Welcome to PracticeUpdate! We hope you are enjoying access to a selection of our top-read and most recent articles. Please register today for a free account and gain full access to all of our expert-selected content.
Already Have An Account? Log in Now
Impact of Guideline-Directed Statin Intervention for Primary Prevention in Patients With Diabetes
abstract
This abstract is available on the publisher's site.
Access this abstract nowOBJECTIVE
We examined guideline-directed statin intensity (GDSI) use and atherosclerotic cardiovascular disease (ASCVD) outcomes in patients with diabetes across a contemporary health care system.
RESEARCH DESIGN AND METHODS
Patients without preexisting ASCVD were categorized by diabetes status and 10-year ASCVD risk (borderline [5-7.4%], intermediate [7.5-19.9%], high [≥20%]). Mean ±SD time to start of or change to GDSI was calculated. Incident ASCVD and all-cause mortality association, stratified by ASCVD risk, was calculated using Cox regression.
RESULTS
Among 282,298 patients, 28,807 (10.2%) had diabetes and 253,491 (89.8%) did not. Only two-thirds of intermediate- and high-risk patients with diabetes were receiving GDSI therapy at 5-year follow-up. In fully adjusted models, patients with diabetes not taking a statin (vs. GDSI) had a significantly higher risk of stroke and mortality in the intermediate- and high-risk groups (hazard ratio for mortality 1.81 [95% CI 1.58-2.07] vs. 1.41 [1.26-1.57]; P for interaction < 0.01).
CONCLUSIONS
Significant gaps remain in GDSI use for high-risk patients with diabetes, conferring an increased risk of ASCVD outcomes and all-cause mortality.
Additional Info
Impact of Guideline-Directed Statin Intervention for Primary Prevention in Patients With Diabetes
Diabetes Care 2023 Dec 01;46(12)2273-2277, P Muluk, J Zhu, F Thoma, E Hay, O Marroquin, A Makani, A Aiyer, K Nasir, M Gulati, MD Shapiro, S Mulukutla, A SaeedFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
The efficacy and safety of HMG-CoA reductase inhibitors (statins) as the drug of choice for lowering LDL-C in primary and secondary prevention of cardiovascular (CV) events and reducing mortality has been well-established for more than 35 years. Of the seven statins, six have been available in generic form for many years. Yet, it is astounding that such a proven, inexpensive, and highly effective therapy remains underutilized, even in those with a high risk of CV events, established CVD, multiple risk factors, and diabetes. In a recent survey across 12 healthcare systems with US adults (N = 282,298) with established ASCVD, <60% were taking any statin, and <30% were taking high-intensity statins, as recommended by current guidelines.1 It was recommended that patients with diabetes aged between 40 and 75 years be treated with moderate-intensive statins for primary prevention, in addition to lifestyle therapy; yet only 37% were on statins.2 Moreover, as reported in the NHANES data (2013–2020), the use of statin in the intermediate- and high-risk categories of primary prevention (10-year calculated risk, 7.5%–19.9% and ≥20%, respectively) was 30% to 40%, with the lowest rates in Black and Hispanic individuals at <25%, likely due to lack of access to care.3
In this context, the current study by Muluk et al is a stark reminder of not only the under-prescribing and under-intensification of statin therapy but also the adverse long-term consequences in the specific cohort of individuals with diabetes and intermediate or high risk of ASCVD events, as defined above. Using a large US adult population dataset, in which 28,807 individuals had diabetes (mean age, 57.5 years), they confirmed a marked underutilization of the statins. After a 6-year follow-up of this cohort, only around 50% were on optimal statin dose. The patients not treated on optimal statin dose had a near doubling of stroke and total mortality, after multivariate analyses, compared with those who initiated and remained on guideline-directed use of statins. Of note, and not surprisingly, there was still a residual risk of increased ASCVD events, compared with the non-diabetic cohort. It should be noted that mean LDL-C was still elevated at 104 mg/dL in patients on statin treatment, raising the question about adherence. Also, 87% of this cohort was White, a reminder that the overall outcome could possibly be worse in certain ethnic and racial groups, likely due to even lower utilization of statins, due to non-initiation or poor adherence.
Finally, there remains a large educational gap among people with hypercholesterolemia regarding the awareness of high risk, reasons for lipid treatment, and goals of therapy, as reported in an ongoing registry of >5000 people with ASCVD in the US, including those with diabetes.4 Obviously, more educational effort is needed. In a minority of patients with statin intolerance to the desired dose, several non-statin options with proven CV benefits (ezetimibe, PCSK9 inhibitors, bempedoic acid) are currently available and can be added to the maximum tolerated statin dose for those with high-risk.
References