Poll Results: When Do You Start Statin Therapy in a Person with Diabetes?

This recent poll assessed our readers' statin prescription patterns in routine clinical practice in patients with diabetes but without established cardiovascular disease.

The 2018 American Heart Association (AHA)/American College of Cardiology (ACC)/ Multisociety guidelines for lipid management provide revised recommendations for the prevention of atherosclerotic cardiovascular disease (ASCVD). In primary prevention, statins are recommended for patients with LDL-C levels ≥190 mg/dL, patients with diabetes mellitus aged 40-75 years, and for those with no diabetes with LDL-C levels ≥70 mg/dL - <190mg/dL and 10-year ASCVD risk ≥7.5%. For most patients with diabetes aged 40-75 years, the current guidelines recommend initiating moderate-intensity statin without estimation of their 10-year ASCVD risk, and the decision to initiate a high-intensity statin is determined by the level of ASCVD risk. While prior guidelines suggested high-intensity statins for patients with diabetes if their 10-year ASCVD risk is ≥7.5%, the current guidelines recommend initiating high-intensity statin for those with the presence of multiple risk factors to reduce LDL-C levels by ≥50%. Additionally, 2018 guidelines incorporated recommendations for nonstatin cholesterol-lowering drugs based on evidence from recent randomized controlled trials. The current guidelines suggest the addition of ezetimibe to maximally tolerated statin therapy in patients with diabetes and 10-year ASCVD risk of ≥20% to achieve a reduction of LDL-C levels by ≥50%.

Our poll, which garnered a total of 171 votes, seems to confirm our readers' interest in further risk stratifying patients with diabetes to determine intensity of preventive therapy. Approximately 28% (48) of readers would use a moderate-intensity statin in most patients with diabetes but without clinical ASCVD. According to the 2018 guidelines, moderate-intensity statin therapy is indicated in patients aged 40-75 years with diabetes, regardless of their 10-year ASCVD risk. In patients at higher risk, especially in the presence of additional risk factors or 10-year ASCVD risk score ≥20%, nearly half of respondents, 47% (81), preferred treatment with a high-intensity statin, consistent with the current recommendations. Moderate- intensity statins reduce LDL-C levels by 30-49%, whereas high-intensity statins reduce LDL-C levels by ≥50%. When risk decision is uncertain, the guidelines suggest the use of 10-year ASCVD risk scoring for further risk stratification in patients aged 40-75 years with diabetes and LDL-C levels 70-189 mg/dL. A small percentage of our readers, 15% (26), indicated their decision to initiate or modify statin intensity if LDL-C levels were ≥100mg/dL (as opposed to basing decision on risk factors or global risk). Only 10% (16) indicated that they would initiate high-intensity statin for all diabetes patients in primary prevention settings regardless of the presence or absence of additional risk factors for ASCVD. The 2018 recommendations for statin therapy in patients with diabetes but without established ASCVD according to age group are summarized below (Table 1).

Table 1: The 2018 recommendations for statin therapy in patients with diabetes but without established ASCVD according to age group

Primary Prevention: 2018 ACC/AHA/MS statin recommendations for patients with diabetes mellitus by age group
Age Statin Recommendations
20 - 39 years Moderate-intensity statin for patients with one or more diabetes-specific risk enhancers a (IIb)
40 - 75 years Moderate-intensity statin regardless of the 10-year ASCVD risk (class I)
High-intensity statin for patients with multiple risk factors a b c (IIa)
>75 years Continue statin therapy if already on statin therapy (IIa)
Initiate statin therapy after clinician-patient discussion of potential benefits and risks of initiating statin therapy (IIb)
Note:For patients with diabetes and 10-year ASCVD risk of ≥20%, addition of ezetimibe, a nonstatin therapeutic agent to maximally tolerated statin therapy may be considered to reduce LDL-C levels by ≥50% (IIb).
a Diabetes-specific risk enhancers: long duration (10 years of type 2 diabetes mellitus, ≥20 years of type 1 diabetes mellitus), albuminuria (≥30 mcg of albumin/mg creatinine), estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2, retinopathy, neuropathy or ankle brachial index (ABI) <0.9
b Major ASCVD risk factors: age (50-75 years), elevated blood pressure, dyslipidemia, cigarette smoking, obesity, family history of ASCVD
c ASCVD risk enhancers: family history of premature ASCVD, persistently elevated LDL > 160mg/dL (>4.1mmol/L, chronic kidney disease, metabolic syndrome, history of preeclampsia, history of premature menopause, inflammatory disease (especially rheumatoid arthritis, psoriasis, HIV), ethnicity (e.g., South Asian ancestry), persistently elevated triglycerides > 175mg/dl (>2.0mmol/L), Hs-CRP > 2mg/L, Lp(a) > 50mg/dl or >125nmol/L, Apo B > 130mg/dl, ankle-brachial index (ABI) < 0.9

Patients with diabetes have an increased lifetime risk of ASCVD events compared to those without diabetes, and there does appear to be marked heterogeneity in the ASCVD risk. The revised guidelines emphasize the importance of ASCVD risk assessment and recommend the inclusion of risk enhancers (diabetic-specific and non-specific) for initiating or modifying statin intensity to facilitate a more personalized approach for lipid management in patients with diabetes in primary prevention of ASCVD. As presented here, the results from this recent poll highlight the complex decision-making process involved in deciding appropriate statin therapy for the prevention of ASCVD in patients with diabetes. Therefore, an effective clinician-patient risk discussion continues to remain central to facilitate shared decision making about the potential benefits, adverse effects, and importantly, patient preferences for initiating or intensifying statin therapy in primary prevention of ASCVD.

We thank all our participants.

Clinical Topics: Diabetes and Cardiometabolic Disease, Dyslipidemia, Lipid Metabolism, Nonstatins, Novel Agents, Statins

Keywords: Diabetes Mellitus, Metabolic Syndrome, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Diabetes Mellitus, Type 2, American Heart Association, Diabetes Mellitus, Type 1, Cholesterol, LDL, Risk Factors, Creatinine, Albuminuria, Apolipoproteins B, Glomerular Filtration Rate, Ankle Brachial Index, Cardiovascular Diseases, Blood Pressure

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