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Multidisciplinary insights on the role of GLP-1 RAs in the modern management of stroke in patients with T2D

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Diabetes, Cardiovascular Risk CE/CME ACCREDITED Watch Time: 48 mins

touchMDT Multidisciplinary insights on the role of GLP-1 RAs in the modern management of stroke in patients with T2D

A multidisciplinary team and a patient discuss GLP-1 RAs and their role in stroke prevention in patients with T2D.

Overview & Learning Objectives

Patient with type 2 diabetes at risk of stroke

Endocrinologist, primary care physician and patient

An endocrinologist, a primary care physician and a patient with T2D who has survived a stroke discuss the burden of stroke and risk factors for stroke in patients with T2D.

Expert Spotlight
Prof. Tina Vilsbøll
Steno Diabetes Center Copenhagen and University of Copenhagen, Denmark
Dr Yassir Javaid
Nene CCG, Northamptonshire, UK
Ms Hyvelle Ferguson-Davis
Fort Lauderdale, FL, USA

Prof. Tina Vilsbøll, Dr Yassir Javaid and Ms Hyvelle Ferguson-Davis discuss the risk factors for stroke in patients with T2D and its impact upon daily life.

Listen on the Go

Learn more Back to MDT Hub Time: 12:37
 
Primary care physician, endocrinologist and neurologist

A primary care physician, an endocrinologist and a neurologist discuss the role of GLP-1 RAs in the prevention of stroke in patients with T2D.

Expert Spotlight
Dr Yassir Javaid
Nene CCG, Northamptonshire, UK
Prof. Tina Vilsbøll
Steno Diabetes Center Copenhagen and University of Copenhagen, Denmark
Prof. Georgios Tsivgoulis
National and Kapodistrian University of Athens, Greece

Dr Yassir Javaid, Prof. Tina Vilsbøll and Prof. Georgios Tsivgoulis discuss how GLP-1 RAs can help to reduce the incidence of stroke in patients with T2D.

Listen on the Go

Learn more Back to MDT Hub Time: 13:50
 
Neurologist and endocrinologist

A neurologist and an endocrinologist discuss the current treatment guidelines for stroke management in patients with T2D and the key data that support them.

Expert Spotlight
Prof. Georgios Tsivgoulis
National and Kapodistrian University of Athens, Greece
Prof. Tina Vilsbøll
Steno Diabetes Center Copenhagen and University of Copenhagen, Denmark

Prof. Georgios Tsivgoulis and Prof. Tina Vilsbøll discuss the current treatment guidelines for stroke management and prevention in patients with T2D.

Listen on the Go

Learn more Back to MDT Hub Time: 09:53
 
Endocrinologist, neurologist and patient

An endocrinologist, a neurologist and a patient with T2D who has survived a stroke discuss how the MDT can effectively collaborate to improve stroke outcomes in patients with T2D in clinical practice.

Expert Spotlight
Prof. Tina Vilsbøll
Steno Diabetes Center Copenhagen and University of Copenhagen, Denmark
Prof. Georgios Tsivgoulis
National and Kapodistrian University of Athens, Greece
Ms Hyvelle Ferguson-Davis
Fort Lauderdale, FL, USA

Prof. Tina Vilsbøll, Prof. Georgios Tsivgoulis and Ms Hyvelle Ferguson-Davis discuss the modern management of stroke in patients with T2D and how the MDT can collaborate to improve outcomes.

Listen on the Go

Learn more Back to MDT Hub Time: 11:27
 
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Learning Objectives & Overview
Overview

In this activity, a multidisciplinary team of specialists plus a patient with T2D who has survived a stroke share their perspectives on the burden of stroke, how GLP-1 RAs can help to reduce the incidence of stroke in patients with T2D, and clinical practice guidelines for stroke management and prevention in such patients.

This activity is jointly provided by USF Health and touchIME. read more

Target Audience

This activity has been designed to meet the educational needs of endocrinologists, neurologists and primary care physicians involved in the management of stroke in patients with T2D.

