Gaps in evidence-based therapy use in patients with type 2 diabetes mellitus and atherosclerotic cardiovascular disease

1. Significant gaps were found in the use of evidence-based therapies in insured patients with atherosclerotic cardiovascular disease and type 2 diabetes mellitus.

Evidence Rating Level: 2 (Good)

Prevalence of atherosclerotic cardiovascular disease (ASCVD) in patients with type 2 diabetes mellitus (T2DM) is twice as high as those without T2DM, resulting in worse health outcomes and premature death. Several classes of medications have proven efficacy for individuals with ASCVD and T2DM, such as angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), high-intensity statins, sodium glucose cotransporter-2 inhibitors (SGLT-2is), and glucagon-like peptide-1 receptor agonists (GLP-1RAs). However, evidence suggests that these medications are underutilized with this population. A total of 699,380 patients with T2DM insured with Anthem on April 30, 2018 and enrolled for a period of 12 months thereafter were included in this cohort study. Among these, 155,958 had evidence of ASCVD and were greater than 18 years of age without chronic kidney disease stage 4 or 5. The primary outcome was the proportion of patients with prescription claims for each of the three classes of evidence-based therapy on, or covering, the index date ±30 days: ACEI/ARB (or angiotensin receptor-neprilysin inhibitor), high-intensity statin (atorvastatin 40-80mg or rosuvastatin 20-40mg), and SGLT-2i or GLP-1RA. Of the patients in this sample, 24.7% were using a high-intensity statin, 53.1% were using an ACEI/ARB, and 9.9% were using a SGLT-2i or GLP-1RA. Only 2.7% of the population were covered by prescriptions for all three therapies; 37.4% were on none of these therapies. Over the course of 12 months, only 18% visited an endocrinologist while 70.6% had visited a cardiologist. Lastly, the potential benefit of achieving 100% adoption of the three therapies was simulated using pooled treatment estimates from clinical trials. Increasing the use of these evidence-based therapies to 100% over three years of treatment could reduce 4,546 major atherosclerotic cardiovascular events, such as stroke, myocardial infarction, or cardiovascular death, in eligible but untreated patients. Overall, this study found significant deviations from contemporary use of the three evidence-based therapies in insured patients with T2DM and ASCVD.

Click to read the study in JAHA

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