Building Competency in Diabetes Education THE ESSENTIALS

TREATMENT MODALITIES: PHARMACOLOGICAL THERAPIES | 6- The screening and diagnosis of chronic kidney disease is outlined in figure 3 of Chapter 29: Chronic Kidney Disease in Diabetes of the 2018 Diabetes Canada Clinical Practice Guidelines and further described in chapter 9 (see 9-28). CKD is generally identified with repeated estimated glomerular filtration rate (eGFR) of less than or equal to 60 mL/min/1.73m 2 and/or an albumin-to-creatinine ratio (ACR) of greater than or equal to 2.0 mg/mmol. Studies investigating the cardiorenal benefits of antihyperglycemic agents have included individuals who do not have established ASCVD, CKD, nor heart failure. In these primary prevention trials, cardiovascular (CV) risk factors were determined within the study parameters. Although these trials have used a variety of clinically-accepted CV risk factors (including the presence of microalbuminuria or proteinuria, left ventricular hypertrophy, left ventricular systolic or diastolic dysfunction, and an ankle-brachial index of less than 0.9 [SUSTAIN-6]), it was the REWIND trial with dulaglutide 1.5mg s.c. once weekly and the DECLARE TIMI 58 trial with dapagliflozin 10mg which used similar inclusion criteria in their protocol that now allows us to include a person amongst high-risk populations as: • A person 60 years or older with at least 2 of the following cardiovascular risk factors o Smoking (tobacco use) o Hypertension  Untreated BP ≥140/95, OR  Current antihypertensive therapy o Dyslipidemia  Untreated LDL >3.4 mmol/L or HDL-C <1.0 mmol/L (men) <1.3 mmol/L (women) or triglyceride >2.3 mmol/L, OR  Current lipid-lowering therapy o Central obesity In the case where the adult with type 2 diabetes meets one or more of the high-risk population determinants, an antihyperglycemic agent with demonstrated cardiorenal protection plus metformin, unless contraindicated/not tolerated, should be considered, even if the person’s A1C is at their individualized A1C target, see figure 2.1. The REWIND trial was the first cardiovascular outcome trial (CVOT) to have a majority of its participants as primary prevention, in contrast to most CVOT which mainly included participants with a history of CV disease. Further, unlike other CVOTs where baseline A1C was ≥8.0%, REWIND had a baseline A1C median of 7.2% with 25% having a baseline A1C of less than 6.6%. As many would consider these median A1C to be “at target”, the REWIND trial provides evidence for prevention of MACE with dulaglutide 1.5mg in people with type 2 diabetes who may be at A1C target.