Cardiovascular risk management in the elderly with type 2 diabetes prior to death: A Danish nationwide register study of discontinuation patterns

Background Cardioprotective medication usage among elderly individuals with type 2 diabetes (T2D) is prevalent, however, the degree and timing of discontinuation is unknown. This study aims to describe the extent, timing, and secular changes of discontinuation of cardioprotective medication in elderly with T2D. Methods In this register-based cohort study all individuals with T2D, deceased between 2006-2018 at an age of 80 years or older, were identified through Danish nation-wide registers. We followed the population backward in time, from death to last intake of antihypertensive, lipid-lowering, and antithrombotic medication. Poisson regression models were used to model rates of discontinuation prior to death while binomial models were used to estimate the proportion on medication at time of death. Results We identified 52,523 individuals (55% women) with a mean (SD) age at T2D diagnosis of 77.3 (7.8) years and median (Q1-Q3) age at death of 86.5 [83.3-90.3] years. The proportion on any antihypertensive and antithrombotic medication was high (approximately 78% [95% CI 77-78] and 48% [95% CI 47-49%] at time of death, respectively) and increased slightly with increasing calendar year of death. Discontinuations occurred predominantly in the last year of life but were initiated earlier for individuals who died in recent calendar years. However, for angiotensin-converting enzyme, thiazides, and acetylsalicylic acid we found a more continuous discontinuation in the decade prior to death in the recent calendar years of death. The proportion on statins increased markedly with calendar year of death, peaking at 34% [95% CI 33-35%] in 2016 with a subsequent decrease to 29% [95% CI 28-30%] in 2018. Discontinuation patterns shifted from predominantly occurring in the last years of life to continues discontinuation in the decade before death. Conclusion Our results suggest an intensification with cardioprotective medication among elderly with type 2 diabetes and a more pronounced discontinuation during the last years of life. This may be a result of increased focus on individualized-treatment-regimens. ### Competing Interest Statement VK, BB and HRC have nothing to declare. GSA, MEJ and BC own shares in Novo Nordisk A/S. GSA is employed at Novo Nordisk A/S. JR reports personal fees from Boehringer-Ingelheim, personal fees from Abbott, personal fees from Novo Nordisk, personal fees from Astra-Zeneca, outside the submitted work. MEJ has received research grants from Amgen, Astra Zeneca, Boehringer Ingelheim, Novo Nordisk and Sanofi Aventis. ### Clinical Trial not relevant ### Funding Statement none ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study was approved by the Danish Data Protection Agency. All data were anonymized and located at Statistics Denmark. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as [ClinicalTrials.gov][1]. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Study data cannot and therefore will not be made publicly available as all data is held at Statistics Denmark's servers, and individual data from these are confidential for data privacy reasons. Access to data requires an application and permissions to access the patient level data. [1]: http://ClinicalTrials.gov