‘Cholesterol complacency’ call to action
For the first time in nearly a decade, new data highlights the potential extent of the cholesterol problem among high-risk patents costing the economy $1.5 billion in direct healthcare costs each year.
Researchers from the Baker Heart and Diabetes Institute, Melbourne say Australia’s cholesterol problem remains unsolved as cardiovascular disease (CVD) remains our biggest killer and the most expensive disease group to treat. In Australia, more than one in four deaths in 2017 was due to CVD, which claims the life of one person every 12 minutes.
Managing high cholesterol, which includes healthy eating and lifestyle modification, medications, GP attendances, cholesterol testing and attributable hospital admissions, is already costing the Australian community $1.5 billion in direct healthcare costs each and every year.
For people with diabetes, CVD—such as heart attack and stroke—is the main cause of death. If a person has diabetes, they can be up to four times more likely to have a heart attack or stroke than people who don’t.
The report, Code Red: overturning Australia’s cholesterol complacency, analysed MedicineInsight data from 2010 to mid-2019 of 107,664 Australians who have experienced a prior cardiovascular event and were being cared for by a GP.
The key findings showed:
- 79% of Australians examined were prescribed the recommended lipid-lowering therapy.
- But almost half (48%) of high-risk Australians managed in primary care are not meeting the recommended LDL-C targets.
- A higher proportion of those with a sub-optimal LDL-C were women (56%), had cerebrovascular disease (58%), and had a more recent CVD event within the last 5 years (58%).
- Over the past decade, the number of Australians not reaching the treatment targets for LDL-C has remained steady (56% in 2010 compared to 52% in 2019). In any year, LDL-C was higher for women than men.
- New modelling reveals more than 3738 lives could be saved and over 13,740 CVD events prevented over the next five years with optimal cholesterol management.
- Over the next five years, $66.6 million healthcare costs could be saved with intervention to achieve optimal LDL-C targets.
A systematic and stepped care approach is needed to reform cholesterol management, in a way that unites the sector—from policy and political decision-makers, to the manufacturers, as well as the patient, clinical, and advocacy communities, said the report authors.
According to lead researcher, Associate Professor Melinda Carrington, many patients prescribed therapy are still not meeting targeted cholesterol goals, despite having experienced a cardiovascular event and being under GP care.
“We believe that increasing the intensity of statin doses or adding on an additional therapy when goal levels are not achieved (within a timely manner and with regular testing) would go some way to bridge the gap. In addition, patients need to be made aware of the benefits of statin medication and the importance of adhering to treatment regimes,” Prof Carrington told the AJP.
This especially includes women as the research also highlighted they are sometimes incorrectly considered as a lower risk group. As a result, they may not receive the most appropriate treatment or more intensive treatments—even when they are recording LDL-C levels above the recommended guidelines, she added.
“[For all patients] Lipid therapy needs to be prescribed prior to discharge and after a CVD event and routine testing performed post-discharge at regular intervals—with up-titration in statins does or the addition of another therapy until the target level is achieved. Rapid cholesterol testing could help increase compliance,” she said.
While cholesterol testing in some pharmacies with referrals back to GPs already occurs, the addition of nurse prevention clinics or prevention nurses operating in other settings could help to reduce the Australia’s cholesterol burden, Prof Carrington continued.
“Better transition from hospital to community care with good patient tracking and recall for lipid testing, via a registry, would be a way to improve the problem. Nurses acting as the conduit between hospital and community care would be hugely beneficial following discharge and for a follow-up period during which time they could evaluate the achievement of target LDL-C levels, provide education and advice, symptom monitoring and refer to GPs for escalating treatment,” she said.
A copy of the report can be downloaded from: baker.edu.au/-/media/documents/impact/baker-institute_code-red-report.pdf?la=en
‘If I had known’—pharmacists encouraged to get behind campaign
A new campaign aims to break down the barriers to optimal diabetes management by featuring real people talking about their personal experiences of type 2 diabetes (T2D).
