From the Guidelines
Statins should be started in most adults with diabetes aged 40-75 years without ASCVD, using moderate-intensity statin therapy in addition to lifestyle therapy. This recommendation is based on the most recent guidelines from the Diabetes Care journal, published in 2025 1. For people with diabetes aged 40–75 years at higher cardiovascular risk, including those with one or more additional ASCVD risk factors, high-intensity statin therapy is recommended to reduce LDL cholesterol by ≥50% of baseline and to obtain an LDL cholesterol goal of <70 mg/dL (<1.8 mmol/L).
Some key points to consider when starting statin therapy in patients with diabetes include:
- For people with diabetes aged 20–39 years with additional ASCVD risk factors, it may be reasonable to initiate statin therapy in addition to lifestyle therapy 1.
- For people with diabetes aged 40–75 years at higher cardiovascular risk, especially those with multiple additional ASCVD risk factors and an LDL cholesterol ≥70 mg/dL (≥1.8 mmol/L), it may be reasonable to add ezetimibe or a PCSK9 inhibitor to maximum tolerated statin therapy 1.
- In adults with diabetes aged >75 years already on statin therapy, it is reasonable to continue statin treatment 1.
The rationale for statin therapy in diabetes is that diabetes significantly increases cardiovascular risk, and statins have been proven to reduce major cardiovascular events and mortality in this population by lowering LDL cholesterol and through pleiotropic effects including anti-inflammatory properties. Before starting statins, baseline liver function tests should be checked, and patients should be monitored for muscle symptoms, which are the most common side effects.
It's worth noting that the 2022 ACC expert consensus decision pathway on the role of nonstatin therapies for LDL-cholesterol lowering in the management of atherosclerotic cardiovascular disease risk also supports the use of statin therapy in patients with diabetes 1. However, the most recent guidelines from 2025 should be prioritized when making clinical decisions 1. The 2014 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults also provides guidance on statin therapy in patients with diabetes, but it is less relevant due to its older publication date compared to the 2025 guidelines 1.
From the Research
Statin Therapy in Diabetes
- Statin therapy is crucial for the primary prevention of atherosclerotic cardiovascular disease (ASCVD) in patients with type 2 diabetes mellitus (T2DM) 2.
- Patients with type 2 diabetes mellitus are at 2 to 4 times increased risk of cardiovascular events compared with those without diabetes 3.
- The use of statin treatment with high intensity is endorsed for all diabetes-and-CVD patients, while a moderate-intensity treatment can be applied to patients with diabetes, having additional risk factors for CVD 4.
Timing of Statin Initiation
- There is no specific evidence on when to start statin therapy in diabetes, but it is recommended to start statin therapy as soon as possible in patients with high cardiovascular risk 3, 2.
- Statins are a fundamental treatment for diabetic dyslipidemia, both for dyslipidemia and for CVD prevention, and their protective effects in CVD progression overcome the risk of statin-associated incident diabetes 4.
Intensity of Statin Therapy
- High-intensity statins have been prescribed only for 38.5% of moderate-high-risk patients, and 30.7% of low-risk patients 2.
- Moderate-intensity statin with ezetimibe combination therapy is a suitable alternative to high-intensity statins if the latter cannot be tolerated, or further reduction in LDL cholesterol is required among patients with DM and ASCVD 5.
- LDL-C target achievement was studied in a randomly selected subsample of 683 and 65.4% achieved LDL-C targets, with 70.7% in low-risk patients and 60.3% in moderate-high-risk patients 2.
Factors Associated with LDL-C Target Achievement
- Female gender, poor adherence to statins, poor glycemic control, and inadequate physical activity were significantly associated with failing to achieve LDL-C targets 2.
- The importance of lifestyle management and other preventive measures is emphasized for management of risks for both T2D and CV disease events in patients receiving statin therapy 6.