medwireNews: The proven cardiovascular benefits of sodium-glucose cotransporter (SGLT)2 inhibitors has not led doctors to prioritize their use in people at high risk, show findings from UK general practice.
Indeed, the data from the Clinical Practice Research Datalink (CPRD) show that people with type 2 diabetes and established cardiovascular disease (CVD) were actually slightly less likely than those without to be given an SGLT2 inhibitor.
In 2018, the ADA/EASD consensus statement was published, placing SGLT2 inhibitors as a priority second-line (after metformin) glucose-lowering option for people with established CVD, particularly those with heart failure or kidney disease.
At that time, 9.2% of 434,120 people identified in the CPRD who were taking glucose-lowering medications were on an SGLT2 inhibitor, which included 7.1% of the 142,231 people with established CVD.
Two years later, in 2020, the overall level of SGLT2 inhibitor prescribing had risen slightly, with 14.9% of 415,267 people taking one. But their use remained lower in the 139,426 people with CVD, at 11.8%.
And of all people taking an SGLT2 inhibitor only about a quarter had CVD, with no increase seen between 2018 and 2020.
“So there’s really no evidence that people with cardiovascular disease are being targeted for SGLT2 treatment, even though they are the group that would presumably benefit the most from taking it,” presenter Katie Young (University of Exeter, UK) told delegates at the 2022 Diabetes UK Professional Conference.
The same issue was evident when looking specifically at people with heart failure, who comprised 8–9% of the two cohorts. Just 5.2% of people with heart failure were given an SGLT2 inhibitor in 2018, rising to 9.4% in 2020.
Moreover, only approximately 5% of all people taking an SGLT2 inhibitor had heart failure, despite the solid evidence for this medication class in heart failure – DAPA-HF published in 2019, following several analyses of SGLT2 inhibitor cardiovascular outcome trials indicating a strong protective effect against heart failure.
Young noted that the latest UK guidelines advise doctors to consider an SGLT2 inhibitor for all people with type 2 diabetes who have high CVD risk, defined as a QRISK2 score greater than 10%.
Including people with established disease, this would comprise 93% of the 2020 cohort, she reported. With only 14% of those people currently receiving an SGLT2 inhibitor, the remaining 86%, extrapolated to the whole UK population, would represent around 2 million people and would cost more than £ 850 million/year (€ 1010 million, US$ 1116 million) if all were given an SGLT2 inhibitor.
Moreover, application of the QRISK2 10% criterion would result in 93% of people with type 2 diabetes currently treated with diet and exercise being eligible for an SGLT2 inhibitor when glucose-lowering medications became necessary.
Young explained that this is because all that is required to be considered high-risk for a White man is age over 50 years – the age cutoffs vary with sex and ethnicity.
“And given that the median age of diagnosis in my cohort was 55 years, it’s unsurprising that most people exceed this threshold,” she said.
The presenter observed that a large proportion of people meeting the QRISK2 threshold would not have been eligible for the clinical trials that demonstrated the cardioprotective abilities of SGLT2 inhibitors, because additional CVD risk factors besides age were required.
“So really the evidence for this QRISK2 10% threshold is unclear, as it does not come from the clinical trials,” she concluded.
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