Using statins for preventing cardiovascular disease in diabetes

More and more people are living with type 2 diabetes, a condition that increases the risk of serious health problems, such as cardiovascular disease, which is the leading cause of illness and early death in these individuals. For many years, cholesterol-lowering drugs called statins have been the main way to reduce this risk. Recently, newer medications for lowering blood sugar, including glucagon like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors, have also been shown to protect the heart.

For Tummas, this raised one important question: which drugs, or combinations of drugs, offer the best protection for people with type 2 diabetes who haven’t yet developed cardiovascular disease? To answer this question, Tummas used health data from nearly 280,000 people in Denmark with type 2 diabetes but without history of cardiovascular disease. 

In the study, Tummas’s group found that taking statins, either alone or together with a newer glucose-lowering drug, was associated with the lowest risk of developing cardiovascular disease for the first time. This suggests that while newer drugs offer benefits, statins remain a key therapy for preventing cardiovascular disease in diabetes. These findings are important “because other studies have indicated that statins remain underused in people with type 2 diabetes, despite guideline recommendations”, Tummas explains.

Addressing population-level challenges

What drew Tummas to this field was the opportunity to address population-level challenges in treating and preventing diseases affecting individuals with type 2 diabetes. According to Tummas, he was particularly motivated by “the chance to answer these questions using the unique and internationally recognised resources available in the Danish health registers and large cohorts”.

With rising rates of obesity, type 2 diabetes is expected to become an even greater public health challenge in the coming decades according to Tummas. Thus, in the words of Tummas this is: “both an urgent issue to address and a meaningful opportunity to contribute”.

Discovering the effects of using statins 

In people with type 2 diabetes who had not yet developed cardiovascular disease, Tummas and his team found that use of statins was associated with substantially lower risk of first-time atherosclerotic cardiovascular disease than cardioprotective glucose-lowering drugs, while a combination of the two classes was associated with similar atherosclerotic cardiovascular risk as statin alone. 

These findings are important because other studies have indicated that statins remain underused in people with type 2 diabetes, despite guideline recommendations. Tummas highlights that their findings do not diminish the value of these newer glucose-lowering therapies. Evidence from other studies show that they reduce the risk of heart failure and chronic kidney disease in people with diabetes. Moreover, in a secondary prevention setting, the effects of these drugs on atherosclerotic cardiovascular outcomes may differ. Taken altogether, they should be considered alongside statins in appropriate clinical contexts.

Working with large, complex datasets can be challenging

According to Tummas, working with the comprehensive Danish health registers was a major strength as it allowed his group to follow the entire population over time with detailed data on medication use and disease outcomes. However, Tummas explains that they did meet challenges, although not unexpected, that required attention. 

First, understanding “how the data is generated is critical”, Tummas says. Since these data came from routine healthcare interactions rather than being collected for a specific research purpose, there are limitations. Second, organising and preparing such large, complex datasets for analysis was both “time-consuming and technically demanding”, Tummas explains. Finally, and perhaps most importantly, there is always risks of biases and confounding in observational studies given the lack of randomisation. To address these issues, Tummas and his team applied rigorous statistical methods to minimise biases and help make meaningful conclusions from real-world data. 

Supporting more informed treatment decisions and long-term health outcomes

The findings from Tummas’ project address an important question in cardiovascular prevention: how and when combination therapies are used in the general population with type 2 diabetes to prevent the development of atherosclerotic cardiovascular disease. According to Tummas: “this is increasingly relevant as the number of available pharmacological treatments targeting blood pressure, blood glucose, and cholesterol has expanded/risen”.

Tummas hopes that his research will “help clarify how different pharmacological treatments are used and what benefits they offer, ultimately contributing to improved prevention of cardiovascular disease in people with type 2 diabetes”, he says. By using real-world data, his goal is to support more informed treatment decisions and better long-term health outcomes in this high-risk population.

Many unanswered questions still to be explored

According to Tummas, there are still several important unanswered questions in relation to the effects of pharmacological treatments on long-term health in individuals with type 2 diabetes. While his study focused on primary prevention of atherosclerotic cardiovascular disease, other relevant health outcomes in both primary and secondary prevention are of interest. Ultimately, Tummas hopes that expanding the scope in this way will help build a more comprehensive understanding of how pharmacological treatments may be used alone, or in combination, to promote long-term health in individuals with type 2 diabetes.