Management of cardiovascular risk in people with type 1 diabetes based on, ADA, NICE and Dutch guideline recommendations

Varkevisser RDM, et al. BMJ Open Diabetes Res Care. 2022;10(4):e002765.

Key Takeaway

This first cross-sectional record review described lipid and BP management in people with T1DM across diabetes centers in the Netherlands using ADA (2018), NICE (2014) and Dutch (2018) guidelines and suggested:

  • Undertreatment of lipid and BP management for CVD prevention
  • Unmet treatment targets by most people using LLM, AHM
  • Great difference between guideline recommendations and medication prescription among younger vs older age groups

Harmonization of international guidelines may be useful to overcome undertreatment of CV risk factors in people with T1D.

Why This Matters

  • CVD a leading cause of mortality in people with T1DM and thus, the risk management is essential.
  • Evidence remains unclear on treatment criteria, initiation of statin therapy, LDL-C target and the resulting CVD risk reduction.

This study examined if people with T1D were optimally treated, and how performance differs according to Dutch, ADA and NICE guidelines.

Study Design

A cross-sectional record review of people with T1DM in Netherlands using data from EMRs.

INCLUSION CRITERIA

  • Age ≥18 years with T1DM on insulin therapy for ≥1 year

EXCLUSION CRITERIA

  • People without total cholesterol, HDL-C, LDL-C and triglycerides

Concordance of recommended and prescribed LLM or AHM according to Dutch,
ADA and NICE guidelines and 10-year age groups was assessed.

For those on medication, achievement of treatment targets was assessed.

Key Results

Overall, 1,855 People with T1D were included in this analysis.

BASELINE CHARACTERISTICS
MEDIAN AGE

27 (IQR = 22−43) years
FEMALES

50.2%
DIABETES DURATION

16 (IQR = 10−24) years
MEAN HbA1c

63 mmol/mol (7.9%)
PRESENCE OF CVD

4.3% of people
PRESCRIPTION OF LLM

19.3%
PRESCRIPTION OF AHM

17.1%

LIPID GUIDELINE RECOMMENDATION AND MEDICATION PRESCRIPTION

People treated with LLM according to the guideline recommendations

BP GUIDELINE RECOMMENDATION AND MEDICATION
PRESCRIPTION

People treated with AHM according to the guideline recommendations

Prescription of LLM and AHM
according to age
  • Age was an important factor in the undertreatment of lipid levels and BP, a gap was noted between recommendation and medication prescription.
  • Despite recommendations to start LLM and AHM, medication was prescribed less frequently in younger age groups (18-25 years) vs older age groups (>70 years).

 

TARGET LDL-C AND TARGET BP ACHIEVEMENT

TYPE OF THERAPY PRESCRIBED THERAPY (n) TARGET PEOPLE ACHIEVING TARGET (%)
LLM 290 people without CVD LDL-C level < 2.6 mmol/L  50.3%
68 people with CVD LDL-C level < 1.8 mmol/L 30.9%
AHM 302 BP target < 140/90 mm Hg 46.4%

 

RECOMMENDATIONS

Guideline-harmonization may be useful to overcome undertreatment of CV risk.

Need further studies on CVRM strategies and CV in people with T1D to:

  • Reduce ambiguity in guideline recommendations
  • Lessen hesitation
  • Start CVRM interventions early

Finding determinants of CVRM guideline implementation can help address undertreatment of people with T1D

Limitations

  • Cross-sectional study design and dependence on healthcare provider reported data
  • Categorization for different recommendations was based on data extracted and may be limited by information in EMRs
  • People below 25 years of age were treated by pediatric endocrinologists possibly using the International Society for Paediatric and Adolescent Diabetes guidelines.

ABBREVIATIONS:

ADA, American Diabetes Association; AMH, anti-hypertensive medication; BP, blood pressure; CVD, cardiovascular disease; CVRM, Cardio vascular risk management; EMRs, electronic medical records; HbA1c, Hemoglobin A1c;

HDL-C, high-density lipoprotein-cholesterol; IQR, Interquartile range; LLM, lipid-lowering medication; LDL-C, low-density lipoprotein cholesterol; NICE, National Institute for Health and Care Excellence; T1DM, type 1 diabetes mellitus.

    Varkevisser RDM, Birnie E, Vollenbrock CE, Mul D, van Dijk PR, van der Klauw MM, et al. Cardiovascular risk management in people with type 1 diabetes: performance using three guidelines. BMJ Open Diabetes Res Care. 2022;10(4):e002765. doi: 10.1136/bmjdrc-2022-002765. PMID: 35858715; PMCID: PMC9305824.

MAT-BH-2201111/V1/DEC2022