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How Do New Statin Guidelines Affect Diabetes Care?

Anne L. Peters, MD

November 21, 2013

Hi. This is Dr. Anne Peters, from the University of Southern California. Today I'm going to talk about the new
American College of Cardiology/American Heart Association (ACC/AHA) guidelines [1] for the treatment of
dyslipidemia and risk for cardiovascular disease.
Many of you have probably already read these guidelines and have some understanding about what they mean. I
want to discuss them from my perspective as a clinician and then discuss how they affect patients with diabetes.
First of all, I want to commend the authors for doing this -- for trying to write new evidence-based guidelines that
really shift how we think about the treatment of lipid disorders. As one of the authors of the new diabetes position
statement on the treatment of hyperglycemia, I know how hard it is both to review the evidence as well as to come
away with conclusions that can help guide our treatment of patients.
The key to these new guidelines is to not look at numbers as targets but rather to look at risk, to see which of our
patients are at highest risk for cardiovascular events, and then to treat them accordingly.

A Review of the Guidelines

The guidelines create 4 different groups. The first group consists of individuals who have already had an event and
who have cardiovascular disease, whether it be a myocardial infarction, unstable angina, stroke, or peripheral
vascular disease. Those patients become the secondary prevention patients, those at highest risk.
Basically, we don't care about what their numbers are. They need to be on intensive statin therapy. They need to
be on a high dose of a statin, and we don't need to measure what their lipids are because we know that giving
them the maximum dose of a statin will maximally reduce their risk for having another event. Those are the
sickest ones, the ones at highest risk.
The individuals in the next group are based on a lipid panel. If the low-density lipoprotein (LDL) cholesterol level is
190 mg/dL, those individuals are also considered to be at very high risk. It is recommended that they are also
treated with intensive statin therapy at the high dose.
The third group consists of individuals with diabetes. The authors actually lumped together patients with type 1
and type 2 diabetes, which, as I'll discuss in a minute, may not be quite fair. But regardless, patients with
diabetes are considered to be at high risk. Depending on their 10-year risk for an event, whether or not it's greater
than or equal to 7.5%, they are put on either a moderate-intensity statin regimen or the high-intensity statin
regimen. But they are all put on statins if they are between the ages of 40 and 75 years.
Finally, the fourth category is basically everybody else who ranges in age from 40 to 75 years. It is recommended
that patients are fit into a pooled risk equation in order to assess the 10-year risk for a cardiovascular disease
event. If the risk is greater than or equal to 7.5%, treatment with a statin is recommended.
These guidelines are basically completely focused on statins, and this is because of the lack of data on other
therapies. Either the other nonstatin treatments are considered to be less effective than statins, or they don't have
the same types of outcome data that we have for statins.
I think that one of the reasons for moving away from just looking at LDL targets is that there are treatments that
we know can make LDL targets better, but they don't necessarily improve outcomes. We know this from such
studies as AIM-HIGH[2] with niacin. We know that when you give estrogen, you can improve the lipid profile but
not improve outcomes.[3] So really, these guidelines say that if you are at high risk -- and they define it in a
number of different ways -- you need to be on statin therapy regardless of your LDL cholesterol.
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A Problem for Patients With Diabetes

Now, that takes me back to the patients with diabetes. One of the problems with lumping people with type 1 and
type 2 diabetes together is that although both are at higher risk, we don't really know what that true risk is,
particularly in individuals with type 1 diabetes. I don't think that type 1 and type 2 diabetes share similar features,
or at least not similar features with regard to the metabolic syndrome in all patients. Therefore, as I ponder these
guidelines, I find myself also pondering about my individual patients.
Just this week, I had a patient who came into the office. He is lean, his body mass index is 20 kg/m2, and he has
had type 1 diabetes for many years. He is in his 50s, and he runs 5 miles a day. He is not hypertensive. In fact,
his blood pressure is 110/70 mm Hg without any medication. He has no diabetes complications, and his LDL
cholesterol is 73 mg/dL, with an HDL of 75 mg/dL. I also measured his C-reactive protein level, which was very
low. Coronary calcium scanning showed no coronary calcium.
So in this particular individual, even though the guidelines would say that he should be on a statin because his
LDL is above 70 mg/dL, I looked at him, discussed this with him, and decided not to treat with a statin -- at least
not yet -- because his risk appears to be fairly low.
But for many of our patients with diabetes, the risk is high. Most of my patients with type 2 diabetes have the
metabolic syndrome, are at higher risk for cardiovascular disease, and benefit from statin therapy.
I think the hardest thing is going to be trying to get over testing lipids all the time. My patients and I love numbers.
I'm a diabetes specialist. I look at numbers all the time. We look at self-monitoring of blood glucose values, we
look at A1c levels, and my patients love to look at their lipid panels to know how they are doing.
So I think I will still monitor lipid panels. Perhaps not for absolute numbers, but to see that a patient is responding
to therapy -- maybe as a marker for the fact that my patients are taking their therapy, and also to reinforce
patients with some of the benefit from the treatments and lifestyle changes they have made, which I think can still
be had along with the use of statin therapy in these high-risk individuals.
This has been Dr. Anne Peters for Medscape. Thank you.
References

1. Stone NJ, Robinson J, Lichtenstein AH, 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. 2013 Nov 12.
[Epub ahead of print]
2. AIM-HIGH Investigators, Boden WE, Probstfield JL, et al. Niacin in patients with low HDL cholesterol levels
receiving intensive statin therapy. N Engl J Med. 2011;365:2255-2267. Abstract
3. Andersson B, Mattsson L, Hahn L, et al. Estrogen replacement therapy decreases hyperandrogenicity and
improves glucose homeostasis and plasma lipids in postmenopausal women with noninsulin-dependent
diabetes mellitus. J Clin Endocrinol Metab. 1997;82:638-643. Abstract
Medscape Diabetes & Endocrinology 2013 WebMD, LLC

Cite this article: How Do New Statin Guidelines Affect Diabetes Care? Medscape. Nov 21, 2013.

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