SGLT2 Inhibitors Like empagliflozin (Jardiance) Should be Part of Optimal Medical Therapy (OMT) for Type 2 Diabetes
Optimal medical therapy is defined by a standardized protocol for your chronic cardiometabolic condition team. Empagliflozin belongs on your protocol. Patients with type 2 diabetes don’t die of high sugar levels. They die of heart attack, stroke, and kidney failure. This study examined patients with type 2 diabetes and known atherosclerotic vascular disease on OMT with or without empagliflozin which reduced the risk of cardiovascular death by almost 40%. That is most impressive because an OMT study in a similar population from 2008 showed dramatic reductions in death, one fourth as many heart attacks, and one fifth as many strokes compared with usual care. The benefits of empagliflozin are added to that. This is the design that diabetic research should take going forward. What is the benefit of the new intervention when added to optimal medical therapy? That is the critical question.
There is a reason that empagliflozin has such a profound impact on cardiovascular death, heart failure and kidney failure. Empagliflozin switches off the master metabolic switch mTOR while switching on AMPK. The heart failure benefits have little to do with blood sugar levels. Empagliflozin reduces heart failure hospitalizations whether the patient is diabetic or not. It is switching on AMPK that makes the difference. Look at the diagram. ACE inhibitors like lisinopril, ARBs like losartan, statins, mineralocorticoid receptor blockers like spironolactone, and smoking cessation all switch on AMPK indirectly. Intermittent fasting, exercise, empagliflozin, and metformin switch on AMPK directly. That is the reason OMT is so much better than usual care and that is the care all diabetics should receive. OMT provided to diabetic patients earlier in the course uses very inexpensive generic medications. It reduces hospitalizations for heart failure by 70% compared with usual care. Metformin switches on AMPK for $4 a month. The cash price of Jardiance is $672 per month. Begin OMT with metformin and carb restriction first and your patients may never develop heart or kidney failure. You may never need empagliflozin. The best care is the least expensive care.