Atherosclerotic cardiovascular disease (ASCVD)

Type 2 diabetes mellitus: Quality prescribing strategy - a guide for improvement
Scottish Government Effective Prescribing & Therapeutics Division
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See section on cardiovascular and renal risk for further information.

This indicator should have a high level of SGLT-2i and/or GLP-1RA prescribing, indicating good practice, with suitable patients receiving appropriate medication.

  • These medicines have positive evidence for cardiovascular and renal outcomes and additional indications for use – ASCVD, HF, CKD – (independent of glycaemic control.)
  • Due to these co-morbidities, there may be individuals with T2DM who may benefit from these therapies, especially if glycaemic control not at target.
  • A higher level of SGLT-2i and/or GLP-1RA indicates good practice, with suitable patients receiving appropriate medication.
  • Prioritise younger individuals for more aggressive treatment.

 

Note: PIS prescribing data is unable to directly identify those with a read code diagnosis of ASCVD, chronic HF or CKD.  Therefore, a surrogate marker of those co-prescribed nicorandil and/or GTN/ISMN for ASCVD is utilised.

The NTI identifies individuals prescribed SGLT-2i and/or GLP-1RA in the same quarter as a nitrate and/or nicorandil, aspirin or clopidogrel as a proportion of people prescribed anything from BNF 060102 in the same quarter as a nitrate and/or nicorandil, aspirin or clopidogrel. This surrogate marker indicates there is a proportion of those with T2DM who may benefit from treatment with SGLT-2i or GLP-1RA, irrespective of glycaemic control. 

Individuals prescribed SGLT-2I and/or GLP-1RA in the same quarter as existing drug therapy suggestive of ASCVD

Action required by boards/clusters/practices

GP clusters should identify practices that are lower users of SGLT-2i/GLP-1RA and consider if there may be unwarranted variation.

Identify individuals who would benefit from prescribing of SGLT-2i or GLP-1RA:

  • Individuals with T2DM with existing CVD but not prescribed SGLT-2i/GLP-1RA
  • Individuals with T2DM with high ASSIGN/QRISK score not on SGLT-2i/GLP-1RA
  • Individuals with T2DM with renal disease, based on (eGFR and) ACR values – identified individuals should have all medications reviewed to ensure doses appropriate for degree of renal impairment. Note: it is acknowledged that many people will not have an ACR recorded and therefore to aid identification of suitability for SGLT-2i/GLP-1RA prescribing, screening with eGFR may be required initially, with an ACR recorded thereafter
  • Target younger individuals with T2DM as priority candidates for more aggressive treatment.
  • Boards to review formularies/treatment algorithms to ensure in line with current guidance.
  • The 7 Step medication review process should be used.