Diabetes medications with cardiovascular protection in the wake of EMPA-REG OUTCOME: the optimal combination may be metformin, pioglitazone and empagliflozin
Abstract
Those of us who were in the huge, packed auditorium when the slide shown in Figure 1 went up on the screen at 17.15 on the 17th September, at the European Association for the Study of Diabetes 2015 congress in Stockholm, were aware that this was one of those landmark moments in the history of diabetes care.There was loud applause.The event was the presentation of the results of the EMPA-REG OUTCOME study, which evaluated the effect of the SGLT2 inhibitor, empagliflozin, on cardiovascular outcomes in people with type 2 diabetes at high cardiovascular risk.1,2 As the whole story of the results unfolded, however, we realised that we were going to be left with as many questions as answers.In particular it seemed that empagliflozin reduced death from cardiac causes but did not reduce non-fatal myocardial infarction or stroke, a combination of findings which was at first sight difficult to understand.Comparing and contrasting the graphs from EMPA-REG, such as the one shown in Figure 1, with those from other studies is a quick way of getting a feel for the subject of antihyperglycaemic medications that might play a part in reducing cardiovascular risk.Figure 2 shows the Kaplan-Meier plots for metformin in the 10-year, observational follow-up of the United Kingdom Prospective Diabetes Study (UKPDS), 3 which suggested the value of metformin as a cardioprotective agent seen in the earlier, randomised phase of the study.4 Intensive glycaemic management with metformin, but not with a…
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Evidence Hub reads this as a randomized trial, done in people. Its evidence level is 2 of 5 (High · randomized trial). Randomized trials of a reasonable size are the strongest single-study design.
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