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Pharmacotherapy in Patients With Diabetes and ASCVD
Quick Takes
- This cohort study reports that more than one-third of patients were receiving none of the three key evidence-based therapies associated with significant cardiovascular benefit, and fewer than 1 in 20 patients were receiving all three.
- It is especially troubling that only one-quarter were prescribed a high-intensity statin and less than one-half an ACEI or ARB, treatments that are now generic and well tolerated.
- The study findings underscore the need to eliminate critical gaps between evidence generation and clinical practice for most patients in the US with diabetes and ASCVD.
Study Questions:
What is the use of evidence-based cardiovascular preventive therapies in a broad US population with diabetes and atherosclerotic cardiovascular disease (ASCVD)?
Methods:
The investigators conducted a multicenter cohort study using health system-level aggregated data within the National Patient-Centered Clinical Research Network, including 12 health systems. Participants included patients with diabetes and established ASCVD (i.e., coronary artery disease, cerebrovascular disease, and peripheral artery disease) between January 1–December 31, 2018. Data were analyzed from September 2020 until January 2021. Patient characteristics by prescription of any of the following key evidence-based therapies—high-intensity statin, angiotensin-converting enzyme inhibitor (ACEI) or angiotensin-receptor blocker (ARB) and sodium glucose cotransporter-2 inhibitors (SGLT2I) or glucagon-like peptide-1 receptor agonist (GLP-1RA)—were assessed. Statistical comparison between treatment groups prescribed each medication of interest (i.e., high-intensity statin, ACEI or ARB, and SGLT2I and/or GLP-1RA) was not possible, given the lack of mutual exclusivity; however, descriptive comparisons were made on the basis of clinically relevant differences and narrow 95% confidence intervals (CIs), generated using pooled standard deviations (SDs) for continuous variables and assumed binomial proportions for categorical variables.
Results:
The overall cohort included 324,706 patients, with a mean (SD) age of 68.1 (12.2) years and 144,169 (44.4%) women and 180,537 (55.6%) men. A total of 59,124 patients (18.2%) were Black, and 41,470 patients (12.8%) were Latinx. Among 205,885 patients with specialized visit data from the prior year, 17,971 patients (8.7%) visited an endocrinologist, 54,330 patients (26.4%) visited a cardiologist, and 154,078 patients (74.8%) visited a primary care physician. Overall, 190,277 patients (58.6%) were prescribed a statin, but only 88,426 patients (26.8%) were prescribed a high-intensity statin; 147,762 patients (45.5%) were prescribed an ACEI or ARB, 12,724 patients (3.9%) were prescribed a GLP-1RA, and 8,989 patients (2.8%) were prescribed an SGLT2I. Overall, 14,918 patients (4.6%) were prescribed all three classes of therapies, and 138,173 patients (42.6%) were prescribed none. Patients who were prescribed a high-intensity statin were more likely to be men (59.9% [95% CI, 59.6%-60.3%] of patients vs. 55.6% [95% CI, 55.4%-55.8%] of patients), have coronary atherosclerotic disease (79.9% [95% CI, 79.7%-80.2%] of patients vs. 73.0% [95% CI, 72.8%-73.3%] of patients), and more likely to have seen a cardiologist (40.0% [95% CI, 39.6%-40.4%] of patients vs. 26.4% [95% CI, 26.2%-26.6%] of patients).
Conclusions:
The authors concluded that in this cohort of patients with diabetes and ASCVD, fewer than 1 in 20 patients were prescribed all three evidence-based therapies, defined as a high-intensity statin, either an ACEI or ARB, and either an SGLT2I and/or a GLP-1RA.
Perspective:
This cohort study of patients across multiple health systems reports that more than one-third of patients were receiving none of the three key evidence-based therapies (a high-intensity statin, ACEI or ARB, and an SGLT2I and/or a GLP-1RA) associated with significant cardiovascular benefit, and fewer than 1 in 20 patients were receiving all three. It is especially troubling that only one-quarter were prescribed a high-intensity statin and less than one-half an ACEI or ARB, treatments that are now generic and well tolerated. The study findings underscore the need to eliminate critical gaps between evidence generation and clinical practice for most patients in the United States with diabetes and ASCVD and highlights the role of cardiologists and primary care physicians to assist with adoption of evidence-based therapies for type 2 diabetes and ASCVD including SGLT2I or GLP-1RAs.
Clinical Topics: Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Dyslipidemia, Prevention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Lipid Metabolism, Nonstatins, Novel Agents, Statins
Keywords: Angiotensin Receptor Antagonists, Angiotensin-Converting Enzyme Inhibitors, Atherosclerosis, Blood Pressure, Cardiologists, Cerebrovascular Disorders, Coronary Artery Disease, Diabetes Mellitus, Type 2, Glucagon-Like Peptide-1 Receptor, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Lipids, Metabolic Syndrome, Peripheral Arterial Disease, Physicians, Primary Care, Prescriptions, Primary Prevention, Sodium-Glucose Transporter 2 Inhibitors, Vascular Diseases
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