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J Gen Intern Med. 2017 Sep;32(9):1044-1051. doi: 10.1007/s11606-017-4061-7. Epub 2017 May 26.

Shifting Paradigms in the Medical Management of Type 2 Diabetes: Reflections on Recent Cardiovascular Outcome Trials.

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Division of Clinical and Molecular Endocrinology, Department of Medicine, Case Western Reserve University and VA Medical Center, 10900 Euclid Ave., Cleveland, OH, 44106-4951, USA.
Department of Medicine, UCLA, Geffen School of Medicine, Los Angeles, CA, USA.
Department of Cardiology, Saint Luke's Mid America Heart Institute, University of Missouri, Kansas City, MO, USA.
Section of Endocrinology, Yale School of Medicine and Yale-New Haven Hospital, New Haven, CT, USA.


An important challenge in the management of patients with type 2 diabetes is cardiovascular disease (CVD) prevention. While it is well established that intensive glycemic control prevents the onset and slows the progression of certain microvascular complications, such a strategy utilized in multiple clinical trials over the past few decades has failed to show a similar benefit with regard to cardiovascular events, including mortality. Despite this, a major hope has been the discovery of glucose-lowering medications that simultaneously improve cardiovascular outcomes. Over the past year and a half, four randomized clinical trials (involving empagliflozin, pioglitazone, liraglutide, and semaglutide) have reported important benefits in preventing adverse cardiovascular outcomes in patients with or at risk for type 2 diabetes and established CVD. On the basis of these landmark trials, we propose that a paradigm shift in the management of patients with type 2 diabetes, specifically in those with prior macrovascular disease. A transition from current algorithms based primarily on hemoglobin A1c values to a more comprehensive strategy additionally focused on CVD prevention seems warranted.


MACE; The views expressed in this article do not represent any organization or entity; glycemic control; heart failure; hypoglycemia; individualization

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