Diabetes Australia (DA) is encouraging healthcare professionals (HCPs) to get behind its latest community campaign—If I had known—which features real stories of real people about what they’d wished they known when they’d been first diagnosed with T2D. It also highlights the need to act early to get the right support to manage the condition; and to live a healthy life to reduce the risk of diabetes complications or associated health conditions, down the track.
It was developed following focus group research that looked at the key challenges faced by people newly diagnosed with T2D. The research identified three key barriers that held people back from optimum diabetes self-management:
- Lack of knowledge: What is diabetes and how do I manage it?
- Lack of support: Who is there to support me?
- Not taking diabetes seriously: It’s nothing serious?
According to DA CEO, Greg Johnson, the campaign highlights the need to act early when people are first diagnosed with T2D—otherwise, the consequences can be far-reaching. “It’s a really powerful campaign and when we developed it we gathered evidence that a lot of people don’t get the right message about T2D,” Johnson told the AJP. “It’s a serious condition which they should take seriously but people don’t always get good advice; and that’s why we’d encourage pharmacists to support our campaign and direct people to its website, IfIhadknown.com.au.
“We know how well accessed community pharmacy is by Australians, and it’s a great opportunity for people to get useful and simple information that will help them understand if they’re at risk of developing T2D. Pharmacy can encourage people to reach out do something about it.
“The key issue is raising awareness, because we know once people have been diagnosed, in general, they can manage T2D well as there’s a lot of things they can do if they have good information. There’s a really important role for pharmacists here, ensuring that people know T2D is a very serious thing and it’s not something they should ignore or take lightly,” he says.
With this in mind, he stresses communication messages about diabetes complications, or associated health conditions like heart disease, for example, need to be strengthened too.
“[In the first place] there’s a community perception that’s incorrect that heart disease, heart attacks and heart failure, affects men more than women, which is not true. And we know that T2D is a serious risk factor for heart failure in both women and men and so there needs to be a much stronger communication message about the risks. That’s really important, especially if a person has T2D,” he says.
In a DA survey of people who already had T2D, as part of its Take Diabetes2Heart campaign, 59% of respondents were unaware that cardiovascular disease was the number one cause of death for people with T2D. However, when asked if they would do something about it if they thought they were at risk, 99% said they would and 80% said they would change their diet or exercise more.
Johnson says the key issue is acting early, backed by good information and support.
“With a good healthcare team, including pharmacists, along with the right medicines and educational support, these serious complications such as vision loss, amputations and kidney problems can be prevented and managed so people can live well.”
Johnson also says he would like to see targeted diabetes screening in more settings, such as hospitals and emergency departments to pick up the estimated half a million people who are unaware they have T2D.
“We are not going to find undetected T2D just by having a one-dimensional approach. Every day tens of thousands of people across Australia are visiting hospital emergency departments, but people are not routinely checked for T2D so targeted screening is really important. We think it should happen in emergency departments, and more generally when people come into hospital, as well as in pharmacies. It should be in multiple settings because the scale of what we’re talking about is very big. We’re not going to solve these problems with a one-dimensional approach to screening.”
Testosterone may reduce risk, but no quick fix
Testosterone may reduce type 2 diabetes (T2D) risk in men, a national Australian study led by the University of Adelaide has shown.
The T4DM (Testosterone for the prevention of Diabetes Mellitus) study, the largest study of testosterone treatment ever conducted anywhere in the world, enrolled more than 1000 men aged between 50 and 74 years old who were overweight or obese.
According to study leader, Professor Gary Wittert, University of Adelaide, the study demonstrated that type 2 risk among men at high-risk can be prevented, and even reversed among newly diagnosed patients. However, he cautioned against seeing testosterone therapy as a quick fix.
“I want to emphasise that this is not a signal to rush for the script pad. The best and safest way to prevent or reverse T2D is through healthy eating, along with regular strength training and aerobic activity,’’ stresses Prof Wittert.
Study participants were split into two groups, receiving injections every three months with either testosterone or a placebo. All men were given access to the WW (formerly known as Weight Watchers) lifestyle program. On average over the two years about 30% of the men in each treatment group attended WW meetings, and 70% achieved the recommended amount of exercise.
