Spotlight on lipid treatment

Control of cholesterol levels among patients with type 2 diabetes commonly falls short of recommendations, according to two recent studies of contemporary practice in other countries.

Two recent studies looked at treatment of dyslipidemia among people with type 2 diabetes.

The first study, published by Diabetes, Obesity and Metabolism on March 2, used a British primary care database to look at 254,925 patients with incident type 2 diabetes and elevated cholesterol levels (n=168,365) and/or hypertension (n=167,896). The patients were categorized by whether they had atherosclerotic cardiovascular disease (ASCVD) at baseline or were at high or low risk of developing ASCVD. Patients were judged to have high ASCVD risk if they had two or more of the following risk factors: current smoking, body mass index of 35 kg/m2 or greater, hypertension or dyslipidemia (as appropriate for the cohort), and microvascular disease. Two-thirds of the patients were found to have dyslipidemia or hypertension at diabetes diagnosis. Over the studied period of 2005 to 2016, this rate remained stable for hypertension in all age groups; dyslipidemia prevalence increased by 10% in people under age 60 years. Among patients judged to have high ASCVD risk, the median months to initiation of lipid therapy were 20.4 for those 18 to 39 years, 10.9 for those 40 to 49 years, and 9.5 for those 50 to 59 years. For hypertensive therapy, the respective time periods were 28.1, 19.2, and 19.9 months. Initiation of either type of therapy after one year, rather than sooner, was associated with higher risk of treatment failure, regardless of ASCVD risk, the study also found. “We have demonstrated that irrespective of baseline ASCVD risk status, earlier cardioprotective treatment initiation, when needed, may reduce at least 20% of uncontrolled lipid and blood pressure burden at population level. Findings presented in this study suggest revisiting the guidelines for proactive management of hypertension and dyslipidaemia, particularly in people with young-onset [type 2 diabetes],” the authors said.

The second study, published by BMJ Open Diabetes Research and Care on Feb. 10, included 288 consecutive patients seen by endocrinologists at a diabetes clinic in Mexico. All had been diagnosed with type 2 diabetes less than five years before and none had disabling complications of diabetes, cardiovascular or otherwise. At baseline, only 10.8% patients were receiving statin therapy (46.5% moderate-intensity therapy and 4.6% high-intensity therapy), 8.3% were on fibrates, and 4.2% took both fibrates and statins. Three months after being seen at the clinic, the proportion of patients on fibrates and statins increased to 41.6%. At one year, it had decreased to 20.8%, but at two years, it was 38.9%. The most common reason for discontinuation of dyslipidemia treatment was that the patient did not consider it important (37.5%), followed by another physician suspending treatment (31.3%). “The implementation of treatment guidelines in clinical practice is difficult. When a patient is diagnosed with [type 2 diabetes], the guidelines recommend initiation of an extensive treatment regimen that includes several different medication classes,” the authors wrote. “It is necessary to establish strategies to convince about the benefits of starting and maintaining therapy, both for patients and healthcare professionals.”