Diabetes Metab J.  2022 May;46(3):464-475. 10.4093/dmj.2021.0088.

Current Status of Low-Density Lipoprotein Cholesterol Target Achievement in Patients with Type 2 Diabetes Mellitus in Korea Compared with Recent Guidelines

• Yun SJ
• Jeong IK
• Cha JH
• Lee J
• Cho HC
• Choi SH
• Chun S
• Jeon HJ
• Kang HC
• Kim SS
• Ko SH
• Koh G
• Kwon SK
• Lee JH
• Moon MK
• Noh J
• Park CY
• Kim S

• KMID: 2530185
• DOI: http://doi.org/10.4093/dmj.2021.0088

Abstract

Background
We evaluated the achievement of low-density lipoprotein cholesterol (LDL-C) targets in patients with type 2 diabetes mellitus (T2DM) according to up-to-date Korean Diabetes Association (KDA), European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS), and American Diabetes Association (ADA) guidelines.
Methods
This retrospective cohort study collected electronic medical record data from patients with T2DM (≥20 years) managed by endocrinologists from 15 hospitals in Korea (January to December 2019). Patients were categorized according to guidelines to assess LDL-C target achievement. KDA (2019): Very High-I (atherosclerotic cardiovascular disease [ASCVD]) <70 mg/dL; Very High-II (target organ damage [TOD], or cardiovascular risk factors [CVRFs]) <70 mg/dL; high (others) <100 mg/dL. ESC/EAS (2019): Very High-I (ASCVD): <55 mg/dL; Very High-II (TOD or ≥3-CVRF) <55 mg/dL; high (diabetes ≥10 years without TOD plus any CVRF) <70 mg/dL; moderate (diabetes <10 years without CVRF) <100 mg/dL. ADA (2019): Very High-I (ASCVD); Very High-II (age ≥40+ TOD, or any CVRF), for high intensity statin or statin combined with ezetimibe.
Results
Among 2,000 T2DM patients (mean age 62.6 years; male 55.9%; mean glycosylated hemoglobin 7.2%) ASCVD prevalence was 24.7%. Of 1,455 (72.8%) patients treated with statins, 73.9% received monotherapy. According to KDA guidelines, LDL-C target achievement rates were 55.2% in Very High-I and 34.9% in Very High-II patients. With ESC/EAS guidelines, target attainment rates were 26.6% in Very High-I, 15.7% in Very High-II, and 25.9% in high risk patients. Based on ADA guidelines, most patients (78.9%) were very-high risk; however, only 15.5% received high-intensity statin or combination therapy.
Conclusion
According to current dyslipidemia management guidelines, LDL-C goal achievement remains suboptimal in Korean patients with T2DM.

Keyword

Cholesterol, LDL; Diabetes mellitus, type 2; Dyslipidemias; Guideline; Hydroxymethylglutaryl-CoA reductase inhibitors

Figure

• 

  Fig. 1. Study design.

• 

  Fig. 2. Low-density lipoprotein cholesterol (LDL-C) target achievement rates according to recent guidelines. (A) LDL-C target achievement rates according to Korean Diabetes Association (KDA) 2019 guidelines. (B) LDL-C target achievement according to European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) 2019 guidelines. (C) Lipid-lowering treatment pattern according to American Diabetes Association (ADA) 2019 guidelines. (A, B) ‘Yes’ indicates the portion of patients who meet the target goal and (C) ‘Yes’ denotes the portion of patients who received recommended lipid-lowering treatment, high-intensity statin or statin combined with ezetimibe. a101 patients out of the total 1,899 subjects were excluded since their cardiovascular (CV) risk was not clearly determined due to missing body mass index data, bThe treatment pattern for patient groups with very-high CV risk was reported selectively. Others are heterogeneous and are reported in Supplementary Table 1.

• 

  Fig. 3. The prescribing pattern of lipid-lowering agents and low-density lipoprotein cholesterol (LDL-C) target achievement rates of each treatment according to the risk categories of recent guidelines. (A) LDL-C target goal achievement according to lipid-lowering treatment methods by cardiovascular (CV) risk groups defined by Korean Diabetes Association (KDA) 2019 guidelines. (B) LDL-C target goal achievement according to lipid lowering treatment methods by CV risk groups defined by European Society of Cardiology (ESC)/European Foundation for the Study of Diabetes (EASD) 2019 guidelines. (C) Lipid lowering treatment by CV risk groups defined by American Diabetes Association (ADA) 2019 guidelines. TX, treatment; w/o, without. aRecommended treatment includes high-intensity statin or statin combined with ezetimibe treatment.

