By Dr Paul Maggiore, Cardiologist, and Dr Joey Kaye, Endocrinologist, Osborne Park
Cardiovascular disease remains the primary cause of premature death in Australian adults.
Patients with metabolic dysfunction – such as diabetes or obesity – and renal disease remain exposed to elevated risk.
Patients with metabolic dysfunction – such as diabetes or obesity – and renal disease remain exposed to elevated risk.
The underlying complex pathophysiology is referred to as the cardio-metabolic renal syndrome (CMRS). Excess adiposity has multiple negative physiological effects including insulin resistance, inflammation and endothelial dysfunction.
The result is an accelerated risk of cardiovascular events, heart failure, kidney failure, and premature mortality. Patients often require recurrent hospitalisations, with reduced quality of life, while the healthcare system bears the burden of chronic disease management.
Evolving therapeutic strategies
Whilst insulin resistance is a feature of CMRS, traditional glucose-centric treatment approaches have been largely ineffective at improving outcomes.
New therapies initially developed for diabetes – SGLT2 inhibitors and incretin-based agents – are demonstrating cardiac and renal benefits, largely independent of glucose lowering.
CMRS management is shifting to addressing broader cardio-metabolic and renal risks, though is limited by differing treatment priorities across specialties as well as complexities of Australia’s Pharmaceutical Benefits Scheme (PBS) prescribing restrictions.
Sodium-glucose co-transporter-2 (SGLT2) inhibitors have both glycemic and non-glycemic effects, with resultant cardiovascular and renal benefits.
Heart failure hospitalisations are lower, CKD progression delayed, and survival improved. This has led to widespread use and incorporation into multiple guidelines.
However, in practice, their use is constrained by competing priorities across specialties, for example heart failure benefits vs renoprotective effects vs glucose lowering, complex PBS eligibility criteria, important drug-interactions and side-effects such as hypoglycaemia with insulin, electrolyte disturbance and dehydration with diuretics, limited evidence for use in type 1 diabetes, limited trial evidence for efficacy and safety of specific combinations like SGLT2 inhibitors and GLP-1 analogues.
Key messages
- Cardiovascular disease remains the leading cause of premature death in Australia
- Despite effective therapies, barriers to treatment remain
- A multidisciplinary model can improve outcomes.
Incretin-based therapies
Emerging evidence suggests glucagon-like peptide-1 receptor agonists (GLP-1RAs) reduce major adverse cardiovascular events, promote weight loss, and may offer renal protection.
RELATED: Juggling renal and CVD management
However, PBS restrictions limit access to those with type 2 diabetes, excluding many with weight-related co-morbidities who might benefit from these therapies based on cardiovascular or renal indications alone.
Furthermore, shortages of GLP-1RAs, driven in part by off-label use for obesity, have created inequities in access. As highlighted with SGLT2i’s above, competing priorities across specialities may limit adaptation of incretin-based therapies.
Limitations of current approaches
Despite the availability of new and effective therapies, several barriers hinder optimal CMRS management in Australia, including:
- Fragmented care across specialties – patients with CMRS ideally require input from GP’s, cardiologists, nephrologists, endocrinologists, hepatologists and various allied health professionals. However, siloed care often results in delays, inconsistent prescribing practices, and missed opportunities for holistic management.
- Competing treatment priorities – clinicians may focus on different aspects of CMRS management, leading to therapeutic inertia, adverse drug effects or conflicting recommendations.
- PBS restrictions, access, supply and evidence limitations – Australia’s PBS listing criteria, while based on best available evidence and cost considerations, still creates barriers to early intervention and adds to the complexities of clinical decision making and individualising care.
- Allied health underutilisation – while GPs and specialists focus on medical management, allied health professionals, including dietitians, exercise physiologists, diabetes educators, and pharmacists, play a crucial role in lifestyle modification, medication adherence, and patient education. However, access to these services is often limited by Medicare restrictions, funding constraints and a system that rarely provides all the care in one place.
Coordinated, multidisciplinary approach
Reducing cardiovascular disease and premature mortality in the setting of a complex condition such as the cardio-metabolic renal syndrome, requires dedicated management strategies across multiple specialties.
RELATED: Managing chronic kidney disease in general practice – myths and the 3 Ps
To overcome the barriers outlined in this article, a shift towards multidisciplinary, patient-centred and coordinated care is needed.
A cardiometabolic clinic, which delivers evidence-based therapy whilst integrating GPs, specialists and allied health professionals in one service, is a proposed solution to improving outcomes.
Author competing interests – both authors have served on advisory boards and received honoraria for education events regarding therapeutics referred to in this article
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