Diabetes
Elizabeth Briand
An April 4, 2024, review article in NEJM noted that patients with T1D are facing an added medical challenge: the increased risk of CVD that accompanies a T1D diagnosis.
The number of people diagnosed with T1D continues to grow in the United States. CDC estimates that currently more than 1.7 million adults and roughly 300,000 children have T1D.
While care for T1D has improved dramatically in recent decades, the study researchers noted that the life expectancy of patients with T1D is still approximately 13 years less than that of the general population—and CVD is the primary cause of that deficit.
“Fifty years ago, people with type 1 diabetes did not live long enough to get cardiovascular disease because they were dying from renal failure,” said Irl Hirsch, MD, article co-author and professor at the UW Medicine Diabetes Institute in Seattle. Even though patients with T1D are living longer and escaping renal complications, Hirsch said they are facing higher cardiovascular risk.
Hirsch noted a broad range of factors that contribute to this elevated risk, including hyperglycemia, hypertension, obesity, kidney disease, and more.
“There are so many comorbidities that are all interrelated,” said Candis Morello, PharmD, professor of clinical pharmacy at UC San Diego’s Skaggs School of Pharmacy and Pharmaceutical Sciences. She said it’s not just one disease state to treat with T1D. “There’s such complex physiology that stems from these interconnected conditions,” Morello said.
Finding ways to reduce risk
It is that complexity that makes it difficult to mitigate cardiovascular risk for patients with T1D. In the review paper, researchers examined a number of approaches to CVD management and prevention, including “the timing and dose of statins, specific blood-pressure targets, the use of aspirin for primary prevention, the comparative efficacy of incretin mimetic therapy and bariatric surgery, and the risks and benefits of SGLT2 inhibition.” Researchers noted, however, that much of the data on T1D come from observational studies or from trials primarily involving patients with T2D.
Jennifer Trujillo, PharmD, a professor at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, said there is a need for additional evidence to aid in the treatment of T1D and cardiovascular risk.
“For example, there is very strong evidence that statins reduce the risk of CV events in people with type 2 diabetes. And guideline recommendations regarding the use of statins in people with diabetes is primarily based on evidence in the type 2 diabetes population,” she said. “More studies conducted specifically in people with type 1 diabetes are needed. This is true both for older medications like statins to lower cholesterol, but also for newer medications like SGLT2 inhibitors and GLP-1 receptor agonists.”
Support and guidance from pharmacists
Pharmacists, especially community pharmacists, can improve heart health for patients with T1D by supporting overall care, said Morello. This includes providing diabetes screenings as well as working with patients to improve medication adherence by simplifying dosing as much as possible. Pharmacists can also be invaluable, she said, in “explaining to patients the ‘whys’ and the ‘hows’ of their care—why is it important, how does it work, what are the adverse events to look for, how to get the most out of a medication.”
“As both the medication expert and the most accessible health care provider, the pharmacist can provide education and support about the importance of a heart-healthy diet, regular physical activity, smoking cessation, and weight management,” added Trujillo. “They can promote medication adherence and help the patient navigate challenges with access to medications and technology. They can ensure that insulin regimens are designed and used to achieve optimal glucose control and they can recommend and manage cholesterol and blood pressure medications.” ■