The under-use of statin in type 2 diabetic patients attending diabetic clinics in Italy

Trends and Gaps in Statin Use for Cardiovascular Disease Prevention in Type 2 Diabetes: A Real-World Study in Shanghai, China

BACKGROUND

Cardiovascular disease (CVD) is the major cause of death among persons with diabetes. As the preventative use of statin has been proved to reduce CVD risks, understanding the current status and the trend in statin use is crucial to improve clinical treatment strategies.

OBJECTIVE

Our study aimed to answer the question of what were the status and trend of statin use in Shanghai, China.

METHODS

Our study estimated statin use and trends from 2015 to 2021 among 702 727 patients with type 2 diabetes mellitus (T2DM) based on electronic health records from the Shanghai Hospital Link Database. Patients were grouped according to the presence of CVDs, tested separately for statin primary and secondary prevention use, and stratified by age and sex.

RESULTS

In the study population, 221 127 patients (31.5%) received statin therapy, and among patients with CVD, 157 622 patients (51.62%) received statin therapy for secondary prevention, but only 15% of patients received statins for primary prevention. The trend in the use of statins was still on the rise from 28.3% in 2015. Statin use increased with age (18-39 years, 14.0%; 40-59 years, 26.8%; 60-74 years, 33.35%; and 75 and over, 36.1%), and women (29.7%, n = 93 977) were less likely to receive statin therapy compared to men (32.9%, n = 127 150).

CONCLUSION

Despite the rise in statin use in T2DM in recent decades, a large proportion of subjects with T2DM did not receive statin therapy.

Cholesterol lowering therapies and achievement of targets for primary and secondary cardiovascular prevention in type 2 diabetes: unmet needs in a large population of outpatients at specialist clinics

BACKGROUND

The well-established benefit of Low-Dense-Lipoprotein-cholesterol (LDL-c) lowering treatments (LLTs) has led clinical guidelines to lower the cardiovascular prevention targets. Despite this, there is a surprising scarcity of real-world studies (RWS) evaluating whether recommendations are applied in the routine clinical management of patients with type 2 diabetes (T2D). We therefore evaluated, in a large RWS, the pattern of LLTs use and the achievement of LDL-c targets in patients with T2D in Italian diabetes specialist clinics.

METHODS

We collected data from 46 diabetes outpatient clinics (following 281,381 subjects), including 104,726 T2D patients, for whom use of LLTs between 2015 and 2016 was ascertained. We used the 2016 and 2019 European Atherosclerosis Society and European Society of Cardiology (EAS-ESC) guidelines to define cardiovascular risk categories, LDL-c targets, and the expected LDL-c reduction and cardiovascular benefit achievable with LLT intensification.

RESULTS

63,861 patients (61.0%) were on statin therapy, 9.2% of whom were also on ezetimibe. Almost all subjects were at high (29.3%) or very high (70.4%) cardiovascular risk, including 17% being in secondary prevention. Among very high-risk patients, 35% were not on statin despite half of them had LDL-c > 2.6 mmol/l, and only 15% of those on statins had LDL-c < 1.4 mmol/l. 83% of subjects in secondary prevention were on a statin, but half of them had LDL-c > 1.8 mmol/l. Overall, 35% and 14% of subjects achieved the LDL-c targets as suggested by 2016 and 2019 EAS-ESC Guidelines, respectively. Based on anticipated response to treatment, we estimated that 38% of the entire population would require high-intensity-statin (HI-statin), 27% a combination of HI-statin plus ezetimibe, and 27% the addition of proprotein-convertase-subtilisin/kexin-9 (PCSK9) inhibitors. These LLT intensifications would reduce the incidence of cardiovascular events by 32%, from 23.511 to 16.022 events per 100.000 patients/10-years (incidence-rate-ratio 0.68; 95% C.I 0.67-0.70, p < 0.001).

