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Epidemiology/Health Services Research
Adherence to lipid-lowering therapy and risk for cardiovascular disease and death in type 1 diabetes mellitus: a population-based study from the Swedish National Diabetes Register
  1. Christel Hero1,2,
  2. Sofia Axia Karlsson3,
  3. Stefan Franzén4,5,
  4. Ann-Marie Svensson1,4,
  5. Mervete Miftaraj4,
  6. Soffia Gudbjörnsdottir1,4,
  7. Karolina Andersson Sundell3,6,
  8. Björn Eliasson1,2,
  9. Katarina Eeg-Olofsson1,2
  1. 1Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
  2. 2Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
  3. 3Department of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
  4. 4National Diabetes Register, Centre of Registers, Västra Götaland, Gothenburg, Sweden
  5. 5Health Metrics Unit, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
  6. 6Medical Evidence and Observational Research Centre, AstraZeneca AB, Gothenburg, Sweden
  1. Correspondence to Dr Christel Hero; christel.hero{at}vgregion.se

Abstract

Aims/hypothesis Dyslipidemia is an important modifiable risk factor and lipid-lowering treatment (LLT) is essential to reduce the risk of cardiovascular disease (CVD). Studies in type 2 diabetes indicate that low adherence to statin therapy is a barrier to reach full protective potential, and less is known in type 1 diabetes (T1D). The aim was to assess risk of CVD by adherence and nonpersistence to LLT in T1D. 

Method A population-based study with a retrospective longitudinal design was conducted between 2006 and 2010, with follow-up until December 2013. In total, 6192 adult individuals with T1D, initiating LLT between 2006 and 2010, were included. Information on LLT, socioeconomic characteristics, comorbidities and cardiovascular events were collected. After 18 months, refill adherence was estimated by calculating medication possession ratio (MPR). Nonpersistence was defined as being without medicines on hand for at least 180 days. Individuals were thereafter followed until CVD, death or end of follow-up in December 2013. Cox regression analyses were performed to assess adherence level and nonpersistence of LLT as predictor of CVD. Analyses were adjusted for cardiovascular risk factors and socioeconomic status.  

Results Mean MPR was 72%, 52% of the participants had an MPR above 80% and 27% discontinued LLT. There were 637 nonfatal and 58 fatal CVD events, mean follow-up 3.6 and 3.9 years, respectively. MPR above 80% was associated with reduced risk for nonfatal CVD compared with lower MPR, HR 0.78 (95% CI 0.65 to 0.93)). For fatal CVD, results indicated a negative effect of high adherence but the association did not reach statistical significance, HR 1.96 (0.96 to 4.01). Individuals discontinuing LLT had higher risk of nonfatal CVD, HR 1.43 (95% CI 1.18 to 1.73). 

Conclusions/Interpretation In T1D, the risk for nonfatal CVD was lower among individuals with high adherence and higher among those discontinuing LLT within 18 months. It is important to evaluate and emphasize adherence to prescribed LLT at clinical visits to achieve treatment goals and reduce the risk of CVD.

  • cardiac risk reduction
  • lipid-lowering drugs/medication
  • insulin-deficient Type 1 diabetes
  • adherence to medications
http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjdrc-2019-000719

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    Footnotes

    • Contributors Study concept and design: CH, SAK, A-MS, KAS, BE and KE-O. Statistical analyses: MM and SF. Interpretation of data: CH, SAK, KAS, A-MS, BE, KE-O, SF and SG. Drafting of manuscript: CH and KE-O. Critical revision and completion of manuscript by all authors. The manuscript has been read and approved by all coauthors.

    • Funding The study was financed by grants from the Swedish state under the agreement between the Swedish government and the county councils, the ALF agreement (ALFGBG-698991 and ALFGBG-430711) and from the Gothenburg Society of Medicine. The Swedish Diabetes Association and the Swedish Society of Diabetology support the NDR. The Swedish Association of Local Authorities and Regions funds the NDR.

    • Competing interests KAS is employed by AstraZeneca. However, the views expressed in this study are her own and not those of AstraZeneca. SG has received personal fees (lecture fees and research grants) from AstraZeneca, Boehringer Ingelheim, Eli Lilly, MSD, Novo Nordisk and Sanofi. KE-O has received personal lecture fees from Eli Lilly and Abbott. BE has received personal fees for lectures and serving on advisory boards from Amgen, AstraZeneca, Boehringer Ingelheim, Eli Lilly, Merck Sharp & Dohme, Mundipharma, Navamedic, Novo Nordisk and RLS Global and research grants from Sanofi. CH has received personal lecture fees from Eli Lilly.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement No data are available. The data that support the findings of this study are not publicly available. The study presented here have been subject to an application to an ethical board and approved for publication related to the specific aim of our research project. With reference to the European General Data Protection Regulation (GDPR), the data are personal data and thereby protected by secrecy. Study definitions and descriptive statistics are available on request.