SOURCE: Yandrapalli S, et al. Cardiovascular benefits and safety of non-insulin medications used in the treatment of type 2 diabetes mellitus. Postgrad Med 2017;129:811-821.

The primary goals of diabetes management are reductions in microvascular endpoints (retinopathy, neuropathy, nephropathy), macrovascular endpoints (myocardial infarction, stroke), and improved quality of life (less dry mouth, urinary frequency, visual disturbance). In the most recent decade, the FDA has mandated that new pharmacologic entities for management of glucose in type 2 diabetes (T2DM) establish cardiovascular (CV) safety with a substantial clinical trial. As a result, there are now several agents that have shown not only CV safety in T2DM, but also actual reductions in CV endpoints.

The three agents with FDA labeling for CV risk reduction based on their successful clinical trials are empagliflozin (EMPA-REG), canagliflozin (CANVAS), and liraglutide (LEADER). Another glucagon-like peptide-1 receptor agonist, semaglutide, has been approved for treatment of T2DM. It demonstrated CV risk reduction in a recent clinical trial (SUSTAIN), but does not yet carry FDA labeling for CV risk reduction.

The most recent American Diabetes Association 2018 guidance for pharmacotherapy of T2DM suggests that for patients with existing CV disease who are uncontrolled on metformin and lifestyle, consideration should be given to prioritizing agents demonstrated to provide CV risk reduction (empagliflozin, liraglutide, and canagliflozin).