The American College of Cardiology has released this month a guidance on CVD Risk Reduction in Diabetes. It is all about the currently most trendy and fasionable drug groups in diabetes, of course SGLT2-i and GLP-1 RAs. The whole consensus is focused in CV risk reduction.
After an introduction that explains the high CV risk in type 2 diabetes and the fact that all measures so far used are not enough to reduce it so much, it reviews the mechanisms of action of these drugs and the clinical trials that have showed benefits in CV events, both atherosclerotic CVD (for both groups) and heart failure and renal deterioration (for gliflozins).
Next it presents the main adverse effects and contraindications for each group, and ends up with some algorithms to use them in clinical practice. It includes recommendations to detect previously undetected diabetes and initiate those therapies right away.
So far, so good. Or maybe not, because, as a diabetes specialist, I see a couple of problems. The most important is that, at least the way I understand clinical practice in diabetes, the process of diabetes care should follow a series of steps: diagnosis, self management education, drugs, and continuous assessment. To begin with, diagnosis should be made by someone with experience in diabetes (GPs, internist, endocrinologists, etc) based in current criteria, because it has quite a lot of long-term implications for the individual; Second: after diagnosis, Self-Management Education is the main and most important action of care the diabetes care providers should do, and of course must be delivered by trained professionals with experience in diabetes. This part is not mentioned at all in this guideline, just the cardiologist look at the analyses, diagnose diabetes if hyperglycemia or elevated A1c, and 2 minutes later you get a drug prescription!! That in my opinion should not be like that. And finally, diabetes is a very complex disease, its management should be performed by someone capable of coordinate every part of treatment, evaluate its effect on every diabetes complication or comorbidity. This implies a comprehensive medical evaluation and a profound knowledge of the disease, which clearly is beyond the scope of a cardiology specialist.
I am of course absolutely sure of the integrity and honesty of all board members that have written this guide, but when I see something that pushes doctors to a "fast diagnosis - fast prescription" medicine, I can't help but think the great beneficiary is big pharma. We should not forget that diabetes has tripled its prevalence in the last decades due to changes in lifestyle, and I would't like that polypharmacy were the only response the medical community gives to this challenge.
