What would be the best choice regarding next steps in treatment for an adult male aged 65 years with Type 2 diabetes for 10 years duration who has had a myocardial infarction 6 months ago, with a blood pressure of 140/90 mmHg, HbA1c of 8.5%, low-density lipoprotein cholesterol (LDL-C) of 90 mg/dl, and with chronic kidney disease (CKD) with estimated glomerular filtration rate (eGFR) of 40 ml/min/1.73m2? He is currently on hydrochlorothiazide for his blood pressure, simvastatin 20 mg and metformin.
Which of the following is the best choice for this patient?
Show Answer
The correct answer is: C. Switch statin to atorvastatin 80 mg or rosuvastatin 40 mg, add ACE-inhibitor or ARB and GLP1-RA.
Option A is not correct. The patient is only on 20 mg simvastatin and should be on a high intensity statin first before trying other non-statin agents, given he is at very high risk according to his recent acute coronary syndrome.1 In addition, due to his eGFR of 40 ml/min/1.73m2 an SGLT-2 inhibitor would be contraindicated, with a GLP-1 RA the preferred second line therapy for diabetes and to reduce cardiovascular risk.2 Liraglutide is the only GLP-1 RA with a current indication for cardiovascular risk reduction.
Option B is not correct. Again, before trying a non-statin, a high intensity statin should be prescribed.
Option C is correct. Atorvastatin 80 mg or rosuvastatin 40 mg are examples of high intensity statins that should be attempted before moving to a non-statin. Because of the reduced kidney function, an SGLT-2 would not be the preferred next antidiabetic agent, but a GLP-1 would. Liraglutide is the only GLP-1 with a current FDA indication for cardiovascular risk reduction.
Option D is not correct, for reason above that the GLP-1 would be the next preferred antidiabetic agent to reduce cardiovascular risk.
Other Considerations:
While the switch to the high intensity statin should be expected to reduce his LDL-C to below 70 mg/dl, the recent 2018 cholesterol management guidelines note that if this is not achieved on maximally tolerated statin, ezetimibe should be attempted first in such patients defined to be at very high risk,1 followed by a PCSK9 inhibitor if necessary. In addition, latest 2017 hypertension guidelines recommend a target blood pressure of <130/80 mmHg which is especially important to reduce residual risk in the very high risk patient such as this one.3 The choice of an ACE inhibitor or ARB as the second line agent could be recommended due also to their effects in preventing future progression of CKD.
References
Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018. Epub ahead of print.
Das SR, Everett BM, Birtcher KK, et al. 2018 ACC Expert Consensus Decision Pathway on Novel Therapies for Cardiovascular Risk Reduction in Patients With Type 2 Diabetes and Atherosclerotic Cardiovascular Disease: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol 2018. Epub ahead of print.
Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018;71:e127-248.
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