Disclosures

USF Health adheres to the Standards for Integrity and Independence in Accredited Continuing Education. All individuals in a position to influence content have disclosed to USF Health any financial relationship with an ineligible organization. USF Health has reviewed and mitigated all relevant financial relationships related to the content of the activity. The relevant relationships are listed below. All individuals not listed have no relevant financial relationships.

Faculty

Dr Yassir Javaid discloses: Advisory board/panel fees from AstraZeneca, Bayer, Daiichi Sankyo, Novartis. Speaker’s bureau fees from Abbott, Amgen, AstraZeneca, Bayer, BMS, Boehringer Ingelheim, Daiichi Sankyo, Edwards Lifesciences, Eli Lilly, iRhythm, Medtronic, Menarini, MSD, Napp, Novartis, Novo Nordisk, Pfizer, Sanofi and Servier.

Prof. Tina Vilsbøll discloses: Advisory board/panel fees from Amgen, AstraZeneca, BMS, Boehringer Ingelheim, Gilead, GSK, Eli Lilly, Novo Nordisk, Sanofi and Sun Pharmaceuticals. Consultant for Amgen, AstraZeneca, BMS, Boehringer Ingelheim, Eli Lilly, Gilead, GSK, Novo Nordisk, Sanofi and Sun Pharmaceuticals. Grants/research support from Boehringer Ingelheim and Novo Nordisk. Speaker’s bureau fees from Amgen, AstraZeneca, BMS, Boehringer Ingelheim, Eli Lilly, Gilead, GSK, Novo Nordisk, Sanofi and Servier.

Prof. Georgios Tsivgoulis discloses: Advisory board/panel fees from Abbott, AbbVie, Actavis, Allergan, Bayer, Biogen, Boehringer Ingelheim, CSL Behring, Daiichi Sankyo, Genesis Pharma, Ipsen, ITF Pharma, Medtronic, Merck, Novartis, Sanofi, Shionogi, Shire, Specifar, Teva and Takeda. Grants/research support from Abbott, AbbVie, Allergan, Amicus, Bayer, Boehringer Ingelheim, Genesis Pharma, Ipsen, Medtronic, Merck, Novalis, Novartis, Roche, Shire and Teva.

Ms Hyvelle Ferguson-Davis discloses: Advisory board/panel fees from Boehringer Ingelheim.

Content reviewer

Julie Hallanger-Johnson, MD has no financial interests/relationships or affiliations in relation to this activity.

Touch Medical Director

Sola Neunie has no financial interests/relationships or affiliations in relation to this activity.

USF Health Office of Continuing Professional Development and touchIME staff have no financial interests/relationships or affiliations in relation to this activity.

Requirements for Successful Completion

In order to receive credit for this activity, participants must review the content and complete the post-test and evaluation form. Statements of credit are awarded upon successful completion of the post-test and evaluation form.

If you have questions regarding credit please contact cpdsupport@usf.edu.

Accreditations

Physicians

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through a joint providership of USF Health and touchIME. USF Health is accredited by the ACCME to provide continuing medical education for physicians.

USF Health designates this enduring material for a maximum of 1.0 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

The European Union of Medical Specialists (UEMS) – European Accreditation Council for Continuing Medical Education (EACCME) has an agreement of mutual recognition of continuing medical education (CME) credit with the American Medical Association (AMA). European physicians interested in converting AMA PRA Category 1 CreditTM into European CME credit (ECMEC) should contact the UEMS (www.uems.eu).

Advanced Practice Providers

Physician Assistants may claim a maximum of 1.0 Category 1 credits for completing this activity. NCCPA accepts AMA PRA Category 1 CreditTM from organizations accredited by ACCME or a recognized state medical society.

The AANPCP accepts certificates of participation for educational activities approved for AMA PRA Category 1 CreditTM by ACCME-accredited providers. APRNs who participate will receive a certificate of completion commensurate with the extent of their participation.

