Multifaceted Therapy Interventions Suggested for Patients with Diabetes, ASCVD

Christopher B. Granger, MD

New research found more than one-third of patients with type 2 diabetes (T2D) and atherosclerotic cardiovascular disease (ASCVD) in a large cohort were receiving none of the 3 evidence-based therapies associated with significant cardiovascular benefit, including lipid-, blood pressure-, and glucose-lowering pharmacotherapy.

The therapies defined in the study included high-intensity statins (atorvastatin 40 - 80 mg or rosuvastatin 20 - 40 mg), angiotensin-converting enzyme inhibitors (ACEI) or angiotensin-receptor blockers (ARB), and sodium glucose cotransporter-2 inhibitors (SGLT2I) or glucagon-like peptide-1 receptor agonists (GLP-1 RA).

Additional findings show fewer than 1 in 20 patients were receiving all 3 therapies, only one-quarter of patients were prescribed a high-intensity statin, and less than half were prescribed an ACEI or ARB.

Study author Christopher B. Granger, MD, Duke Clinical Research Institute noted this new data helped “amplify the need to close these critical gaps between evidence generation and clinical practice for most patients in the US with diabetes and ASCVD.”

The multicenter cohort study used data from the US National Patient-Centered Clinical Research Network (PCORnet). The study occurred between January 2018 - December 2018 and patients ≥18 years with evidence of diabetes and ASCVD were included.

They defined ASCVD as patients with coronary artery disease, peripheral arterial disease, or cerebrovascular disease. Demographic data including race and ethnicity were included in the analysis, as were comorbid conditions, active smoking status, and laboratory results, including estimated glomerular filtration rate (eGFR) and hemoglobin A1c (HbA1c).

Data from 12 health systems and 16 data marts were analyzed from September 2020 - January 2021. Of a total of 324,706 patients included in the analysis, the overall mean age was 68.1 years, 144,169 (44.4%) were women, and 59.124 (18.2%) were Black.

Moreover, coronary artery disease was present in 237,012 patients (73.0%), while 60,125 patients (18.5%) had cerebrovascular disease, and 151,709 patients (46.7%) had peripheral arterial disease.

Among the 205,885 patients with specialized visit data, 17,971 patients (8.7%) visited an endocrinologist, 54,330 patients (26.4%) visited a cardiologist, and 154,078 (74.8%) visited a primary care physician.

Investigators further highlighted that although 190,346 patients (58.6%) were prescribed a statin, only 87,160 (26.8%) of patients were prescribed a high-intensity statin:

• 147,762 patients (45.5%) were prescribed a ACEI or ARB
• 12,724 patients (3.9%) were prescribed a GLP-1 RA
• 8989 patients (2.8%) were prescribed an SGLT2I

Overall, data show 14,918 patients (4.6%) were prescribed all 3 classes, compared to 138,173 patients (42.6%) who were prescribed none.

Further comparisons to the overall cohort show those prescribed a high-intensity statin were more likely to:

• be male (59.9%; 95% CI, 59.6% - 60.3% versus 55.6%; 95% CI, 55.4% - 55.8%)
• have coronary atherscelrotic disease (79.9%; 95% CI, 79.7% - 80.2% versus 73.0%; 95% CI, 72.8% - 73.3%)
• have seen a cardiologist (40.0%; 95% CI, 39.6% - 40.4% versus 26.4%; 95% CI, 26.2% - 26.6%)

"These data suggest that previously described gaps in the use of evidence-based therapies for individuals with diabetes and ASCVD in selected environments extend to this large, distributed network of health systems across the US," Granger wrote.

The study, “Use of Lipid-, Blood Pressure–, and Glucose-Lowering Pharmacotherapy in Patients With Type 2 Diabetes and Atherosclerotic Cardiovascular Disease,” was published in JAMA Network Open.