Recommendation 9: We recommend that diabetes should be treated according to the Diabetes Canada’s national guidelines (guidelines.diabetes.ca) to achieve optimal control of blood glucose levels (Strong Recommendation, Moderate Quality Evidence).
Values and preferences: There is no convincing evidence from RCTs that tighter glycemic control reduces cardiovascular outcomes. Potential risks of tight glycemic control may outweigh its benefits in certain individuals such as those with long duration of diabetes, frequent episodes of hypoglycemia; those with advanced cardiovascular disease; advanced age, frailty or multiple comorbidities.
Practical tip:
Recommendation 10: We suggest that metformin may be considered a first-line agent for type 2 diabetes treatment (Weak Recommendation, Moderate Quality Evidence).
Values and preferences: Metformin is the current Diabetes Canada first line treatment for type 2 diabetes.
Practical tip:
Recommendation 11: We suggest that the use of empagliflozin, a SGLT-2 inhibitor, be considered for patients with type 2 diabetes and established cardiovascular disease for the prevention of HF-related outcomes (Weak Recommendation, Low Quality Evidence).
Values and preferences: This recommendation places weight on the fact that empagliflozin is the first diabetes-related medication to show a reduction in HF hospitalization. Empagliflozin was well tolerated and associated with an acceptable side-effect profile within the clinical trial establishing its efficacy and safety. There are ongoing trials of this class of medications that may change this recommendation.
Recommendation 12: We do not recommend the use of the DPP-4 inhibitor saxagliptin in patients with or at risk for heart failure (Strong Recommendation, Moderate Quality Evidence).
Recommendation 13: We suggest that if a DPP-4 inhibitor is to be used, linagliptin or sitagliptin should be considered for patients with diabetes and with, or at risk for heart failure (Weak Recommendation, Moderate Quality Evidence).
Values and preferences: The Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with Diabetes Mellitus (SAVOR) trial showed an increase in HF hospitalizations with use of saxagliptin. Other DPP-4 inhibitors (e.g., sitagliptin, alogliptin, linagliptin) did not have the same adverse effect of HF hospitalization as saxagliptin; there are ongoing trials of other DPP-4 inhibitors.
Recommendation 14: We recommend that thiazolidinediones should not be used in patients with HF (Strong Recommendation, High Quality Evidence).