Management of High Cardiovascular Risk in Diabetic Patients: Focus on Low Density Lipoprotein Cholesterol and Appropriate Drug Use in General Practice

Abstract

This study aimed to evaluate the management of high cardiovascular risk (CVr) in the patients with diabetes by exploring the prescribing behavior in a setting of general practitioners (GPs). A retrospective cohort study was carried out using the data recorded between 2018 and 2020 in the clinical database of 10 GPs. Diabetes was defined using the International Classification of Diseases (ICD-9-CM) coding (250*) or using the laboratory parameters (hyperglycemia condition: ≥126 mg/dL). A cohort was described stratifying by demographic, clinical and therapeutic characteristics, and laboratory tests. Both the CVr and statin prescriptions were evaluated; adherence to statin therapy (medication possession ratio, MPR ≥ 80) was calculated in accordance with the low-density lipoprotein cholesterol (LDL-C) target. The multivariate logistic regression models with adjusted odds ratios (ORs) and the corresponding 95% Confidence Intervals (CIs) were calculated to identify the predictors of lipid modifying agents use and achieved target therapy; moreover, glucose-lowering drugs use was evaluated. Out of 13,206 people screened, 1,851 (14.0%) patients were affected by diabetes mellitus (DM), and 1,373 were identified at high/very high CVr. Of them, 1,158 (84.3%) had at least one measurement of LDL-C, and 808 (58.8%) received a prescription with at least one lipid-lowering drug (LLD). The patients at high/very high CVr treated or not treated with LLD, reached the LDL-C target in 24.0 and 10.3%, respectively (p < 0.001). Furthermore, 34.6% of patients treated with high intensity LLDs and adherent to therapy showed the LDL-C values below the therapeutic target. Out of 1,373 patients at high/very high CVr, 958 (69.8%) had at least one prescription of glucose-lowering drugs. Of them, 52.0% (n = 498) were prescribed not in agreement with the current guidelines. More specifically, 392 patients (40.9%) were treated with metformin only, while the remaining 106 (11.1%) were treated with metformin together with hypoglycemic agents other than glucagon-like peptide-1 receptor agonists (GLP1-RA) or sodium-glucose-transporter 2 (SGLT2) inhibitors. Our results suggest the urgent need to improve the management of patients with diabetes at high and very high CVr in the real life, to reduce the burden of diabetes on the health system.

Diabetic dyslipidemia impairs coronary collateral formation: An update

“…Cholesterol-lowering therapy is the mainstay in primary and secondary prevention of cardiovascular diseases ( 69 , 70 ). Statins effectively decrease serum LDL-C and sdLDL-C while increasing HDL-C levels and reduce the susceptibility of apo B of LDL to undergo oxidation and glycation.…”

Pharmacological Treatment of Diabetic and Non-Diabetic Patients With Coronary Artery Disease in the Real World of General Practice

“…The complexity of this clinical scenario makes generally very hard the appropriateness of the pharmacological treatment in the real world, as previously shown ( Squadrito et al, 2020 ; Rottura et al, 2021 ). An optimal management of diabetes, hypertension, and other cardiovascular risk factors in patients with CAD is essential, especially in the elderly.…”

“…Any variation within defined ranges is investigated and back-submitted to each participating GP, in order to receive immediate feedback about data quality and completeness. Data quality and completeness have been already validated in previous drug-utilization studies ( Barbieri et al, 2020 ; Squadrito et al, 2020 ; Rottura et al, 2021 ). The database contains the information recorded during 2018–2020 on each GP’s patient, aged at least 18 years old, including age, sex, height, weight and body mass index (BMI), systolic blood pressure (SBP) and diastolic blood pressure (DBP), information on lifestyle (alcohol, smoke), and data on diagnostic laboratory exams including fasting plasma glucose (FPG), glycated haemoglobin (HbA1c), and lipid profile.…”

“…The clinical correlation of this complex pathophysiology is that patients generally require a close monitoring of the disease and an accurate and intensive pharmacological treatment, as specifically detailed in the recommendations issued by the European Society of Cardiology ( Neumann et al, 2020 ). However, the implementation of the guidelines in the real world is not easy and it is frequently hindered by the presence of concomitant comorbidities, as previously reported ( Rottura et al, 2021 ).…”

Chronic kidney disease progression in diabetic patients: Real world data in general practice

“…In fact, SGLT-2 inhibitors are one of the main classes of drugs recommended by the ADA guidelines as the first-line treatment for glycemic control in patients with CVD and CKD, in replacement of metformin which remains the main oral hypoglycemic agent recommended to patients with diabetes [ 31 ]. However, several studies have shown poor under-prescription of SGLT-2 in clinical practice [ 32 , 33 ]. Metformin prescriptions should be evaluated taking into account the renal function status of the patients.…”