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Diabetes Distilled: Missed opportunities: Statins underprescribed in ethnic minorities

Pam Brown
Compared to people of European ethnicity with newly diagnosed type 2 diabetes without established atherosclerotic cardiovascular disease (ASCVD), African/African Caribbean people were 24% less likely to receive guideline-indicated statin therapy for primary prevention and people of South Asian ethnicity were 9% less likely, according to an observational cohort study of UK primary care records. These differences in statin prescribing persisted after adjusting for differences in cholesterol levels, other CV risk factors, demographic factors, deprivation, comorbidity, healthcare usage and polypharmacy. The authors, reviewing data from 2006 to mid-2019, and comparing against current guideline recommendations in force at each time point, estimated that equalising statin prescribing for primary prevention across the three ethnicities could prevent up to 12,600 heart attacks and strokes over the lifetime of people currently diagnosed with type 2 diabetes in the UK.

People of South Asian and African/African Caribbean ethnicity are three times more likely to develop type 2 diabetes and are more at risk from CV complications compared to those of European ethnicity in the UK, with African/African Caribbean people at increased stroke risk independent of cholesterol levels. Lowering cholesterol with statin therapy for primary prevention is effective in reducing the burden of CV disease across ethnic groups, but previous UK studies identified ethnic differences in prescribing. This observational cohort study used the Clinical Practice Research Datalink (CPRD) to identify 31,000 people, between January 2006 and June 2019, who were newly diagnosed with type 2 diabetes and did not have ASCVD, and who were not already taking a statin but met the NICE guideline recommendations for statin prescribing for primary prevention (Eastwood et al, 2021). According to self-defined and Read-coded ethnicity, 88% of the cohort were European ethnicity, 8% South Asian and 4% African/African Caribbean ethnicity, reflecting the age and ethnic mix of the UK population.

Using age- and gender-adjusted models, people of African/African Caribbean ethnicity meeting the guideline recommendations for statin initiation were one third less likely to have them prescribed and South Asians were 12% less likely, compared to those of European ethnicity. The cholesterol to high-density lipoprotein ratio slightly attenuated the differences between ethnic groups, but there was no significant impact when adjustment for CV risk factors, demographic factors, deprivation, comorbidity, healthcare usage and polypharmacy were explored. After all adjustments, compared to people of European ethnicity newly diagnosed with type 2 diabetes and meeting guideline recommendations for statin therapy, African/African Caribbean people remained 24% less likely to be prescribed statins and South Asians 9% less likely. The authors concluded that they were unable to fully account for the prescribing differences. Lower baseline cholesterol in the South Asian and African/African Caribbean groups may have influenced those who prescribed based on cholesterol alone.

It was calculated that equalising statin initiation across these three ethnic groups could prevent around 12,600 ASCVD events in people currently living with a diagnosis of type 2 diabetes. The authors call for further research to confirm their findings, to further evaluate possible reasons for the prescribing differences and to provide education to equalise statin prescribing across ethnic groups, and thus contribute to reducing ASCVD events.

Strengths of the study included access to a large, nationally representative population with individual-level prescribing data and accounting for changes in the NICE statin guideline recommendations in force when assessing eligibility for the cohort.

Click here to read the study in full.


Eastwood SV, Mathur R, Sattar N et al (2021) Ethnic differences in guideline-indicated statin initiation for people with type 2 diabetes in UK primary care, 2006–2019: A cohort study.” PLoS Med 18: e1003672

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