Cardiovascular risk management in people with type 1 diabetes: performance using three guidelines

Abstract

IntroductionCardiovascular disease (CVD) is the leading cause of mortality in individuals with type 1 diabetes mellitus (T1DM). Cardiovascular risk management is therefore essential in the management of individuals with T1DM. This study describes the performance of lipid and blood pressure management in individuals with T1DM using three guidelines.Research design and methodsIndividuals ≥18 years with T1DM, treated with insulin for ≥1 year, visiting Diabeter or the University Medical Center Groningen between January 1, 2018 and December 31, 2018, were included. Lipid and blood pressure management were examined using the Dutch, American Diabetes Association (ADA) and National Institute for Health and Care Excellence (NICE) guidelines. Concordance of recommended and prescribed lipid-lowering (LLM) or antihypertensive medication (AHM) was assessed per guideline and 10-year age groups. Achievement of treatment targets was assessed for those prescribed medication.ResultsA total of 1855 individuals with T1DM were included. LLM and AHM was prescribed in 19% and 17%, respectively. In individuals recommended LLM, this was prescribed in 22%–46% according to Dutch, ADA or NICE guideline recommendations. For individuals recommended AHM, this was prescribed in 52%–75%. Recommended and actual prescription of LLM and AHM increased over age for all three guidelines. However, discordance between treatment recommendation and medication prescribed was higher in younger, compared with older, age groups. Low-density lipoprotein-cholesterol targets were achieved by 50% (without CVD) and 31% (with CVD) of those prescribed LLM. The blood pressure target was achieved by 46% of those prescribed AHM.ConclusionThis study suggests that there is undertreatment of lipid and blood pressure according to guideline recommendations, particularly in younger age groups. Treatment targets are not met by most individuals prescribed medication, while guidelines recommendations differ considerably. We recommend to investigate the factors influencing undertreatment of lipid and blood pressure management in individuals with T1DM.

Differences in lipid and blood pressure measurements between individuals with type 1 diabetes and the general population

“…Type 1 Diabetes population: Diabeter/UMCG study Data from individuals with T1D visiting Diabeter, a specialised T1D outpatient clinic with ve separate locations in The Netherlands, and the University Medical Center Groningen were used in this study. Crosssectional data were collected in 2018 from electronic medical les, as described earlier (17). Individuals were included if they were diagnosed with T1D, were ≥ 18 years of age, and had been using insulin for ≥ 1 year.…”

Lipid-lowering therapies and cardiovascular risk-stratification strategies in adults with type 1 diabetes

“…Contemporary ASCVD rates in T1D across two countries generated a risk predication model that demonstrated current guidance likely overestimates 10-year ASCVD risk in younger age groups, nonetheless statin therapy may still be indicated because of high lifetime risk [39,40 ▪▪ ]. As there is discordance, additional risk-stratification methods may be required to help determine need for statin therapy [32,41 ▪ ].…”

“…Despite the importance of lipid-lowering for reducing ASCVD risk, dyslipidaemia remains under-recognized and under-treated, particularly in individuals with T1D who have not developed vascular complications [12,41 ▪ ,70–72]. Reasons for suboptimal lipid management in individuals with T1D are likely multifactorial, relating to clinicians, patients and healthcare funding models that do not prioritize prevention or chronic care.…”

“…However, in the AdDIT study, a randomized trial of angiotensin-converting enzymes and statins in adolescents with T1D, muscle symptoms were only reported by one of the 443 participants [75]. Clinician uncertainty around indications for lipid-lowering therapy because of numerous treatment guidelines with varying recommendations, lack of T1D-specific trial evidence for lipid-lowering therapies, as well as a limited understanding of 10-year versus lifetime ASCVD risk may affect utilization of lipid-lowering therapy [41 ▪ ]. Clinicians may also be reluctant to prescribe statins in T1D during child-bearing ages, as statins are contraindicated in pregnancy and in women planning pregnancy because of risk of foetal malformation.…”

Management of Glycemia during Acute Aerobic and Resistance Training in Patients with Diabetes Type 1: A Croatian Pilot Study

“…Patients with T1DM and uncontrolled glucose levels can develop cardiovascular complications, while glucose-lowering treatment strategies can prevent or postpone their appearance. In those patients, exercise is advised for reducing the risk of several chronic conditions [ 1 , 2 ]. Nevertheless, there are some associated risks with exercise, such as fluctuating blood glucose levels from hyperglycemia to hypoglycemia [ 3 ].…”