Date of original release: 17 November 2022. Date credits expire: 17 November 2024.

If you have any questions regarding credit please contact cpdsupport@usf.edu.

Learning Objectives

After watching this activity, participants should be better able to:

  • Describe the burden of stroke and risk factors for stroke in patients with T2D
  • Evaluate the latest data for GLP-1 RAs in the context of stroke management and prevention
  • Interpret current treatment guidelines for T2D in the context of stroke management and prevention and apply it to clinical practice
Faculty & Disclosures
Dr Yassir Javaid

Nene CCG, Northamptonshire, UK

Dr Javaid graduated from Cambridge University and completed his vocational training scheme in Northampton, UK. He has a specialist interest in cardiology and echocardiography and is the cardiovascular lead at the Nene Clinical Commissioning Group and primary care cardiovascular lead for the East Midlands Clinical Network. read more

He was named Pulse ‘GP of the Year’ in 2015 for his work in reducing stroke emergency admissions in the East Midlands. He is also a council member of the British Heart Valve Society, accredited member of the British Society of Echocardiography and on the editorial board for the British Journal of Cardiology. 

Dr Yassir Javaid discloses: Advisory board/panel fees from AstraZeneca, Bayer, Daiichi Sankyo and Novartis. Speaker’s bureau fees from Abbott, Amgen, AstraZeneca, Bayer, BMS, Boehringer Ingelheim, Daiichi Sankyo, Edwards Lifesciences, Eli Lilly, iRhythm, Medtronic, Menarini, MSD, Napp, Novartis, Novo Nordisk, Pfizer, Sanofi and Servier.

Prof. Tina Vilsbøll

Steno Diabetes Center Copenhagen and University of Copenhagen, Denmark

Prof. Tina Vilsbøll has been involved in diabetes research since 1997, and in 2004 she established the Center for Diabetes Research at Gentofte Hospital, University of Copenhagen, Denmark, which is now part of the Steno Diabetes Center Copenhagen. read more

Her research is focused on the pathophysiology of obesity, prediabetes, type 2 diabetes, regulation of appetite and food intake, and the utilization of incretins as therapeutics. Integration of the gut in the understanding of human glucose metabolism has become a major focus in her lab over recent years. Prof. Vilsbøll is an experienced teacher and supervises several PhD and medical students conducting diabetes research. In addition to her teaching and research posts, she is a member of numerous professional societies and committees, and referees for several international journals. 

She has contributed to more than 390 scientific publications (H-index 75), and edited or written numerous books and book chapters. She is a frequently invited speaker at international meetings.

Prof. Tina Vilsbøll discloses: Advisory board/panel fees from Amgen, AstraZeneca, BMS, Boehringer Ingelheim, Gilead, GSK, Eli Lilly, Novo Nordisk, Sanofi and Sun Pharmaceuticals. Consultant for Amgen, AstraZeneca, BMS, Boehringer Ingelheim, Eli Lilly, Gilead, GSK, Novo Nordisk, Sanofi and Sun Pharmaceuticals. Grants/research support from Boehringer Ingelheim and Novo Nordisk. Speaker’s bureau fees from Amgen, AstraZeneca, BMS, Boehringer Ingelheim, Eli Lilly, Gilead, GSK, Novo Nordisk, Sanofi and Servier.

Prof. Georgios Tsivgoulis

National and Kapodistrian University of Athens, Greece

Prof. Georgios Tsivgoulis currently serves as professor of neurology and chairman in the Second Department of Neurology at the School of Medicine, National and Kapodistrian University of Athens. He is also the director of the Neurosonology Laboratory and of the Resident Training and Cerebrovascular Fellowship Program. In addition, he is a visiting professor of neurology and director of stroke research in the Department of Neurology at the University of Tennessee Health Science Center in Memphis, TN, USA. read more

Prof. Georgios Tsivgoulis’s research interests focus on acute reperfusion therapies in acute ischaemic stroke, applications of neurosonology in cerebrovascular diseases, secondary stroke prevention and clinical trial methodology. He has served as the national coordinator and International Steering Committee member in multiple phase II and III trials in acute stroke and in secondary stroke prevention. 

