Background
Type 2 diabetes mellitus (T2D) is common in post-heart transplant patients. Commonly
used T2D medications, especially insulin, can promote weight gain and are not associated
with cardiovascular (CV) benefits. Glucagon-like Peptide-1 receptor agonists (GLP-1
RA) and Sodium-Glucose Cotransporter-2 inhibitors (SGLT2i) are two drug classes that
produce CV benefits in T2D and promote weight loss with minimal risk of hypoglycemia.
Their use has not been previously evaluated in this particular group, and there have
been theoretical concerns about safety in immunosuppressed patients.
Methods
Patients with T2D are sequentially referred by the Heart Transplant program to the
Cardiometabolic Center of Excellence (CMCE) at our institution, allowing minimal selection
bias. CMCE provides treatment algorithms that emphasize the use of cardioprotective
T2D medications. We analyzed this initial series of transplant patients with T2D who
have been on GLP-1 RA and/or SGLT-2i with at least two visits at CMCE.
Results
Among 15 patients, the mean age was 59.4 ± 2.6 years, 66.7% were males, 73.3% were
Caucasians, 33.3% had history of ischemic cardiomyopathy and baseline eGFR was 53.5
± 7.9 mL/min/1.73m2. The median time from transplant was 4.6 (1.6 - 10.5) years. The median follow-up
time at CMCE was 5.4 (2.8 - 10.9) months. At baseline, 73% were on insulin, 40% on
Metformin, 13% on Sulfonylurea, 13% on Dipeptidyl peptidase-4 inhibitors, and 7% on
Thiazolidinediones. Following initiation of therapy at CMCE, 86.7% of patients were
on a combination of GLP-1 RA and SGLT-2i, while the rest were taking only GLP-1 RA.
Overall, the median total daily insulin requirements decreased substantially from
94 (40.5 - 124) to 34 (5 - 60) units at latest clinic visit; p = 0.003. Further, median
hemoglobin A1c dropped from 7.7% (7.3 - 9.5) to 6.6% (6 - 8.5); p = 0.007. There was
also a significant reduction in mean body weight (241.9 ± 35.8 at baseline vs. 217.1
± 34.2 lbs at follow-up; p = 0.001), and mean body mass index (34.9 ± 4.5 vs. 31.1
± 3.7; p = 0.001). Only one patient experienced side effects as one episode of severe
nausea with Liraglutide that resolved when switched to Semaglutide. No infectious
complications (including urinary tract or genital mycotic infections) were observed.
Conclusions
In this limited case series, combination therapy with GLP-1 RA and SGLT-2i was well
tolerated in heart transplant patients and associated with favorable results in insulin
requirement, hemoglobin A1c, and body weight.
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© 2020 Published by Elsevier Inc.
