1. Canadian Diabetes Association Clinical Practice Guidelines Treatment of Diabetes in People with Heart Failure Chapter 28 Jonathan G. Howlett, John C. MacFadyen

2. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Treat heart failure in patients with diabetes the SAME as you would a patient without diabetes METFORMIN recommended if eGFR >30 mL/min If eGFR <60 mL/min, use RAAS blockade carefully Do NOT use thiazolidinediones 2013 Diabetes in Heart Failure Checklist

3. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Diabetic cardiomyopathy 2 to 4-fold increase incidence of heart failure in DM Asymptomatic abnormalities of ventricular systolic and diastolic function, independent of ischemic heart disease or systemic hypertension Independent risk factors for CHF – Elevated A1C – Microalbuminuria Diabetes → Increased Risk of Heart Failure Independent of Ischemia

4. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Use the same heart failure therapies in diabetes as you would in non-diabetes based on the Canadian Cardiovascular Society (CCS) Recommendations (www.ccsguidelineprograms.ca)

5. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Beta-blocker for systolic heart failure if indicated Same target drug dose as indicated by CCS If eGFR <60 mL/min – Starting dose of ACEi/ARB should be halved with gradual up-titration – Monitor electrolytes, creatinine, blood pressure, weight within 7-10 days of starting Use Same Treatments as in Non-diabetes …

6. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association ACEi = Angiotensin-Converting Enzyme inhibitor; CHF = Chronic Heart Failure; MI = Myocardial Infarction; SU = Sulfonylurea Tayside, Scotland (population 400,000) n=422 with CHF and diabetes Antihyperglycemic therapy: – Metformin alone n=68 – SU alone n=217 – Combination n=137 Cumulative mortality 1.0 0.8 0.6 0 0.4 0.2 Time (days) 0 10002000300040005000 Sulfonylurea monotherapy Metformin monotherapy + combination Evans JM, et al. Am J Cardiol 2010;106:1006-10. Metformin Use in Heart Failure Patients

7. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Veterans Affairs 6,185 with CHF & DM Oral antihyperglycemic: -With metformin (n=1,561) -Without metformin Statistically adjusted for co-variables Death:0.76 (0.63-0.92) p < 0.01 CHF hospitalization:0.93 (0.74-1.18) p = 0.56 Total hospitalization:0.94 (0.83-1.07) p = 0.35 Survival estimates 1.00 0.95 0.90 0.75 0.85 0.80 Time (days) 0 700100200300600400500 Metformin No metformin p = 0.01 Aguilar D, et al. Circ Heart Fail 2011;4:53-8. Metformin Use in Heart Failure Patients

8. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Use metformin in heart failure patients when eGFR >30 mL/min

9. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 1.Individuals with diabetes and heart failure should receive the same heart failure therapies as those identified in the evidence- based Canadian Cardiovascular Society heart failure recommendations (http://www.ccsguidelineprograms.ca) [Grade D, Consensus]http://www.ccsguidelineprograms.ca Recommendation 1

10. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 2.In people with diabetes and heart failure and an eGFR <60 mL/min, or if combined RAAS blockade is employed: – Starting doses of ACE inhibitors or angiotensin receptor II antagonists (ARBs) should be halved [Grade D, Consensus]. – Serum electrolytes and creatinine, blood pressure and body weight, as well as heart failure symptoms and signs, should be monitored within 7-10 days of any initiation or titration of therapy [Grade D, Consensus] Recommendation 2

11. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association – Dose-up titration should be more gradual (with monitoring of blood pressure, serum potassium and creatinine) [Grade D, Consensus]. – The target drug doses should be the same as those identified in the evidence-based Canadian Cardiovascular Society recommendations on heart failure (http://www.ccsguidelineprograms.ca), if well tolerated [Grade D, Consensus]http://www.ccsguidelineprograms.ca Recommendation 2 (continued)

12. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 3.Beta blockers should be prescribed when indicated for systolic heart failure, as they provide similar benefits in people with diabetes compared with people without diabetes [Grade B, Level 2] Recommendation 3

13. CDA Clinical Practice Guidelines www.guidelines.diabetes.cawww.guidelines.diabetes.ca – for professionals 1-800-BANTING (226-8464) www.diabetes.ca www.diabetes.ca – for patients