Patients with type 2 diabetes and CVD may receive suboptimal treatment
medwireNews: Specialist physicians and antidiabetic medications reported to confer cardiovascular benefit are being underutilized by patients with type 2 diabetes and cardiovascular disease (CVD), US study data show.
Kevin Pantalone (Cleveland Clinic, Ohio) and colleagues found that among more than 40,000 patients with type 2 diabetes and CVD, 82% did not see an endocrinologist during a 1-year observation period and 62% did not see a cardiologist.
Furthermore, only 4.1% were using glucagon-like peptide (GLP)-1 receptor agonists and just 2.5% were using sodium–glucose cotransporter (SGLT)-2 inhibitors, both of which are reported to reduce cardiovascular risk compared with placebo. The corresponding rates of use among more than 50,000 patients without CVD were significantly higher, at 5.4% and 4.1%.
In total, the study included 95,569 adults with type 2 diabetes who were seen at the Cleveland Clinic between 2005 and 2016. Of these, 40,910 (42.8%) had established CVD.
The researchers report in Cardiovascular Diabetology that patients with CVD were significantly older than those without CVD (median age 69.1 vs 58.2 years), more often male (53.8 vs 42.6%), and significantly more likely to have Medicare insurance (69.4 vs 35.3%), but significantly less likely to be obese (65.8 vs 69.9%) or a current smoker (10.5 vs 11.5%).
The patients with versus without CVD had a significantly higher prevalence of hypertension (93.5 vs 74.4%) and hyperlipidemia (84.7 vs 66.5%), and patients with CVD also had a greater number of diabetes complications, with 65.0% having a diabetes complications severity index score of 3 or higher, compared with 10.3% of those without CVD.
Antidiabetic medication use also differed significantly between the two groups, with 36.4%, 16.1%, and 5.6% of patients with CVD receiving one, two, or three or more oral antidiabetic drugs, compared with a respective 42.4%, 17.4% and 7.3% of those without CVD. The corresponding rates of insulin use were 18.3% versus 11.4%.
Approximately 75% of patients in both groups had at least one visit with a primary care provider during 2016, but only 18–19% saw an endocrinologist.
The researchers suggest that the low rate of specialist care “may be contributing to the low rates of SGLT-2 [inhibitor] and GLP-1 [receptor agonist] therapy utilization observed not only in the population of patients with established CVD, but also in those without established CVD.”
They add: “Improving access to both endocrinologists and cardiologists for patients with type 2 diabetes and established CVD would seem important given our observations that the therapies that have demonstrated CV benefit are not being readily used in this population, and given the ever-increasing complexity of diabetes and [cardiovascular]-risk management overall.”
Pantalone and team do, however, note that the three cardiovascular outcome trials showing the benefits of empagliflozin, canagliflozin, and liraglutide were likely published too late “to have achieved broad adaptation and acceptance by prescribers during the study period of 2016.”
They conclude: “The potential clinical impact of the new guidelines [incorporating data from these trials] remains to be seen and will hopefully be evaluated in the future with additional real-world data.”
By Laura Cowen
medwireNews is an independent medical news service provided by Springer Healthcare. © 2018 Springer Healthcare part of the Springer Nature group
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