• 

Reference

1. International Diabetes Federation. IDF diabetes atlas. Brussels: IDF;2019.

2. Kim BY, Won JC, Lee JH, Kim HS, Park JH, Ha KH, et al. Diabetes fact sheets in Korea, 2018: an appraisal of current status. Diabetes Metab J. 2019; 43:487–94.

3. Shaw JE, Sicree RA, Zimmet PZ. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract. 2010; 87:4–14.

4. Jung CH, Son JW, Kang S, Kim WJ, Kim HS, Kim HS, et al. Diabetes fact sheets in Korea, 2020: an appraisal of current status. Diabetes Metab J. 2021; 45:1–10.

5. Vital Statistics Division Statistics Korea, Shin HY, Kim J, Lee S, Park MS, Park S, et al. Cause-of-death statistics in 2018 in the Republic of Korea. J Korean Med Assoc. 2020; 63:286–97.

6. Kim MK, Ko SH, Kim BY, Kang ES, Noh J, Kim SK, et al. 2019 Clinical practice guidelines for type 2 diabetes mellitus in Korea. Diabetes Metab J. 2019; 43:398–406.

7. Park JH, Ha KH, Kim BY, Lee JH, Kim DJ. Trends in cardiovascular complications and mortality among patients with diabetes in South Korea. Diabetes Metab J. 2021; 45:120–4.

8. Kang YM, Kim YJ, Park JY, Lee WJ, Jung CH. Mortality and causes of death in a national sample of type 2 diabetic patients in Korea from 2002 to 2013. Cardiovasc Diabetol. 2016; 15:131.

9. Kim KJ, Kwon TY, Yu S, Seo JA, Kim NH, Choi KM, et al. Tenyear mortality trends for adults with and without diabetes mellitus in South Korea, 2003 to 2013. Diabetes Metab J. 2018; 42:394–401.

10. American Diabetes Association. 10. Cardiovascular disease and risk management: standards of medical care in diabetes-2019. Diabetes Care. 2019; 42(Suppl 1):S103–23.

11. Cosentino F, Grant PJ, Aboyans V, Bailey CJ, Ceriello A, Delgado V, et al. 2019 ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD. Eur Heart J. 2020; 41:255–323.

12. Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. Circulation. 2019; 139:e1082–143.

13. Gerstein HC, Colhoun HM, Dagenais GR, Diaz R, Lakshmanan M, Pais P, et al. Dulaglutide and cardiovascular outcomes in type 2 diabetes (REWIND): a double-blind, randomized placebo-controlled trial. Lancet. 2019; 394:121–30.

14. Rhee EJ, Kim HC, Kim JH, Lee EY, Kim BJ, Kim EM, et al. 2018 Guidelines for the management of dyslipidemia in Korea. J Lipid Atheroscler. 2019; 8:78–131.

15. Catapano AL, Graham I, De Backer G, Wiklund O, Chapman MJ, Drexel H, et al. 2016 ESC/EAS guidelines for the management of dyslipidaemias. Eur Heart J. 2016; 37:2999–3058.

16. Ko SH, Kim SR, Kim DJ, Oh SJ, Lee HJ, Shim KH, et al. 2011 Clinical practice guidelines for type 2 diabetes in Korea. Diabetes Metab J. 2011; 35:431–6.

17. Hwang JY, Jung CH, Lee WJ, Park CY, Kim SR, Yoon KH, et al. Low density lipoprotein cholesterol target goal attainment rate and physician perceptions about target goal achievement in Korean patients with diabetes. Diabetes Metab J. 2011; 35:628–36.

18. Yang YS, Yang BR, Kim MS, Hwang Y, Choi SH. Low-density lipoprotein cholesterol goal attainment rates in high-risk patients with cardiovascular diseases and diabetes mellitus in Korea: a retrospective cohort study. Lipids Health Dis. 2020; 19:5.

