Statin Use and Target Access Rate in Type 2 Diabetes Mellitus Patients: Resistance in Patients or Doctors?

Year 2019, Volume: 3 Issue: 2, 65 - 72, 31.08.2019

Rumeysa Çolak , Burcu Çoban Süleyman Cem Adıyaman Başak Özgen Saydam Barış Akıncı

Abstract

Aim: Dyslipidemia associated with diabetic subjects is characterized by increased risk of cardiovascular events and is the main cause of morbidity and mortality. Statin therapy is the cornerstone of cardiovascular risk reduction. Current guidelines emphasize that many diabetic patients should be treated with statins. In our study, we aimed to evaluate our practice and the success rates of statin use in  patients with Type 2 Diabetes Mellitus (T2DM) in accordance with current guidelines and to examine the reasons for not using statin in patients and to reveal the factors related to the patient or physician who underwent treatment failure.

Material and Methods: The study included 429 patients with T2DM (223 female, 206 male; mean age: 66.1±8.3 years) who were followed-up by Endocrinology and Metabolism Policlinic between 2016-2018. The records of coronary artery disease (CAD), the use of statin therapy and other related factors, and metabolic parameters were recorded. The need for statin therapy in patients was evaluated according to the recommendations of the 2019 American Diabetes Association (ADA) Guidelines.

Results: The mean LDL-C (Low Density Lipoprotein-Cholesterol) of the patients was 123±43 mg/dL. 48.5% of the patients were receiving statin therapy. The rate of statin use was significantly higher in CAD group (p <0.001). The mean LDL-C of 111 patients with known CAD was 118.3±48.0 mg/dL and 74.8% of them were using statins. 36.1% of patients receiving treatment received highdose statin. LDL-C level was targeted in 13.2% of patients receiving therapy. The mean LDL-C value of 318 patients without CAD was 124.7±41.1 mg/dL. LDL-C level was targeted in 36% of patients receiving therapy. The reason for not using statin therapy in the whole study group; 78.9% physician preference, 19.7% patient preference, 1.4% other reasons; Causes in the group with CAD; 75% physician preference; 21.4% patient preference; 3.6% found as other causes.

Conclusion: Our results show that a significant number of patients with T2DM are not given statin therapy in practice, or that the treatment is not intensified to achieve the goals. In order to evaluate cardiovascular risk factors and patient-physician preferences in more depth, the one-to-one interview phase of the study is ongoing.

Keywords

Cardiovascular risk, Coronary artery disease, LDL-C, Statin, Diabetes mellitus

Tip 2 Diabetes Mellitus Hastalarında Statin Kullanımı ve Hedefe Ulaşma Oranları: Direnç Hastada mı Hekimde mi?

Abstract

Amaç: Diyabetik bireylerde sıklıkla eşlik eden dislipidemi kardiyovasküler olaylar açısından risk artışı ile karakterizedir ve hastalık sürecinde morbidite ve mortalitenin ana nedenidir. Statin tedavisi kardiyovasküler risk azalmasının temel taşıdır. Güncel kılavuzlar birçok diyabetik hastanın statin ile tedavi edilmesi gerektiğini vurgulamaktadır. Çalışmamızda Tip 2 Diabetes Mellitus (T2DM) tanılı hastalarımızda statin kullanımıyla ilgili günlük pratiğimizi ve tedavi başarı oranlarımızı güncel kılavuzlar doğrultusunda değerlendirmeyi ve hastalarımızda statin kullanmama sebeplerini inceleyerek tedavi başarısızlığının altında yatan hastaya veya hekime yönelik faktörlerin ortaya konulması amaçlanmıştır.

Gereç ve Yöntemler: Çalışmaya 2016-2018 yılları arasında Endokrinoloji ve Metabolizma Polikliniğince takipli 40 yaş ve üzeri 429 T2DM tanılı hasta (223’ü kadın 206’sı erkek, ortalama yaş: 66.1±8.3) katıldı. Veri tabanı kayıtları incelenerek hastalarda Koroner Arter Hastalığı (KAH) varlığı, statin tedavisi kullanımı, bununla ilişkili diğer faktörler ve metabolik parametreler kaydedildi. Hastalarda statin tedavisi gereksinimi 2019 Amerikan Diyabet Cemiyeti (ADA) Kılavuzu önerileri doğrultusunda değerlendirildi.

