Real-World Pharmacological Patterns and Residual Cardiometabolic Risk in Patients with Type 2 Diabetes in Romania

Background: Contemporary management of type 2 diabetes mellitus (T2DM) has shifted from a glucose-centered approach toward integrated cardio-renal–metabolic protection. Although sodium–glucose cotransporter-2 (SGLT2) inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1 RAs), and intensive lipid-lowering therapies have demonstrated substantial cardiovascular and renal benefits, implementation in routine outpatient care and the burden of persistent residual risk remain insufficiently characterized in Romania. Objectives: We aimed to evaluate routine-care pharmacological treatment patterns, identify residual cardio-renal–metabolic risk despite ongoing therapy, determine independent correlates of persistent adverse outcomes, and explore potential therapeutic gaps in adults with T2DM. Methods: This cross-sectional observational study included 232 unique adults with T2DM attending a specialized outpatient diabetes clinic in Romania between 1 October 2024 and 19 February 2026. One eligible outpatient record per participant was analyzed; when multiple records were available, the earliest eligible record in the exported dataset was used as the index visit. No a priori sample-size calculation was performed. Pharmacological therapies, cardiovascular and renal phenotypes, metabolic biomarkers, and clinical outcomes were extracted from routinely collected electronic medical records. Residual risk was evaluated using glycemic, lipid, renal, obesity, and blood-pressure targets. Multivariable logistic regression analyses identified independent correlates of persistent cardio-metabolic abnormalities. An exploratory cumulative residual-risk count was constructed by summing seven clinically relevant uncontrolled risk factors. Results: Biguanides were the most frequently prescribed glucose-lowering agents (53.0%), followed by SGLT2 inhibitors (44.8%), insulin (32.3% of the total cohort), GLP-1 receptor agonists (15.5%), and DPP-4 inhibitors (14.7%). Statins were prescribed to 48.7% of participants. SGLT2 inhibitor use did not differ significantly according to established atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease phenotypes, whereas GLP-1 receptor agonists were prescribed more frequently in participants with obesity (22.0% vs. 7.6%, p = 0.003). Clinically important residual risk persisted across all treatment groups. Among SGLT2 inhibitor users, 57.3% had HbA1c ≥ 7%, while 27.9% remained albuminuric. Among insulin-treated participants, 84.0% had HbA1c ≥ 7%; reduced eGFR and albuminuria were also more frequent than among non-users. Despite statin therapy, 33.6% of treated participants continued to exhibit LDL cholesterol ≥ 100 mg/dL. In multivariable logistic regression, insulin therapy was associated with higher odds of HbA1c ≥ 7% (adjusted odds ratio [aOR] 7.41, 95% confidence interval [CI] 3.50–15.65), while SGLT2 inhibitor therapy was associated with lower odds of albuminuria (aOR 0.54, 95% CI 0.30–0.95). Absence of statin-containing therapy was associated with higher odds of LDL cholesterol ≥ 100 mg/dL (aOR 6.01, 95% CI 3.38–10.66). Absence of statin-containing therapy was associated with higher odds of residual LDL cholesterol ≥ 100 mg/dL (aOR 4.21, 95% CI 2.34–7.58). Seventy-two percent of participants presented at least three persistent cardio-renal–metabolic abnormalities, while 24.2% exhibited five or more. More than half of participants with established atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease were not receiving either an SGLT2 inhibitor or a GLP-1 receptor agonist. Conclusions: Significant residual cardio-renal–metabolic risk persists in adults with T2DM despite use of contemporary pharmacological therapies. Disease severity markers and treatment exposure were associated with persistent adverse outcomes, but the cross-sectional design does not establish causality. The study identified potentially modifiable therapeutic gaps among patients with established cardiovascular and renal disease. Comprehensive and repeatedly reassessed cardio-renal–metabolic management, integrating pharmacological optimization with individualized risk stratification, may improve implementation of guideline-directed therapy and reduce long-term complications in routine clinical practice.