He is a fellow of the European Stroke Organization (ESO), European Academy of Neurology and American Academy of Neurology, and currently serves as general secretary of the Hellenic Society of Cerebrovascular Diseases, president of the Hellenic Neurological Society and vice president of ESO, where he is a member of the Guideline Board and serves on the Education Committee. Prof. Tsivgoulis has been the recipient of international awards, including the ESO Scientific Excellence Award 2021.

Prof. Tsivgoulis has authored more than 550 papers and 16 book chapters, and has been a reviewer for over 60 international medical journals. He is an associate editor of Therapeutic Advances in Neurological Disorders, a section editor of Stroke, and editor of Nevrologia. His research has received over 17,000 citations (Google Scholar) and his H-index is 66 (Google Scholar).

Prof. Georgios Tsivgoulis discloses: Advisory board/panel fees from Abbott, AbbVie, Actavis, Allergan, Bayer, Biogen, Boehringer Ingelheim, CSL Behring, Daiichi Sankyo, Genesis Pharma, Ipsen, ITF Pharma, Medtronic, Merck, Novartis, Sanofi, Shionogi, Shire, Specifar, Teva and Takeda. Grants/research support from Abbott, AbbVie, Allergan, Amicus, Bayer, Boehringer Ingelheim, Genesis Pharma, Ipsen, Medtronic, Merck, Novalis, Novartis, Roche, Shire and Teva.

Ms Hyvelle Ferguson-Davis

Fort Lauderdale, FL, USA

Hyvelle Ferguson-Davis is a mother, wife, and stroke and heart attack survivor who continues to live a fulfilling life despite living with type 2 diabetes and heart-related challenges. read more

She is a graduate of Florida Atlantic University and is an ambassador for the American Heart Association and the American Diabetes Association, as well as an inspirational speaker and writer.

Ms Ferguson-Davis is the founder of Heart Sistas, an organization that aims to heighten awareness and deliver education about women’s health to a diverse group of underrepresented women.

Ms Hyvelle Ferguson-Davis discloses: Advisory board/panel fees from Boehringer Ingelheim.

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Question 1/4
Which of these are modifiable risk factors for the development of CVD in people with T2D?

CVD, cardiovascular disease; T2D, type 2 diabetes.
Correct

A recent scientific statement from the AHA on the management of CV risk factors for adults with T2D highlights that several factors in the development of atherosclerosis and CVD are often comorbid in individuals with T2D. These include dyslipidaemia, hyperglycaemia, hypertension, insulin resistance and obesity. Thus, lifestyle changes, weight reduction and cardioprotective therapeutics are stated as vital tools in the primary and secondary prevention of CVD. 

Abbreviations

AHA, American Heart Association; CV, cardiovascular; CVD, CV disease; T2D, type 2 diabetes.

Reference

Joseph JJ, et al. Circulation. 2022;145:e722–59.

Question 2/4
Your 50-year-old female patient with T2D has a family history of stroke and myocardial infarction, and has hypertension and obesity. She recently experienced a TIA and you decide to initiate GLP-1 RA therapy to help reduce her risk of another vascular event. According to the latest data, which of these GLP-1 RAs would you choose?

GLP-1 RA, glucagon-like peptide-1 receptor agonist; T2D, type 2 diabetes; TIA, transient ischaemic attack.
Correct

An exploratory analysis of the REWIND trial, a double-blind, randomized placebo-controlled trial assessing the effects of dulaglutide on major adverse cardiovascular events in people with T2D, found that dulaglutide reduced the risk of non-fatal stroke by 24% (HR 0.76; p=0.017). Dulaglutide also reduced ischaemic stroke (HR 0.75; p=0.012), the composite of non-fatal stroke or all-cause death (HR 0.88, p=0.017) and disabling stroke (HR 0.74, p=0.042), but had no effect on haemorrhagic stroke (HR 1.05, p=0.89). The stroke risk benefits were found to be independent of history of prior stroke/TIA (pInteraction=0.83).1