CONCLUSIONS

Despite the increase in use of LLT in T2D over the last decades, a large proportion of subjects with T2D did not achieve their LDL-c targets. Given the very high cardiovascular risk of these patients, improving LLT is expected to have a dramatic impact on cardiovascular event prevention.

Health care delivery in type 2 diabetes. A survey in an Italian primary care practice

AIMS

Evidence-based guidelines provide targets and performance measures for the treatment of type 2 diabetic patients but a wide gap separates guidelines-driven recommendations from their clinical application, a phenomenon hindering the transfer of proven benefits to affected populations.

METHODS

We analyzed the quality of diabetic care delivered by 8 general practitioners joint in a group practice attending 571 diabetic patients (5.6% of the total enlisted subjects) by assessing process (% of HbA1c, SBP and LDL-C determinations) and intermediate outcome (% of patients with HbA1c <7% vs >8%, systolic BP <130 mmHg vs >140 mmHg, LDL-cholesterol <100 mg/dL vs >130 mg/dL) indicators.

RESULTS

HbA1c was at target in 49% of patients and >8% in 22%; SBP and LDL-C determination was available in about two-thirds of patients, only a minority at target for SBP and LDL-C. Antihyperglycemic and antihypertensive treatment was prescribed in most patients but only a third was on statins. During the post-evaluation phase, percentages of patients with HbA1c >8%, SBP < 130 mmHg and LDL-C < 100 mg/dL and the drug prescription pattern did not change.

CONCLUSIONS

Several weaknesses affect primary care delivery to type 2 diabetic patients and efforts are needed to improve the management of this high-risk group.

Kidney dysfunction and related cardiovascular risk factors among patients with type 2 diabetes

BACKGROUND

Kidney dysfunction is a strong predictor of end-stage renal disease and cardiovascular (CV) events. The main goal was to study the clinical correlates of diabetic kidney disease in a large cohort of patients with type 2 diabetes mellitus (T2DM) attending 236 Diabetes Clinics in Italy.

METHODS

Clinical data of 120 903 patients were extracted from electronic medical records by means of an ad hoc-developed software. Estimated glomerular filtration rate (GFR) and increased urinary albumin excretion were considered. Factors associated with the presence of albuminuria only, GFR < 60 mL/min/1.73 m(2) only or both conditions were evaluated through multivariate analysis.

RESULTS

Mean age of the patients was 66.6 ± 11.0 years, 58.1% were male and mean duration of diabetes was 11.1 ± 9.4 years. The frequency of albuminuria, low GFR and both albuminuria and low GFR was 36.0, 23.5 and 12.2%, respectively. Glycaemic control was related to albuminuria more than to low GFR, while systolic and pulse pressure showed a trend towards higher values in patients with normal kidney function compared with those with both albuminuria and low GFR. Multivariate logistic analysis showed that age and duration of disease influenced both features of kidney dysfunction. Male gender was associated with an increased risk of albuminuria. Higher systolic blood pressure levels were associated with albuminuria, with a 4% increased risk of simultaneously having albuminuria and low GFR for each 5 mmHg increase.

CONCLUSIONS

In this large cohort of patients with T2DM, reduced GFR and increased albuminuria showed, at least in part, different clinical correlates. A worse CV risk profile is associated with albuminuria more than with isolated low GFR.

The impact of cost-sharing schemes on drug compliance in Italy: evidence based on quantile regression

OBJECTIVES

In this article we investigate the causal effect of cost-sharing schemes on compliance with statins in a quantile regression framework.

METHODS

We use the health search CSD-LPD data, a longitudinal observational dataset containing computer-based patient records collected by Italian general practitioners. We exploit a series of natural experiments referring to several introductions of co-payment schemes in some of the Italian regions between 2000 and 2009. We adopt an extended difference-in-differences approach to provide quantile estimates of the impact of co-payments on compliance.

