Therapies 'Not Used Enough' in Patients With Type 2 Diabetes and Cardiovascular Risk

Anne L. Peters, MD


May 04, 2022

This transcript has been edited for clarity.

A recent paper caught my eye discussing how we treat our patients with type 2 diabetes to reduce the risk of cardiovascular events. We are all used to data that demonstrate how we fail to reach our combined targets of A1c, LDL, and blood pressure–lowering in patients with diabetes. A recent paper by Nelson and colleagues not only says that we are not reaching our targets, but that we are not using drugs such as SGLT2 inhibitors and GLP-1 receptor agonists nearly often enough.

This multicenter cohort study used health system–level data within the National Patient-Centered Clinical Research Network, including 12 health systems. Participants included patients with diabetes and established cardiovascular disease who were seen between January 1 and December 31, 2018.

In terms of overall findings, only half of these patients were prescribed a statin and only 27% were on a high-intensity statin. Remember, all patients with type 2 diabetes and established cardiovascular disease should be on a high-intensity statin, so that's pretty disturbing.

In all, 45% were on an ACE inhibitor or an ARB, and arguably more should have been on one of those agents. More disturbingly, when looking at the use of cardiovascular risk–modifying agents, only 4% of these patients were on a GLP-1 receptor agonist and 3% were on an SGLT2 inhibitor.

I know these data are from a few years ago, so hopefully things are better, but I think these numbers are incredibly low. As an endocrinologist, I am always gleeful when I start patients on SGLT2 inhibitors and/or GLP-1 receptor agonists because I know I'm helping reduce the complications related to hyperglycemia and reducing macrovascular risk as well.

When medications aren't used, there are a variety of reasons. One is obviously a lack of knowledge, although hopefully most people are aware of the benefit of these agents. There are issues related to healthcare systems, such as formulary access, the cost of these medications, and prior authorizations. There is provider reluctance in terms of using new drugs and patient reluctance in terms of taking new drugs.

It may be hard to teach or convince a patient to give an injection. Patients may have side effects and they might not really understand the full benefit of these drugs. There are many reasons why people won't necessarily be on these agents that we all now know are incredibly beneficial.

My simplified answer to all these issues is that, as clinicians, we have to be aware of the benefits of these agents and have a willingness to take the time to discuss them with patients. We particularly need to discuss potential side effects and how to deal with them should they occur.

I hope that these agents are being used more commonly in 2022 than they were in 2018, but I'm not wildly optimistic given the low use of statin therapy in these patients who should be on them.

Therefore, we need to be aware of all the medications we have available for use in our patients with type 2 diabetes and cardiovascular disease and make sure we treat every patient optimally.

Thank you.

Anne L. Peters, MD, is a professor of medicine at the University of Southern California (USC) Keck School of Medicine and director of the USC clinical diabetes programs. She has published more than 200 articles, reviews, and abstracts, and three books, on diabetes, and has been an investigator for more than 40 research studies. She has spoken internationally at over 400 programs and serves on many committees of several professional organizations.

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