After two years’ treatment, 87 out of 413 (21%) men in placebo group had T2D (based on an oral glucose tolerance test) compared with 55 out of 443 (12%) men in the testosterone group.
“The proportion of men with diabetes at two years in the testosterone treatment group was significantly lower than in the placebo group,” Prof Wittert said. “Importantly, the men who were most engaged in the WW healthy lifestyle program lost the most body weight.”
Researchers also found that:
- fasting blood sugar was, on average, lower than it was at the start of the study for both groups, but the decrease was greater in the testosterone group
- both groups of men lost, on average, around 4kg of weight but men on testosterone gained muscle mass while losing fat
- men on testosterone also gained small improvements in sexual function
- the most common adverse effect was an increase in red blood cells potentially leading to sludgy blood and clots. This affected 106 (22%) of men being treated with testosterone.
“We do not know either the durability of effect or long-term safety of testosterone for preventing T2D. Treatment with testosterone might be an option for some men, but all men need a thorough physical and mental health assessment, and support to adopt and maintain a healthy lifestyle,” Prof Wittert said.
The T4DM Study was funded through a National Health and Medical Research Council (NHMRC) grant with additional support from Bayer AG, WW (formerly Weight Watchers), the Freemasons Foundation Centre for Men’s Health at the University of Adelaide, and Eli Lilly.
Cancer drug offers heart disease hope
Scientists have repurposed a cancer drug to show it can help reduce plaque build-up caused by diabetes, which can lead to heart attack and stroke.
Atherosclerosis—the build-up of fatty plaques on artery walls that can restrict blood flow and rupture causing dangerous blood clots—is far more common in people with diabetes, leaving them with a much greater risk of cardiovascular disease than the general population.
More than 1.5 million Australians have diabetes, and despite many years of improvements in therapies that lower blood glucose or address other cardiovascular disease (CVD) risk factors, diabetes continues to approximately double the risk of developing or dying from CVD. A drug already in development could be welcome news for these high-risk Australians.
In this preclinical animal study, published in the journal Arteriosclerosis, Thrombosis, and Vascular Biology, scientists tested low doses of a drug that is being developed to clear solid tumours and blood cancers, but has also been shown to reduce the number of platelets—small clotting cells—in the blood.
Senior author Professor Andrew Murphy, head of the Baker Institute’s Haematopoiesis and Leukocyte Biology Lab, said his previous work showed that diabetes increased the number of platelets in the blood and this could be one factor driving increased levels of atherosclerosis.
However, people with diabetes do not tend to respond well to standard anti-platelet therapies, presenting a need for a novel target.
“By using this drug that causes physiological cell death—scientifically known as apoptosis—we reduced the numbers of platelets in the blood to ‘normal’ levels,” Prof Murphy said.
“This then decreased atherosclerosis in mice with diabetes to similar levels of animals without diabetes. These findings show drugs traditionally targeted to treat cancer could be repurposed at sub-toxic doses as interventions to limit cardiovascular disease in high-risk settings such as diabetes.”
Prof Murphy said reducing platelets meant there were less likely to interact with the white blood cells, the cells that would usually enter the blood vessels causing plaque, by reducing their ability to stick to blood vessels.
“This drug also has the ability to dampen platelet activity, so they’re not as reactive, and less likely to form dangerous clots,” he said.
Prof Murphy said the study observed no negative side effects using this low dose approach, and because other drugs are already being used to target this pathway in cancer treatment, progressing to a therapy that could be used in humans to treat cardiovascular disease could be straightforward.
He said the next step would be investigating the best application for the drug, and better understanding any risks.
This study was a collaboration with scientists at Monash University and Ohio State University.
Tool to detect risk of heart attack
Melbourne researchers have developed a ground-breaking new tool which can identify those at highest risk of heart attack.
More than 60,000 heart attacks happen in Australia every year and about 30% of them are fatal.
But heart researcher at the Baker Institute, Professor Karlheinz Peter, believes doctors often “don’t know who is at risk”.
While current tests can identify plaque built up on artery walls, there is no effective way of measuring stability and risk of heart attack.