RESULTS

We find that (i) introduction of co-payments hurts residents of regions with worse quality and provision of health care; (ii) within these regions, co-payments were particularly harmful for high compliers; (iii) gender, clinical history and geographic residence are important determinants of compliance among poor compliers; (iv) compliance decreases with the potency and dosage of statins, particularly for poor compliers.

CONCLUSIONS

In the presence of inefficient health-care provision, co-payments are harmful for drug compliance, and this is especially true for patients who are originally good compliers.

Monitoring the use of lipid-lowering medication among persons with newly diagnosed diabetes: a nationwide register-based study

OBJECTIVES

To develop a register-based monitoring system to provide information on the use of lipid-lowering medication among persons with diabetes in different patient groups and by socioeconomic position.

DESIGN

Longitudinal and register-based, before and after diabetes diagnosis.

SETTING

Finnish population.

PARTICIPANTS

A total of 121 053 persons aged 30-79 years with a new diagnosis of diabetes during 2000-2006. The annual cohorts were divided at the time of diabetes diagnosis by coronary heart disease (CHD) status.

PRIMARY AND SECONDARY OUTCOME MEASURES

Lipid-lowering medication purchases after diabetes diagnosis and prior to the diagnosis.

RESULTS

According to the health insurance reimbursement data the use of lipid-lowering medication advanced rapidly among people with diabetes in the early 2000s in Finland. Of the patients diagnosed with diabetes in 2000 only one-fourth used lipid-lowering medication in 6-12 months after their diagnosis. For those diagnosed in 2006, the utilization rate was 46%. Among those with a history of CHD the use of medication was markedly higher; 51-58% in 2000 and 77-79% in 2006. Taking into account the increasing trend and measuring the independent effect of the diagnosis of diabetes on lipid-lowering medication, setting the diagnosis increased the use by 10-50%. Despite increasing overall utilisation rates, socioeconomic difference in the use of lipid-lowering medication remained throughout the study period. In particular, the lowest income quintile differed from other income groups and in 2006 its use of lipid-lowering medication remained approximately 10% points lower compared with the overall level.

CONCLUSIONS

The lipid-lowering medication is being applied in an increasing population of new diabetes cases; however, modelling the independent effect of the diagnosis of diabetes on lipid-lowering medication shows that the diagnosis increased use, but did not abolish socioeconomic differences.

Ezetimibe + simvastatin versus doubling the dose of simvastatin in high cardiovascular risk diabetics: a multicenter, randomized trial (the LEAD study)

BACKGROUND

The primary goal of therapy in patients with hypercholesterolemia and coronary heart disease (CHD) is reducing low-density lipoprotein cholesterol (LDL-C). This was a multicenter, randomized, double-blind, double-dummy study in patients with type 2 diabetes mellitus (T2DM).

METHODS

Adult patients with T2DM and CHD (N = 93) on a stable dose of simvastatin 20 mg with LDL-C >or= 2.6 mmol/L (100 mg/dL) and

RESULTS

EZ + simva 10/20 mg produced a significantly greater change from treated baseline compared with simvastatin 40 mg in LDL-C (-32.2% vs -20.8%; p < 0.01) and total cholesterol (-20.6% vs -13.2%; p < 0.01). A greater proportion of patients achieved LDL-C < 2.6 mmol/L with EZ + simva 10/20 mg than with simvastatin 40 mg, but this was not statistically significant (78.4% vs 60%; odds ratio = 2.81; p = 0.052). Changes in high-density lipoprotein cholesterol and triglycerides were similar between treatments. Both treatments were generally well-tolerated.

CONCLUSIONS

These results demonstrate that EZ + simva 10/20 mg may provide a superior alternative for LDL-C lowering vs doubling the dose of simvastatin to 40 mg in hyperlipidemic patients with T2DM and CHD. In addition, the combination therapy may provide an alternative treatment for patients who require further LDL-C reduction than they can achieve with simvastatin 20 mg alone.

