RESEARCH ARTICLE SA JOURNAL OF DIABETES & VASCULAR DISEASE 28 VOLUME 21 NUMBER 1 • November 2024 Active surveillance of MDD in patients without T2DM, but with established CVD, demonstrated a greater severity of depressive symptoms than those without a CVD event.65 The aggressive amelioration of treatment of these depressive symptoms has shown a reduction in CVD events of up to 43%.76 Numerous interventional studies with statins have shown a reduction of coronary events, all cardiovascular events and mortality of between 10 and 30% for every mmol/l reduction in LDL-C level, even if the baseline LDL-C level was in the normal range32 in individuals with established CAD.77-79 Besides their lipid-lowering properties, large studies report that statin use was associated with a reduced risk of depression.80 This intrinsic property of statins is beneficial in patients post heart attack and in individuals experiencing excess inflammation due to physical diseases such as stroke, which are highly co-morbid with MDD.81 Lipophilic statins (simvastatin and atorvastatin) showed greater potential to decrease depressive symptoms than hydrophilic statins (rosuvastatin and pravastatin) as these statins can cross the blood– brain barrier.82 In T2DM patients with co-morbid MDD, certain antidepressants such as an SSRI (Fluoxetine) and norepinephrine dopamine reuptake inhibitor (Bupropion) have been associated with improvement in HbA1c control in patients with T2DM + MDD. 83,84 In the T2DM + MDD group in this study, 62% of those on SSRIs were at the HbA1c level of < 7%, while 53% of those not on SSRIs achieved the same target, suggesting glycaemic control among patients with T2DM diagnosed and treated for MDD fared well with their diabetes. Future research should be implemented on the CV risk profile of patients with MDD using the Framingham risk score85 to identify individuals at increased risk for future CVD, and depressive outcomes of the interaction of statins and SSRIs in this group. The present study suggests the need for holistic management of T2DM and associated co-morbidities such as MDD and CVD. Glycaemic and lipid targets attained as per guideline recommendations were suboptimal when treatment and management of NCDs are in silos as seen in this study. Bringing in more awareness on LDL-C control to patients with T2DM and MDD, and to their treating physicians and service providers, through collaborative care for patients with T2DM and co-morbidities in this setting, is a gap that has to be addressed. Early intervention may be needed to assist younger individuals with T2DM and early onset T2DM with MDD, to achieve better glycaemic control. Limitations Firstly, the onset of T2DM and MDD was not recorded in this sample, which is a key feature in the risk stratification of individuals with diabetes for a CVD event. Secondly, the medication compliance of the patients was not recorded. Data on other risk factors such as obesity, smoking and physical exercise, which contribute to the risk of a premature CVD event was not available, as very few members or practitioners forwarded this data to the healthcare organisation. Lastly, this analysis referenced the target LDL-C control for very high-risk patients with T2DM and CVD risk factors at < 1.8 mmol/l. The result would have been even less if the latest ESC guidelinerecommended LDL-C target of < 1.4 mmol/l was used.44 Discrete variables of patients claiming insulin only [12/223 (5.4%) in the T2DM + MDD group and 15/656 (2.3%) in the T2DM – MDD group] were excluded from the multivariate regression analysis as very few were claiming for insulin only. Conclusion In a private managed healthcare setting in SA, this study shows poor ABC goal attainment in both the T2DM – MDD and T2DM + MDD patients. Older patients with T2DM + MDD showed better HbA1c and LDL-C control, highlighting the need to assist younger adults who show poor adherence to medication to achieve ABC control. A significantly higher rate of repeated macrovascular hospitalisations for 2019 in patients with T2DM + MDD may reflect the effect of MDD in the increased risk of CV events. The majority of patients with T2DM with and without MDD showed very poor achievement of the LDL-C target level recommended by the South African Heart Association and Lipid and Atherosclerosis Society of Southern Africa. Currently, the triad of LDL-C, BP and HbA1c are reported independently in the interpretation of patient clinical presentation, however, there is a need to consider all three measures within the context of the ABC target levels in patients with T2DM. A change in clinical case management would potentially reduce the risk of CV events. Acknowledgements The authors thank Mr Bruce Dickson, Dr Philly Masopha, Mrs Linky Olivier and Mrs Megan Rama for the encouragement received for this study, and Mrs Audrey Pestana for her efforts in extracting the claims data. References 1. International Diabetes Federation. IDF Diabetes Atlas, 10th edn. https://www.idf. org/e-library/epidemiology-research/diabetes-atlas.html [Accessed on July 22, 2022] 2. Tomlinson M, Grimsrud AT, Stein DJ, Williams DR, Myer L. The epidemiology of major depression in South Africa: results from the South African stress and health study. S Afr Med J 2009; 99(5): 368–373. 3. Naidoo L, Butkow N, Barnard-Ashton P, Libhaber E. Hospitalisation of type 2 diabetes mellitus patients with and without major depressive disorder in a private managed healthcare organisation. J Endocrinol Metab Diabetes S Afr 2019; 24(3): 70–76. 4. Sarwar N, Gao P, Seshasai SR, Gobin R, Kaptoge S, Di Angelantonio E, et al. Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies. Lancet 2010; 375(9733): 2215–2222. 5. ABC goals in patients with Type 2 diabetes. https://pro.aace.com/disease-stateresources/diabetes/depth-information/type-2-diabetesglucose-managementgoals [Accessed on April 3, 2022] 6. Amod A. The society for endocrinology, metabolism and diabetes of South Africa type 2 diabetes guidelines expert committee. The 2017 SEMDSA guideline for the management of type 2 diabetes guideline committee. J Endocrinol Metab Diabetes S Afr 2017; 22(1): S1–S196. 7. Vouri SM, Shaw RF, Waterbury NV, Egge JA, Alexander B. Prevalence of achievement of A1c, blood pressure, and cholesterol (ABC) goal in veterans with diabetes. J Managed Care Pharm 2011; 17(4): 304–312. 8. Stark Casagrande S, Fradkin JE, Saydah SH, Rust KF, Cowie CC. The prevalence of meeting A1C, blood pressure, and LDL goals among people with diabetes, 1988– 2010. Diabetes Care 2013; 36(8): 2271–2279. 9. American Diabetes Association. Standards of medical care in diabetes – 2010. Diabetes Care 2010; 33(Suppl 1): S11–61. 10. Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 129(25 Suppl 2): S1–45. 11. Klug E. South African Heart Association (SA Heart); Lipid and Atherosclerosis Society of Southern Africa (LASSA). South African Dyslipidaemia Guideline Consensus Statement. S Afr Med J 2012; 102(3). 12. Yahagi K, Kolodgie FD, Lutter C, Mori H, Romero ME, Finn AV, et al. Pathology
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