Bulgular: Çalışmadaki hastaların ortalama LDL-K (Low Density Lipoprotein-Cholesterol-Düşük Dansiteli Lipoprotein-Kolesterol) değeri 123±43 mg/dL bulundu. Hastaların %48.5’i statin tedavisi almaktaydı. Koroner arter hastalığı olan grupta statin kullanım oranı anlamlı olarak yüksek bulundu (p<0.001). Koroner arter hastalığı olan 111 hastanın ortalama LDL-K değeri 118.3±48.0 mg/dL olup bu hastaların %74.8’i statin kullanmaktaydı. Tedavi alan hastaların %36.1’i etkin doz statin (atorvastatin ≥ 40 mg/gün veya rosuvastatin ≥ 20 mg/gün) almaktaydı. Tedavi alan hastaların %13.2’sinde LDL-K düzeyi hedefteydi. Koroner arter hastalığı olmayan 318 hastanın ortalama LDL-K değeri 124.7±41.1 mg/dL olup bu hastaların %39.3’ü statin kullanmaktaydı. Tedavi alan hastaların %36’sında LDL-K düzeyi hedefteydi. Tüm çalışma grubunda statin kullanmayan hastalar değerlendirildiğinde statin tedavisi almama sebebi; %78.9 hekimin tercihi, %19.7 hasta tercihi, %1.4 diğer nedenler iken; KAH olan gruptaki sebepler; %75 hekimin tercihi; %21.4 hasta tercihi; %3.6 diğer nedenler olarak bulundu.

Sonuç: Bulgularımız günlük pratikte T2DM’li önemli sayıda hastada statin tedavisi verilmediği ya da tedavinin hedeflere ulaşacak şekilde intensifiye edilmediğini göstermektedir. Kardiyovasküler risk faktörlerini ve hasta-hekim tercihlerini daha derinlemesine değerlendirmek amacıyla çalışmanın birebir görüşme aşaması sürmektedir.