19. Cho S, Jang H, Park K. Trends in the management levels of metabolic risk factors in middle-aged and elderly patients with type 2 diabetes mellitus: the Korean National Health and Nutrition Examination Survey 1998-2014. PLoS One. 2017; 12:e0189361.

20. Yang YS, Lee SY, Kim JS, Choi KM, Lee KW, Lee SC, et al. Achievement of LDL-C targets defined by ESC/EAS (2011) guidelines in risk-stratified Korean patients with dyslipidemia receiving lipid-modifying treatments. Endocrinol Metab (Seoul). 2020; 35:367–76.

21. Salami JA, Warraich H, Valero-Elizondo J, Spatz ES, Desai NR, Rana JS, et al. National trends in statin use and expenditures in the US adult population from 2002 to 2013: insights from the Medical Expenditure Panel Survey. JAMA Cardiol. 2017; 2:56–65.

22. Cannon CP, Braunwald E, McCabe CH, Rader DJ, Rouleau JL, Belder R, et al. Intensive versus moderate lipid lowering with statins after acute coronary syndromes. N Engl J Med. 2004; 350:1495–504.

23. Dinneen SF, Gerstein HC. The association of microalbuminuria and mortality in non-insulin-dependent diabetes mellitus. A systematic overview of the literature. Arch Intern Med. 1997; 157:1413–8.

24. Kannel WB, McGee DL. Diabetes and cardiovascular risk factors: the Framingham study. Circulation. 1979; 59:8–13.

25. Collins R, Reith C, Emberson J, Armitage J, Baigent C, Blackwell L, et al. Interpretation of the evidence for the efficacy and safety of statin therapy. Lancet. 2016; 388:2532–61.

26. Mooradian AD. Dyslipidemia in type 2 diabetes mellitus. Nat Clin Pract Endocrinol Metab. 2009; 5:150–9.

27. Jellinger PS, Handelsman Y, Rosenblit PD, Bloomgarden ZT, Fonseca VA, Garber AJ, et al. American Association of Clinical Endocrinologists and American College of Endocrinology guidelines for management of dyslipidemia and prevention of cardiovascular disease. Endocr Pract. 2017; 23(Suppl 2):1–87.

28. Cannon CP, Giugliano RP, Blazing MA, Harrington RA, Peterson JL, Sisk CM, et al. Rationale and design of IMPROVE-IT (IMProved Reduction of Outcomes: Vytorin Efficacy International Trial): comparison of ezetimbe/simvastatin versus simvastatin monotherapy on cardiovascular outcomes in patients with acute coronary syndromes. Am Heart J. 2008; 156:826–32.

29. Breuker C, Clement F, Mura T, Macioce V, Castet-Nicolas A, Audurier Y, et al. Non-achievement of LDL-cholesterol targets in patients with diabetes at very-high cardiovascular risk receiving statin treatment: incidence and risk factors. Int J Cardiol. 2018; 268:195–9.

30. Ding R, Ye P, Zhao S, Zhao D, Yan X, Dong Y, et al. Effect of physician characteristics and knowledge on the quality of dyslipidemia management and LDL-C target goal achievement in China: subgroup analysis of the Dyslipidemia International Study. J Glob Health. 2017; 7:020702.

31. Khunti K, Ceriello A, Cos X, De Block C. Achievement of guideline targets for blood pressure, lipid, and glycaemic control in type 2 diabetes: a meta-analysis. Diabetes Res Clin Pract. 2018; 137:137–48.

32. Lee SH, Song WH, Jeong MH, Hur SH, Jeon DW, Jeung W, et al. Dyslipidemia and rate of under-target low-density lipoprotein-cholesterol in patients with coronary artery disease in Korea. J Lipid Atheroscler. 2019; 8:242–51.

33. Kim S, Han S, Rane PP, Qian Y, Zhao Z, Suh HS. Achievement of the low-density lipoprotein cholesterol goal among patients with dyslipidemia in South Korea. PLoS One. 2020; 15:e0228472.

34. Liao JK. Safety and efficacy of statins in Asians. Am J Cardiol. 2007; 99:410–4.

35. Naito R, Miyauchi K, Daida H. Racial differences in the cholesterol-lowering effect of statin. J Atheroscler Thromb. 2017; 24:19–25.