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MESH Headings

• Aged
• Anticholesteremic Agents/administration & dosage
• Azetidines/administration & dosage
• Biomarkers/blood
• Blood Glucose/metabolism
• Cholesterol, HDL/blood
• Cholesterol, LDL/blood
• Coronary Disease/blood
• Coronary Disease/drug therapy
• Diabetes Mellitus, Type 2/blood
• Diabetes Mellitus, Type 2/drug therapy
• Double-Blind Method
• Drug Combinations
• Ezetimibe, Simvastatin Drug Combination
• Female
• Glycated Hemoglobin/metabolism
• Humans
• Hydroxymethylglutaryl-CoA Reductase Inhibitors/administration & dosage
• Hypercholesterolemia/blood
• Hypercholesterolemia/drug therapy
• Italy
• Male
• Middle Aged
• Odds Ratio
• Risk Assessment
• Risk Factors
• Simvastatin/administration & dosage
• Time Factors
• Treatment Outcome
• Triglycerides/blood

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Grants Collapse

Affiliation(s)

Gianluca Bardini Unit of Endocrinology, Department of Clinical Pathophysiology, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy
Carlo B Giorda Diabetes Unit ASL Turin 5 Chieri, Italy
Antonio E Pontiroli Univeristy of Milan, Milan, Italy and San Paolo Hospital, via A di Rudinì 8, 20142 Milan, Italy
Cristina Le Grazie Medical Director, MSD, Centro Direzionale Milano Due, Palazzo Borromini, 20090 Segrate Milano, Italy
Carlo M Rotella Unit of Endocrinology, Department of Clinical Pathophysiology, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy

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Assessing prescriptions for statins in ambulatory diabetic patients in the United States: a national, cross-sectional study

BACKGROUND

Diabetes mellitus affects >20 million people in the United States each year, and >4000 new cases are diagnosed daily.

OBJECTIVE

This study assessed the prescription of statin medications in the ambulatory setting in US diabetic patients.

METHODS

We used data from the 2002 through 2004 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. All ambulatory medical visits associated with a diabetes diagnosis by the International Classification of Diseases, Ninth Revision, Clinical Modification were included. Prescriptions for statin medications were determined by searching each ambulatory visit for relevant drug names (trade and generic). Demographic characteristics were assessed, including survey year, sex, age group, race, ethnicity, payment type, region of the country, and physician's specialty and degree. Analyses used sample weights to calculate national estimates.

RESULTS

From 2002 to 2004, 10,046 (unweighted) ambulatory visits were made by diabetic patients, representing a weighted national estimate of approximately 153 million visits. A statin prescription was associated with 21.1% of all diabetic visits and 14.1% of those without a hyperlipidemia-related diagnosis. Diabetic men were more likely than diabetic women to be given a prescription for a statin (odds ratio [OR], 1.38; 95% CI, 1.09-1.73). Compared with diabetic patients treated in 2002, those treated in 2003 and 2004 were more likely to be prescribed statin therapy (2003 OR, 1.51; 95% CI, 1.02-2.24; 2004 OR, 1.48; 95% CI, 1.03-2.15). Compared with diabetic patients aged 45 to 64 years, those in younger age groups were less likely to be given a statin prescription (1-24 years OR, 0.10; 95% CI, 0.01-0.84; 25-44 years OR, 0.48; 95% CI, 0.31-0.74), and those aged 65 to 74 years were more likely to be given a statin (OR, 1.38; 95% CI, 1.01-1.90). No differences were noted for diabetic patients aged > or = 75 years.

CONCLUSIONS

From 2002 through 2004, <25% of the ambulatory medical visits by diabetic patients in the United States were associated with a statin prescription. Male sex and age up to 75 years had an increased association with statin prescription. Additional study is anticipated to assess changes in statin use in diabetic patients in the United States as updated treatment guidelines are released.

