Docs must get better on diabetes, says expert

the word diabetes is written on a chalkboard

Increasing the use of novel and well-established drugs would offer a significant opportunity to reduce harms caused by diabetes, a new report shows

Modelling by the Baker Heart and Diabetes Institute, outlined in the new report The Dark Shadow of Type 2 Diabetes, analysed findings from large international trials that revealed the major benefits of SGLT2 inhibitors for heart failure and renal disease, and the smaller benefits of SGLT2 inhibitors and GLP-1 agonists for myocardial infarction and stroke.

The modelling found that the use of SGLT2 inhibitors for one year in 75% of Australians with type 2 diabetes who also have prior cardiovascular disease would prevent 680 major cardiovascular events; 511 hospital admissions for heart failure; and 78 people developing end-stage kidney disease.

It also found that a 75% utilisation of GLP-1 receptor agonists in the same population would prevent more than 630 major cardiovascular events in one year, and that a 20% increase in use of ACE inhibitors (or ARBs) and statins would prevent more than 300 cardiovascular deaths in one year.

“There were 963,066 Australians with type 2 diabetes on the NDSS in 2015, among whom 227,624 were aged 40-79, and were estimated to have prior CVD,” the authors wrote.

“Within this group, there were 6,473 MACE [major adverse cardiovascular events], 2,200 HHF [hospitalisations for heart failure] and 236 ESKD [end-stage kidney disease] events in the year 2015.

“Among those on the NDSS aged 40-79, irrespective of prior CVD or treatment, there were 4,239 CVD deaths in 2015.

“In the analysis modelling glucose-lowering medications, we found that assuming that half of the eligible population take the drugs, the introduction of SGLT2 inhibitors would reduce the number of people having MACE events in a single year by 453, while GLP-1 agonists reduced the number of MACE events by 421.

“As the uptake of SGLT2 inhibitors and GLP-1 agonists increases to 75%, the number of MACE prevented increased to 680 and 631 respectively.

“For statins and antihypertensive medications, the number of CVD deaths which could be prevented, assuming the population taking these increased by 20%, were 162 and 143, respectively.”

“In summary, we have shown that, within the Australian type 2 diabetes population, there are significant opportunities to reduce the population-wide burden of cardiovascular and renal outcomes by increasing the use of novel and of well-established drugs.”

Report lead author and Head of Clinical Diabetes and Population Health at the Baker Institute, Professor Jonathan Shaw, said the effects of greater use of new generation diabetes therapies were modelled on just one year, but would be greatly magnified over time.

Prof Shaw said he hopes the report will address a gap between evidence and practice, in the prescription and use of these medications.

“Reducing excess cardiovascular risk in people with diabetes requires far more than just controlling blood glucose levels,” he said.

“We need to ensure as many people as possible with type 2 diabetes and cardiovascular disease are receiving an SGLT2 inhibitor or GLP-1 receptor agonist, even if blood glucose control appears adequate.”

Prof Shaw says that on average, a 45-year-old Australian with diabetes can expect to live six years less than a person free of diabetes.

“While cardiovascular disease is the leading cause of this loss of life years, we mustn’t forget other high-risk complications associated with type 2 diabetes,” he said.

“The shadow cast by type 2 diabetes is far greater than many people realise. As doctors, we must get better at managing these wider health risks, especially among the growing number of younger patients who may live with type 2 diabetes for decades.”

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