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A Horse, a Jockey, and a Therapeutic Dilemma: Choosing the Best Option for a Patient with Diabetes and Coronary Artery Disease

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Abstract

Current guidelines for the management of hyperglycemia recommend the use of agents with proven cardiovascular (CV) benefit in patients with type 2 diabetes (T2D) and established CV disease. Although both glucagon-like peptide 1 receptor agonists (GLP-1 RA) and sodium-glucose co-transporter 2 inhibitors (SGLT2i) have been shown to reduce the risk of major adverse CV events (MACE) in high-risk populations with T2D, the ideal choice between the two classes for people with coronary artery disease remains controversial. SGLT2i reduce CV risk primarily through hemodynamic effects and changes in energy metabolism, making them the first choice in cases where heart failure or chronic kidney disease predominates. On the other hand, GLP-1 RA exert powerful anti-atherogenic properties that are the main drivers of their cardioprotection, and seem to have a consistent benefit in the atherosclerotic components of MACE. However, most people with diabetes and CV disease could take advantage of the complementary effects of the two drug categories on glycemic control, body weight, and diabetic complications. Future mechanistic studies and clinical head-to-head trials are expected to shed more light on this intriguing clinical dilemma and provide clear guidance for daily practice.

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Authors and Affiliations

  1. Division of Endocrinology and Metabolism and Diabetes Center, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, 1 St. Kiriakidi Street, 54636, Thessaloníki, Greece

    Theocharis Koufakis & Kalliopi Kotsa

  2. First Department of Propaedeutic Internal Medicine, Medical School, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece

    Evangelos N. Liberopoulos

Authors
  1. Theocharis Koufakis
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  2. Evangelos N. Liberopoulos
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  3. Kalliopi Kotsa
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Correspondence to Kalliopi Kotsa.

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No external funds were used in the preparation of this article.

Conflict of interest

TK has received honoraria for lectures from AstraZeneca, Boehringer Ingelheim, Pharmaserve Lilly, and Novo Nordisk and for advisory boards from Novo Nordisk, and has participated in studies sponsored by Eli-Lilly. ENL has participated in educational, research, and advisory activities sponsored by AstraZeneca, MSD, Lilly, Bayer, Amgen, Sanofi, Boehringer Ingelheim, Novartis, Novo Nordisk, and Servier. KK has received honoraria for lectures/advisory boards and research support from Astra Zeneca, Boehringer Ingelheim, Pharmaserve Lilly, Sanofi-Aventis, ELPEN, MSD, and Novo Nordisk.

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TK reviewed the literature and drafted the first version of the manuscript. ENL and KK reviewed the literature and edited the manuscript. All authors have read and approved the final version of the manuscript.

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Koufakis, T., Liberopoulos, E.N. & Kotsa, K. A Horse, a Jockey, and a Therapeutic Dilemma: Choosing the Best Option for a Patient with Diabetes and Coronary Artery Disease. Am J Cardiovasc Drugs 22, 357–361 (2022). https://doi.org/10.1007/s40256-022-00527-8

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