The clinical reality of guidelines for primary prevention of cardiovascular disease in type 2 diabetes in Italy

INTRODUCTION AND AIM

Guidelines for cardiovascular prevention in diabetes have been issued by the national and international scientific societies. No audit as ever been performed to evaluate the implementation of these documents in clinical practice in Italy. The study evaluates the prevalence, treatment, and control of major cardiovascular risk factors in type 2 diabetic patients, to assess the clinical practice of primary cardiovascular prevention in type 2 diabetes.

PATIENTS AND METHODS

Two thousand four hundred and sixty-five men and women with type 2 diabetes, aged 50-75 and free of cardiovascular events were recruited on a consecutive basis at 10 hospital based outpatients diabetes clinics. Clinical variables were measured by standard protocol. Biochemical parameters were evaluated at each centre. The laboratories were monitored by an external quality control assessment in order to reach and maintain a standard of quality and traceability among the participating centres.

RESULTS

A minority of patients (5%) met the recommended targets for LDL cholesterol, blood pressure, glycated haemoglobin and smoking habits, whereas the vast majority (66%) had unsatisfactory control of three or more of the above. Achievement of desirable control of risk factors differed according to gender and known diabetes duration. Lipid lowering and, to a lesser extent, antihypertensive medications were under-used and their titration insufficiently target-driven. Prophylactic use of antiplatelet agents was scarce, only one out of five patients was treated independent of absolute cardiovascular risk.

CONCLUSION

In clinical practice there is poor adherence to national and international guidelines for primary cardiovascular prevention in type 2 diabetes in Italy. The study underlines the great potential for prevention, particularly in women and in high-risk patients.

Atorvastatin: pharmacological characteristics and lipid-lowering effects

By inhibiting 3-hydroxy-3-methylglutaryl coenzyme-A (HMG-CoA) reductase, the statins reduce hepatocyte cholesterol levels, which results in up-regulation of low-density lipoprotein (LDL) receptors and, consequently, increased clearance of LDL-cholesterol (LDL-C) from the plasma. Structural differences among the available statins partially account for differences in their capacity to inhibit HMG-CoA reductase and their lipid-lowering efficacy, and for variability in other biological properties, such as their pharmacokinetic characteristics and their tolerability and propensity to interact with other drugs. In terms of pharmacokinetic properties, the synthetic (type II) HMG-CoA analogue atorvastatin exhibits a number of characteristics that are different to those of other members of the class, including a longer plasma half-life and metabolites that have an ability to inhibit HMG-CoA reductase equivalent to that of the parent drug. These characteristics are postulated to be responsible for a more prolonged inhibition of HMG-CoA reductase, and, hence, for the greater efficacy of atorvastatin in decreasing total and LDL-C levels relative to other statins (with the exception of rosuvastatin) noted in clinical trials in patients with dyslipidaemias. From the available clinical trial data, atorvastatin can be considered one of the most effective statins, not only by taking into account its effects on LDL-C and ability to meet recommended treatment guidelines for this parameter, but also its effect on triglyceride levels and capacity to modify lipoprotein composition in a non-atherogenic manner. Clinical studies with atorvastatin have also shed some light on the question as to whether it is better to focus on obtaining maximal reduction of LDL-C in at-risk patients or on cardiovascular outcomes. Cardiovascular event rates have been shown to be substantially lower in patients attaining LDL-C levels between 1.0 and 1.6 mmol/L (40-60 mg/dL) or < or =1.0 mmol/L (< or =40 mg/dL) compared with higher levels (>2.1-2.6 mmol/L [>80-100 mg/dL]). This finding reinforces the update of the National Cholesterol Education Programme's clinical practice guidelines, which recommend LDL-C levels <2.6 mmol/L (100 mg/dL) to be the goal of antihyperlipidaemic drug therapy in high-risk patients with CHD, with an optional therapeutic target of <1.8 mmol/L (70 mg/dL) in patients at very high risk.