canadian diabetes association clinical practice guidelines treatment of diabetes in people with...
TRANSCRIPT
Canadian Diabetes Association Clinical Practice Guidelines
Treatment of Diabetes in People with Heart Failure
Chapter 28
Jonathan G. Howlett, John C. MacFadyen
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Treat heart failure in patients with diabetes the SAME
as you would a patient without diabetes
METFORMIN recommended if eGFR >30 mL/min
If eGFR <60 mL/min, use RAAS blockade carefully
Do NOT use thiazolidinediones
2013Diabetes in Heart Failure Checklist
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
• Diabetic cardiomyopathy
• 2 to 4-fold increase incidence of heart failure in DM
• Asymptomatic abnormalities of ventricular systolic
and diastolic function, independent of ischemic
heart disease or systemic hypertension
• Independent risk factors for CHF– Elevated A1C
– Microalbuminuria
Diabetes → Increased Risk of Heart Failure Independent of Ischemia
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Use the same heart failure therapies in diabetes as you would
in non-diabetes based on the Canadian Cardiovascular Society
(CCS) Recommendations (www.ccsguidelineprograms.ca)
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
• Beta-blocker for systolic heart failure if indicated
• Same target drug dose as indicated by CCS
• If eGFR <60 mL/min– Starting dose of ACEi/ARB should be halved with gradual
up-titration– Monitor electrolytes, creatinine, blood pressure, weight
within 7-10 days of starting
Use Same Treatments as in Non-diabetes …
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
ACEi = Angiotensin-Converting Enzyme inhibitor; CHF = Chronic Heart Failure; MI = Myocardial Infarction; SU = Sulfonylurea
Tayside, Scotland (population 400,000)
n=422 with CHF and diabetes
Antihyperglycemic therapy:– Metformin alone n=68– SU alone n=217– Combination n=137
Cum
ulat
ive
mor
talit
y
1.0
0.8
0.6
0
0.4
0.2
Time (days)
0 1000 2000 3000 4000 5000
Sulfonylurea monotherapy
Metformin monotherapy + combination
Evans JM, et al. Am J Cardiol 2010;106:1006-10.
Metformin Use in Heart Failure Patients
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Veterans Affairs• 6,185 with CHF & DM• Oral antihyperglycemic:
- With metformin (n=1,561)
- Without metformin
• Statistically adjusted for co-variables
Death: 0.76 (0.63-0.92) p < 0.01CHF hospitalization: 0.93 (0.74-1.18) p = 0.56Total hospitalization: 0.94 (0.83-1.07) p = 0.35
Sur
viva
l est
imat
es
1.00
0.95
0.90
0.75
0.85
0.80
Time (days)
0 700100 200 300 600400 500
Metformin
No metformin
p = 0.01
Aguilar D, et al. Circ Heart Fail 2011;4:53-8.
Metformin Use in Heart Failure Patients
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Use metformin in heart failure patients when eGFR >30 mL/min
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
1. Individuals with diabetes and heart failure should
receive the same heart failure therapies as those
identified in the evidence- based Canadian
Cardiovascular Society heart failure recommendations
(http://www.ccsguidelineprograms.ca) [Grade D, Consensus]
Recommendation 1
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
2. In people with diabetes and heart failure and an
eGFR <60 mL/min, or if combined RAAS blockade
is employed:
– Starting doses of ACE inhibitors or angiotensin
receptor II antagonists (ARBs) should be halved [Grade D, Consensus].
– Serum electrolytes and creatinine, blood pressure
and body weight, as well as heart failure
symptoms and signs, should be monitored within
7-10 days of any initiation or titration of therapy [Grade D, Consensus]
Recommendation 2
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
– Dose-up titration should be more gradual (with monitoring of blood pressure, serum potassium and creatinine) [Grade D, Consensus].
– The target drug doses should be the same as those identified in the evidence-based Canadian Cardiovascular Society recommendations on heart failure (http://www.ccsguidelineprograms.ca), if well tolerated [Grade D, Consensus]
Recommendation 2 (continued)
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
3. Beta blockers should be prescribed when indicated for systolic heart failure, as they provide similar benefits in people with diabetes compared with people without diabetes [Grade B, Level 2]
Recommendation 3
CDA Clinical Practice Guidelines
www.guidelines.diabetes.ca – for professionals
1-800-BANTING (226-8464)
www.diabetes.ca – for patients