DENVER — While traditional antidiabetic therapies have not been associated with a significant decrease in stroke risk in major trials, some of the newer drugs are demonstrating this benefit. However, the protection offered is not necessarily tied to tighter glycemic control.
Larry B. Goldstein, MD, chair of neurology at the University of Kentucky College of Medicine, emphasizes that in patients with type 2 diabetes mellitus (T2DM), these medications are not solely effective due to glycemic control. The exact mechanism behind their benefits remains unclear.
Historically, trials such as ACCORD showed that tighter glycemic control did not result in meaningful stroke protection. This lack of efficacy was consistent across various drugs, even prior to the availability of modern therapies.
Recent evidence suggests that newer antidiabetic drugs, such as sodium-glucose co-transporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA), offer significant reductions in cardiovascular events, including strokes. However, it’s uncertain whether both classes perform equally in stroke prevention.
GLP-1RA drugs have shown a stronger association with stroke risk reduction compared to SGLT2i. Studies indicate a risk reduction of approximately 15% with GLP-1RA, while the effect of SGLT2i is less pronounced.
Weight loss may be a contributing factor to the cardiovascular benefits of these medications. However, while both GLP-1RA and SGLT2i are associated with weight loss, it may not entirely explain the reduction in stroke risk.
Guidelines recommend GLP-1RA or SGLT2i as add-on therapy to metformin for glycemic control in T2DM patients with atherosclerotic cardiovascular disease (ASCVD) risk factors. GLP-1RA is particularly highlighted for its potential in reducing the risk of ASCVD events, including stroke.
For patients with T2DM at high risk of stroke, GLP-1RA may be a reasonable choice for prevention, especially for those with an ASCVD risk greater than 10% in the next decade. While the exact mechanism of protection is not fully understood, the recommendation for GLP-1RA is supported by guidelines and emerging evidence.
Dr. Goldstein and Dr. Kelley disclose no conflicts of interest.
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