1c management.

Several landmark trials have solidified the CV benefits of GLP-1s. the LEADER trial (liraglutide), SUSTAIN-6 (semaglutide), and REWIND trial (dulaglutide) all demonstrated important reductions in MACE. A meta-analysis of eight CV outcome trials further confirmed these findings, showing an overall 14% reduction in MACE with GLP-1 therapy, including a 13% reduction in CV death, a 16% reduction in non-fatal stroke, and a 9% reduction in non-fatal myocardial infarction (MI).

“The highest percent is that non-fatal stroke,” Roth said during the APhA session. “That is an advantage that GLP-1s have.”

Roth emphasized the superior stroke prevention offered by GLP-1s, a critical advantage. She also pointed to the more pronounced weight loss associated with GLP-1s compared to SGLT2 inhibitors, a crucial factor in overall CV health.

“With GLP-1s, there are very high categories of weight reduction,” Roth said. “GLP-1s are also a little bit more effective here in reducing glycemic goals overall.”

Round 2: The Case for SGLT2 Inhibitors

Heather Johnson, an assistant professor, presented the case for SGLT2 inhibitors, focusing on their significant impact on heart failure (HF) and chronic kidney disease (CKD).With over 6 million Americans battling heart failure, a condition associated with high mortality rates and increased CV event risk, Johnson argued that SGLT2 inhibitors offer a unique advantage.

Unlike GLP-1s, which primarily work through metabolic pathways, SGLT2 inhibitors directly benefit heart failure patients by reducing hospitalizations and mortality, even in individuals without diabetes

Why are GLP-1 agonists sometimes preferred over SGLT2 inhibitors for treating type 2 diabetes,despite the latter’s benefits in heart failure and kidney disease?