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• W1857487125 abstract "Type 2 diabetes patients (T2D) have a substantially increased risk of cardiovascular events 1. Statins are widely accepted to reduce the risk of cardiovascular disease (CVD) in diabetes 2-4, with most considered at high enough cardiovascular risk to justify statin therapy without further assessment 1, 5. The UK National Institute for Health and Care Excellence (NICE) 2008 guidelines 6 recommended, at diagnosis, (i) a full lipid profile to evaluate CVD risk, and (ii) instigation of lipid-modifying treatment in all patients with T2D to achieve treatment targets. A target Total Cholesterol (TC) < 5 mmol/l (< 193 mg/dl) was proposed as the minimum standard of care, with the expectation that lipid-lowering therapy would be titrated to increase the chances of achieving this target. The UK primary care Quality Outcomes Framework (QOF) for the management of T2D also has a target TC ≤ 5 mmol/l. However, studies suggest that large discrepancies exist between treatment targets and clinical reality 7-9. In relation to this background, the authors undertook a primary care-based retrospective study to (i) assess whether newly diagnosed patients with T2D were initiated on lipid-lowering therapy, (ii) examine whether lipid measurements were used to assess achievement of targets and (iii) determine whether failure to achieve targets resulted in escalation to higher dose/intensity of statin therapy. Data were collected from 41 GP surgeries in Cheshire for people diagnosed with T2D in 2010. Searches (from 2009–2011; covering −6 months prediagnosis to +12 months postdiagnosis) interrogated the EMISWeb® database (EMIS Group, Leeds, UK), to extract date of diagnosis, TC results/sample dates and prescribed lipid-lowering therapy (grouped according to Table 1). A total of 1,212 patients were included (740 men/472 women; mean age: 64 years (range 41–85); 96% White European). While increasing numbers of patients had TC measured prior to, and shortly after diagnosis [in keeping with guidance 6, 10], 10.4% and 8.5% remained untested at +6 and +12 months postdiagnosis respectively. Of those tested, 42.2% had a TC > 5.0 mmol/l at diagnosis. By +6 and +12 months, this was 29.2% and 26.5% respectively. Despite guidance, at +6 months, 42.4% were still not on lipid-lowering therapy, falling to 39.9% at +12 months. Of those not on treatment by +12 months, 35.8% had a TC > 5.0 mmol/l and 19.7% had still not been tested. The majority were treated with simvastatin 40 mg or equivalent (36.1% and 36.9% at +6 and +12 months respectively). Surprisingly, 8.5% of patients were started on therapy without a recorded TC level. At +6 months, 24.4% in the statin 4 group and 19.2% in the statin five group still had TC > 5.0 mmol/l (18.3% and 23.4%, respectively, at +12 months). Comparing the TC ≤ 5.0 mmol/l and > 5.0 mmol/l groups (Figure 1), no detectable shift upwards to a higher statin potency was seen between 6 and 12 months postdiagnosis in the TC > 5.0 mmol/l group. NICE guidance 6 in place during this study recommended a full lipid profile when assessing CVD risk at T2D diagnosis and the need for lipid-modifying treatment to achieve treatment targets. Our data shows these guidelines were largely not followed. While TC levels were checked and a decision to start antilipid therapy was generally made by +4 months, many remained with TC levels unchecked and/or were not on lipid-lowering therapy, or an inappropriate dose. A decrease in all those with a TC > 5 mmol/l was seen during this study, possibly because of lifestyle changes, medication and/or improvement in glycaemic control. Interestingly, when divided into groups on and off statin treatment, a similar pattern was observed. This lack of additional impact by statin treatment may reflect an absence of dose escalation in patients with a TC > 5.0 mmol/l. Previous reports 7-9 show that not all eligible patients receive cholesterol-lowering therapy or, if treated, it is ineffective because of poor dose escalation. This is consistent with our observations, even by +12 months, of (i) a significant proportion not on therapy and (ii) a lack of detectable shift in prescribing of more potent statins in the high-risk > 5 mmol/l group (if indeed TC was even measured). Clearly, significant numbers of patients remained above target, whether on therapy or not. The latest 2014 NICE guidance 10 recommends baseline TC and high-density lipoprotein cholesterol (HDL-C) to best estimate CVD risk, and a full lipid profile before starting treatment, followed by TC, HDL-C and non-HDL-C measurement after 3 months post-treatment initiation, aiming for a > 40% reduction in non-HDL-C. NICE now favors flat dosing of statin therapy, as used in the trials that proved their effectiveness. This may be considered a more beneficial strategy having a greater impact on the general population as a whole. Prescription of atorvastatin 20 mg is recommended for primary prevention of CVD in people with and without T2D who have ≥ 10% 10-year risk of CVD. Our results raise the question of whether GPs are content to hit diabetes QOF targets for TC by providing ‘good enough’ practice (e.g. 90% of patients), leading to some not being treated to target, particularly in hard-to-reach groups. However, the effectiveness of QOF targets is questionable if meeting these targets is not reflected in the clinical reality. Other reasons for not reaching target may include non-adherence to prescribed statins or communication difficulties between clinicians and their patients. Our work illustrates a gap between guidelines and practice with regard to statin prescribing and monitoring of impact. We assessed the NICE minimum standard of care of < 5 mmol/l, but even this was not being met. High-risk patients could have been managed much more effectively and existing programmes were not bringing patients to recommended targets. Further education regarding CVD risk and prevention in newly diagnosed T2D patients is required. Whether the updated NICE guidelines are being followed is uncertain, but data from our and other work 11, 12 suggest that it is unlikely that untargeted publication of national guidance will have an impact in changing current prescribing practices. Hence, alternative systems to improve guideline compliance should be developed and continuing audit is needed to ensure improved patient outcomes. None. Not applicable. None to declare." @default.
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• W1857487125 date "2015-10-27" @default.
• W1857487125 modified "2023-09-23" @default.
• W1857487125 title "Are cholesterol levels being checked and managed appropriately in UK primary care type 2 diabetes?" @default.
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• W1857487125 doi "https://doi.org/10.1111/ijcp.12717" @default.
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