A laser developed by researchers at the Baker Heart and Diabetes Institute and Swinburne University can differentiate between plaques that are stable and unstable for the first time.
Prof Peter said too many people were suffering from heart attacks even after undergoing an angiogram—the gold-standard detection measure for plaque build-up—highlighting the need for a better solution.
“While an angiogram can determine the presence and the degree of narrowing caused by plaque build-up, it cannot accurately determine whether an area of plaque is stable or unstable. Nor can any other test currently available.
“Currently, preventative treatment is determined by the amount of narrowing in the artery, typically if it is blocked more than 70%. However, extensive evidence shows unstable plaque can cause heart attacks well below that threshold. That means we could be walking around with a ticking time bomb, without knowing it.
“The new solution we have developed offers a way to detect the contents within coronary plaques so we have a much better idea of those that are vulnerable to rupture.”
The core technology is guided through a catheter, which is inserted into the coronary artery being examined. Near-infrared light is then directed at plaques, which if unstable will produce a signal due to the contents associated with plaque instability having high auto-fluorescence properties. This auto-fluorescence signal is detected by the device and presented to the cardiologist, who may then decide to apply interventional therapies such as stents or medication to stabilise the plaque, in the hope of preventing future heart attacks.
The laser has received some government funding, but more money is needed to make it widely available to patients.
$2.1 million to support GP tests
From 1 November HbA1c tests will be able to be completed at a GP surgery, by an appropriately trained GP or specialist and the results will be available immediately, Health Minister, Greg Hunt announced in late March.
Diabetes Australia (DA) said it supports the change as it will make it easier for people to manage their diabetes.
“Currently, HbA1c testing is performed in labs. This means a person has to get a referral from a GP, then visit a pathology centre to have blood drawn. The blood is then sent to a lab and results are provided back to the GP. Then a person has another appointment to discuss the results. Having to make multiple visits to different healthcare providers can put people off regular tests – which are important for people managing diabetes,” DA said in a statement.
“Now, people will be able to make one trip to their GP and get immediate results. This is particularly good for people in regional, rural and remote communities and people with impaired mobility.
“We have consistently advocated to make it easier for people with diabetes to manage the condition and we are glad the Australian Government has listened.”
Get smart with diabetes
Get Smart with Type 2 Diabetes aims to help people make informed health decisions, manage prediabetes and diabetes, and reduce the risk of preventable diabetes complications. The 160-page book is written by two credentialled diabetes educators, dietitian Helen Jackson and registered nurse Amanda Fryer who operate Driving Diabetes—offering online support and educational materials for people with diabetes, as well as to health professionals in aged care facilities caring for diabetes patients. The second edition includes additional information on commencing insulin therapy (including the psychological factors preventing people commencing), more on physical activity with input from exercise physiologists.
Get Smart with Type 2 Diabetes is available as a hard copy or eBook. For more information go to: drivingdiabetes.com.au
Study to investigate medication adherence
Managing blood glucose levels is a critical part of living well with type 2 diabetes but it can be difficult for many people. In fact, studies have shown that around half of all Australians have difficulty achieving their recommended HbA1c targets.
One important factor in this is people not taking diabetes medication as prescribed.
As a result of a grant from the Diabetes Australia Research Program, the University of Sydney’s Dr Crystal Lee is trying to identify factors that are related to people not taking medication as regularly as they should.
“Blood glucose lowering medications are an integral part of managing blood glucose levels, yet, according to a small-scale survey conducted in New South Wales, a third of the respondents were not taking their medications as regularly as they should,” Dr Lee said.
“I’ll be using a number of different datasets joined together to identify any patterns of people who aren’t taking their medication as often as they are recommended. This may help us work out whether this issue is more common in men or women, people of a certain age or socio-economic background.
“Hopefully we will be able to get a better understanding of the impact of this as well. I’m really interested in understanding whether or not taking medication as often as prescribed leads to decreased hospitalisations and deaths.
“We need to understand how best to keep people healthy and out of hospital and the Diabetes Australia Research Program helps ensure Australia’s diabetes researchers can continue to do their important work.”