Cardiovascular Benefits of GLP-1 Agonists

APRIL 08, 2019

A discussion of the cardiovascular benefits with GLP-1 agonists and the pharmacists’ role in helping patients manage their diabetes.

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: Of the GLP-1 [glucagon-like peptide-1] receptor agonists that we have, out of the different cardiovascular outcomes trials that have been completed, the only one that currently has a labeled indication for cardioprotective benefit is liraglutide. And so it has very broad cardiovascular label in the sense that it has an indication for a nonfatal MI [myocardial infarction], nonfatal stroke, as well as cardiovascular death. Others have shown noninferiority, meaning they’re not going to cause additional harm, they’re not going to provide additional cardiovascular protection. But they’re neutral from a cardiovascular profile, and so the only one that currently has that is liraglutide, which is Victoza. There will be others in the pipeline that will eventually follow that path, but at the moment that’s the only one that has a labeled indication.

I’ll tell you a little bit about the differences in some of the trial designs for these various completed trials that we have. The majority of the trials that we’ve looked at are what we call secondary prevention. Meaning if patients had 1 cardiovascular event, you’re looking to prevent another one from happening. Whereas in a primary prevention study, we’re looking to prevent the first event from happening. So in the majority of these trials, because of the FDA mandate and the patient populations that they recruited, they happen to be patients who have secondary prevention in their groups, some as many as 100% of the study population in various differing amounts. Some are 80/20 mix, 80% being secondary prevention and 20% being primary prevention.

As these further studies completed, the mix kept changing because we kind of answered the question of what the value or what the benefit is in secondary prevention, and that was pretty clear. And so what we’re looking to understand is will this benefit carry out from a primary prevention standpoint. And we have some top-line early information from some of the dulaglutide studies, but we don’t have those full results. So we’re not going to be able to fully know if that benefit is going to be conferred to those from a primary prevention standpoint until we see those results at the ADA [American Diabetes Association’s Scientific Sessions] in June.

Tripp Logan, PharmD: Pharmacists, specifically community pharmacists, often see patients much more often than their primary care provider or their specialist. Research has shown that sometimes it’s 10 times more often than a primary care provider. That means that we’ve got not only the opportunity but almost the responsibility to help patients manage their diabetes, but also to pick up on things that could potentially improve their outcomes, modify their care plans, and get them on the right track. GLP-1s are definitely something that we consider when we’re working with patients.

Patients walk into pharmacies all the time to check their blood pressure, check their blood glucose, to see if something may be wrong with their blood glucose monitor. It’s a great opportunity to check their blood sugar.
We often have patients that bring their blood glucose monitor into pharmacies to download their reading prior to their provider’s office visit, which we actually recommend for all our diabetes patients. Bring in your monitor and we’ll download the readings, that way you can take it into your prescriber.

It also gives us a really good opportunity to look at their readings and come up with any recommendations that we may want them to relay to their prescriber. And it shows us when people have been running up high, on average, blood glucose and also gives us the ability to look at that patient holistically and think about what’s the best option for them if they have cardiovascular disease. Would they be reluctant to an injectable? Are they already on insulin? Are they only on 1 oral? What would be a good addition? We consider GLP-1s in this process because they’re usually easily administered, once weekly. We can help train them on how to administer these drugs, and we’ve seen a really positive response. We’ve had a few patients who have had adverse reactions to the GLP-1s, but overall we’ve had a very positive response to those.