CVOTs for liraglutide (LEADER trial), lixisenatide (ELIXA trial) and exenatide (EXSCEL trial) have not demonstrated a statistically significant reduction in the risk of stroke with these agents versus placebo in patients with T2D.2–4

Abbreviations

CVOT, cardiovascular outcomes trial; HR, hazard ratio; T2D, type 2 diabetes; TIA, transient ischaemic attack.

References

  1. Gerstein HC, et al. Lancet Diabetes Endocrinol. 2020;8:106–14.
  2. Marso SP, et al. N Engl J Med. 2016;375:311–22.
  3. Pfeffer MA, et al. N Engl J Med. 2015;373:2247–57.
  4. Holman RR, et al. N Engl J Med. 2017;3771228–39.
Question 3/4
Your 62-year-old male patient was diagnosed with T2D 7 years ago. Since his diagnosis, he has been taking metformin and his latest HbA1c measurement was 6.7%. One month ago, he experienced an ischaemic stroke. According to the 2021 AHA/ASA guidelines, what would you consider next to prevent further vascular events in your patient?

AHA, American Heart Association; ASA, American Stroke Association; CVD, cardiovascular disease; GLP-1 RA, glucagon-like peptide-1 receptor agonist; HbA1c, glycated haemoglobin; T2D, type 2 diabetes; TZD, thiazolidinedione; SGLT2i, sodium-glucose cotransporter 2 inhibitor.
Correct

The 2021 AHA/ASA guideline for the prevention of stroke in patients with stroke and TIA recommend that, in those patients with T2D and established ASCVD, including ischaemic stroke, when prevention of further vascular events is the priority, a GLP-1 RA should be added to metformin independently of baseline HbA1c.

Abbreviations

AHA, American Heart Association; ASA, American Stroke Association; ASCVD, atherosclerotic cardiovascular disease; GLP-1 RA, glucagon-like peptide-1 receptor agonist; HbA1c, glycated haemoglobin; TIA, transient ischaemic attack; T2D, type 2 diabetes.

Reference

Kleindorfer DO, et al. Stroke. 2021;52:e364–467.

Question 4/4
The 2022 ADA/EASD guidelines recommend a GLP-1 RA or SGLT2i with proven CVD benefit in addition to first-line metformin in patients with T2D and:

ADA, American Diabetes Association; ASCVD, atherosclerotic CVD; CKD, chronic kidney disease; CVD, cardiovascular disease; EASD, European Association for the Study of Diabetes; GLP-1 RA, glucagon-like peptide-1 receptor agonist; SGLT2i, sodium-glucose cotransporter 2 inhibitor; T2D, type 2 diabetes.
Correct

The 2022 ADA/EASD guidelines recommend the use of either a GLP-1 RA with proven CVD benefit, or an SGLT2i with proven CVD benefit for cardiorenal risk reduction in high-risk patients with T2D that have ASCVD or indicators of high risk. ASCVD is defined differently across the CVOTs that form the basis of this recommendation, but all included individuals with established CVD (e.g. myocardial infarction, stroke or any revascularization procedure). Definitions of indicators for high risk also varied, but most included being ≥55 years old with two or more additional risk factors (including obesity, hypertension, smoking, dyslipidaemia or albuminuria).

Abbreviations

ADA, American Diabetes Association; ASCVD, atherosclerotic CVD; CVD, cardiovascular disease; CVOT, cardiovascular outcomes trial; EASD, European Association for the Study of Diabetes; GLP-1 RA, glucagon-like peptide-1 receptor agonist; SGLT2i, sodium-glucose cotransporter 2 inhibitor; T2D, type 2 diabetes.

Reference

Davis MJ, et al. Diabetologia. 2022;doi:10.1007/s00125-022-05787-2.

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