Lipids Remain Uncontrolled in Patients with Diabetes

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ORLANDO—According to new data released at the 64th Scientific Sessions of the American Diabetes Association (ADA), a majority of patients with type 2 diabetes worldwide have not achieved their lipid goals.

A worldwide survey of physician practice patterns related to lipid levels in patients with type 2 diabetes was conducted by Lawrence Leiter, MD, professor of medicine and nutritional sciences, University of Toronto. Dr Leiter and colleagues surveyed 2043 diabetes specialists from 50 countries to compare attitudes and clinical practice patterns in the evaluation and treatment of dyslipidemia in type 2 diabetes patients.

Physicians in the survey tended to overlook recommendations from the ADA and other organizations that people with diabetes have their lipids managed as aggressively as patients with established heart disease, he found.

Although physicians recognized that dyslipidemia is an important risk factor for cardiovascular disease (CVD) in patients with type 2 diabetes, and nearly all (91%) patients with type 2 diabetes globally undergo CVD screening, only about half of the patients attain the goals set for them. Furthermore, the targets that diabetes specialists set for their patients are frequently not as low as their professional organizations recommend.

The ADA guidelines were selected by about one third of all physicians surveyed as the lead determinant in how they practice. In the United States, 51% of respondents said that they follow National Cholesterol Education Panel (NCEP) guidelines and 42% follow ADA guidelines. Nearly half of physicians (46%) said that patient noncompliance is the main barrier to goal attainment.

In addition, many diabetes specialists do not recognize diabetes as a "coronary risk equivalent," as defined by the NCEP's Adult Treatment Panel III. Indeed, 45% of the physicians have a different low-density lipoprotein (LDL) cholesterol goal for persons with CVD versus those without CVD: 85% of physicians have an LDL cholesterol goal of 100 mg/dL for those with CVD versus 59% for patients with diabetes but without CVD.

"The results thus identify a gap between screening for dyslipidemia and aggressive treatment of lipids in type 2 patients, which means that type 2 diabetics aren't managed optimally to thwart the risk of cardiovascular disease and that type 2 diabetes is not widely considered a coronary risk equivalent," Dr Leiter said.

Other data from a major health maintenance organization (HMO) in Michigan showed that lipid testing, treatment, and LDL cholesterol goal attainment have improved but the percentage of patients at their LDL cholesterol goal still remains low.

Manel Pladevall, MD, MSc, and colleagues conducted a retrospective review of 9642 HMO enrollees with diabetes. Each patient was followed for up to 5 years; 74% of the patients were continuously enrolled during the 5 follow-up years. They assessed the percentage of patients who were tested and treated, and the percentage that achieved an LDL cholesterol of 100 mg/dL starting in 1997.

The testing rate improved from 37% in 1997 to 67% in 2001 and the percentage treated increased from 19% to 41%, said Dr Pladevall, clinical epidemiologist, Center for Health Services Research, Henry Ford Health System, Detroit. The percentage of patients who reached their LDL cholesterol goal improved from 22% to 37%.

A second retrospective study of a large managed care group in the southeastern United States mirrored these findings. In this study, 8855 patients with diabetes who were tested for cholesterol levels between October 1, 1999, and September 30, 2000, were identified from the 1.1 million members of the managed care group.

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Lipid-lowering medication was prescribed to 33% of the patients with diabetes compared with 27% of the patients without diabetes. However, patients with diabetes received lipid-lowering medication later than patients without diabetes ( <.05), reported Vincent Willey, PharmD, vice president of research for Health Core, a health outcomes and clinical research group located in Wilmington, Delaware.

Furthermore, only 13% of the patients with diabetes reached their combined lipid fraction targets, which included not only LDL cholesterol, but high-density lipoprotein cholesterol and triglycerides.

"That 2 surveys of major populations in very different areas of the country have come up with identical numbers—only 37% had achieved the ADA-recommended LDL cholesterol goal of =100 mg/dL—supports the evidence that much needs to be done to educate physicians and people with diabetes to reduce CVD risks," said Eugene J. Barrett, MD, PhD, president of the ADA.