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Prescribing paradigm shift? Applying the 2019 European Society of Cardiology-led guidelines on ‘diabetes, pre-diabetes, and cardiovascular disease’ to assess eligibility for sodium-glucose co-transporter-2 inhibitors or glucagon-like peptide-1 receptor agonists as first-line monotherapy (or add-on to metformin monotherapy) in type 2 diabetes in Scotland

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posted on 25.06.2020 by Caparrotta Thomas M, Blackbourn Luke AK, McGurnaghan Stuart J, Chalmers John, Lindsay Robert, McCrimmon Rory, McKnight John, Wild Sarah, Petrie John R, Philip Sam, McKeigue Paul M, Webb David J, Sattar Naveed, Colhoun Helen M, Scottish Diabetes Research Network - Epidemiology Group
Objective: In 2019, the European Society of Cardiology led and released new guidelines for diabetes’ cardiovascular risk management, reflecting recent evidence of cardiovascular disease (CVD) reduction with sodium-glucose co-transporter-2 inhibitors (SGLT-2i) and some glucagon-like peptide-1 receptor agonists (GLP1RA) in type 2 diabetes (T2D). A key recommendation is that all those with T2D who are (anti-hyperglycaemic) drug-naïve or on metformin monotherapy should be CVD-risk-stratified and an SGLT-2i or GLP1RA initiated in all those at high or very high risk, irrespective of glycated haemoglobin. We assessed the impact of these guidelines in Scotland were they introduced as is.

Research Design and Methods: Using a nationwide diabetes register in Scotland, we did a cross-sectional analysis, employing variables in our register for risk stratification at 1 January 2019. We were conservative in our definitions, assuming the absence of a risk factor where data were not available. The risk classifications were applied to those drug-naïve or metformin monotherapy people and the anticipated prescribing change calculated.

Results: Of the 265,774 people with T2D in Scotland, 53,194 (20.0% of T2D) were drug-naïve and 56,906 (21.4%) were on metformin monotherapy. Of these, 74.5% and 72.4% respectively were estimated as at least high risk given the guideline risk definitions.

Conclusion: Thus, 80,830 (30.4%) of all those with T2D (n=265,774) would start one of these drug classes according to table 7 and figure 3 of the guideline. The sizeable impact on drug budgets, enhanced clinical monitoring and the trade-off with reduced CVD-related healthcare costs will need careful consideration.

Funding

TMC is a Diabetes UK ‘Sir George Alberti Clinical Research Fellow’ (Grant number: 18/0005786), although the views represented in this article are his own and not those of Diabetes UK.

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