Keywords

Kardiyovaskuler Risk, Koroner Arter Hastalığı, Statin, Diyabetes Mellitus, LDL-K

References

• 1. Satman I, Grubu T. TURDEP-II Sonuçları. Türk Endokronoloji ve Metabolizma Derneği [homepage on the internet]. 2011.
• 2. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al. Heart disease and stroke statistics--2015 update: a report from the American Heart Association. Circulation. 2015;131(4):e29-322.
• 3. Association AD. Dyslipidemia management in adults with diabetes. Diabetes care. 2004;27(suppl 1):s68-s71.
• 4. Grundy SM, Benjamin IJ, Burke GL, Chait A, Eckel RH, Howard BV, et al. Diabetes and cardiovascular disease: a statement for healthcare professionals from the American Heart Association. Circulation. 1999;100(10):1134-46.
• 5. Haffner SM. Dyslipidemia management in adults with diabetes. Diabetes care. 2004;27 Suppl 1:S68-71.
• 6. Boden WE, Probstfield JL, Anderson T, Chaitman BR, Desvignes-Nickens P, Koprowicz K, et al. Niacin in patients with low HDL cholesterol levels receiving intensive statin therapy. The New England journal of medicine. 2011;365(24):2255-67.
• 7. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). Jama. 2001;285(19):2486-97.
• 8. Warraich HJ, Wong ND, Rana JS. Role for combination therapy in diabetic dyslipidemia. Current cardiology reports. 2015;17(5):32.
• 9. Gurm HS, Hoogwerf B. The Heart Protection Study: high-risk patients benefit from statins, regardless of LDL-C level. Cleveland Clinic journal of medicine. 2003;70(11):991-7.
• 10. Ginsberg HN. REVIEW: Efficacy and mechanisms of action of statins in the treatment of diabetic dyslipidemia. The Journal of clinical endocrinology and metabolism. 2006;91(2):383-92.
• 11. Kearney PM, Blackwell L, Collins R, Keech A, Simes J, Peto R, et al. Efficacy of cholesterol-lowering therapy in 18,686 people with diabetes in 14 randomised trials of statins: a meta-analysis. Lancet (London, England). 2008;371(9607):117-25.
• 12. Mihaylova B, Emberson J, Blackwell L, Keech A, Simes J, Barnes EH, et al. The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials. Lancet (London, England). 2012;380(9841):581-90.
• 13. Turner RC, Millns H, Neil HA, Stratton IM, Manley SE, Matthews DR, et al. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: United Kingdom Prospective Diabetes Study (UKPDS: 23). BMJ (Clinical research ed). 1998;316(7134):823-8.
• 14. Brugts JJ, Yetgin T, Hoeks SE, Gotto AM, Shepherd J, Westendorp RG, et al. The benefits of statins in people without established cardiovascular disease but with cardiovascular risk factors: meta-analysis of randomised controlled trials. BMJ (Clinical research ed). 2009;338:b2376.
• 15. De Cosmo S, Viazzi F, Pacilli A, Giorda C, Ceriello A, Gentile S, et al. Achievement of therapeutic targets in patients with diabetes and chronic kidney disease: insights from the Associazione Medici Diabetologi Annals initiative. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association. 2015;30(9):1526-33.
• 16. Heintjes E, Kuiper J, Lucius B, Penning-van Beest F, Kutikova L, Liem A, et al. Characterization and cholesterol management in patients with cardiovascular events and/or type 2 diabetes in the Netherlands. Current medical research and opinion. 2017;33(1):91-100.
• 17. Thomas MC, Nestel PJ. Management of dyslipidaemia in patients with type 2 diabetes in Australian primary care. The Medical journal of Australia. 2007;186(3):128-30.
• 18. Pokharel Y, Akeroyd JM, Ramsey DJ, Hira RS, Nambi V, Shah T, et al. Statin Use and Its Facility-Level Variation in Patients With Diabetes: Insight From the Veterans Affairs National Database. Clinical cardiology. 2016;39(4):185-91.
• 19. Sattar N, Preiss D, Murray HM, Welsh P, Buckley BM, de Craen AJ, et al. Statins and risk of incident diabetes: a collaborative meta-analysis of randomised statin trials. Lancet (London, England). 2010;375(9716):735-42.
• 20. Kotseva K, De Bacquer D, De Backer G, Ryden L, Jennings C, Gyberg V, et al. Lifestyle and risk factor management in people at high risk of cardiovascular disease. A report from the European Society of Cardiology European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) IV cross-sectional survey in 14 European regions. European journal of preventive cardiology. 2016;23(18):2007-18.
• 21. Fung CSC, Wan EYF, Chan AKC, Lam CLK. Statin use reduces cardiovascular events and all-cause mortality amongst Chinese patients with type 2 diabetes mellitus: a 5-year cohort study. BMC cardiovascular disorders. 2017;17(1):166.
• 22. Mafauzy M, Hussein Z, Chan SP. The status of diabetes control in Malaysia: results of DiabCare 2008. The Medical journal of Malaysia. 2011;66(3):175-81.
• 23. Sazlina S, Zailinawati A, Zaiton A, Ong I. A Clinical Audit on Diabetis Care in Two Urban Public Primary Care Clinics in Malaysia. Malaysian Journal of Medicine and Health Sciences. 2010;6(1):101-9.
• 24. Gant CM, Binnenmars SH, Harmelink M, Soedamah-Muthu SS, Bakker SJL, Navis G, et al. Real-life achievement of lipid-lowering treatment targets in the DIAbetes and LifEstyle Cohort Twente: systemic assessment of pharmacological and nutritional factors. Nutrition & diabetes. 2018;8(1):24.
• 25. Özkan Y, Çolak R, Koca SS, Dağ S, Kan EK, Sırma N. Diyabet ve Hiperlipidemi: Tedavide Ne Kadar Başarılıyız? Fırat Üniversitesi Sağlık Bilimleri Dergisi. 2008;22(2):97-100.
• 26. Sabaté E. Adherence to long-term therapies: evidence for action: World Health Organization; 2003.
• 27. Hwang JY, Jung CH, Lee WJ, Park CY, Kim SR, Yoon K-H, et al. Low density lipoprotein cholesterol target goal attainment rate and physician perceptions about target goal achievement in Korean patients with diabetes. Diabetes & metabolism journal. 2011;35(6):628-36.
• 28. Keskin A. Diyabetes Mellitus Hastalarında Hedef LDL Kolesterol Düzeylerine Ulaşma Durumu ve Statin Tedavisine Uyum Sıklığı. Ankara Medical Journal.12(3).