Why use moderate-intensity statin (HMG-CoA reductase inhibitor) versus high-intensity statin in patients with Diabetes Mellitus type 2 (DM2)?

From the Guidelines

High-intensity statin therapy is recommended for most patients with type 2 diabetes mellitus (DM2) as first-line therapy, unless contraindicated, due to its potential to achieve greater LDL cholesterol reductions and offer better cardiovascular protection. The decision between moderate-intensity and high-intensity statins in patients with DM2 depends on individual cardiovascular risk and tolerance, as discussed in the 2023 standards of care in diabetes 1. For adults 40–75 years of age with diabetes, moderate-intensity statin therapy should be initiated or continued, according to the 2013 ACC/AHA guideline 1. However, high-intensity statin therapy is reasonable for adults 40–75 years of age with diabetes with a 7.5% estimated 10-year ASCVD risk unless contraindicated 1.

Some key points to consider when choosing between moderate-intensity and high-intensity statins in patients with DM2 include:

• The patient's age, comorbidities, and overall cardiovascular risk profile
• The potential for adverse effects, such as myalgias, and drug interactions
• The need for regular monitoring of liver function tests and symptoms of muscle pain, regardless of statin intensity
• The goal of achieving an LDL cholesterol reduction of ≥50% from baseline and an LDL cholesterol goal of <55 mg/dL, as recommended for people with diabetes and ASCVD 1

In general, high-intensity statin therapy has been shown to reduce cardiovascular event rates in high-risk individuals with established cardiovascular disease, including those with diabetes 1. The addition of nonstatin agents, such as ezetimibe or PCSK9 inhibitors, may be considered if the LDL cholesterol goal is not achieved on maximum tolerated statin therapy 1. Ultimately, the decision to use moderate-intensity or high-intensity statin therapy in patients with DM2 should be individualized based on the patient's specific needs and circumstances.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Comparison of Moderate and High-Intensity Statin Therapy in Diabetes Mellitus Type 2

• The choice between moderate and high-intensity statin therapy in patients with diabetes mellitus type 2 (DM2) depends on various factors, including the patient's cardiovascular risk profile and glycemic control 2, 3.
• Studies have shown that high-intensity statin therapy can increase the risk of new-onset type 2 diabetes, particularly in patients with major risk factors for diabetes 3, 4.
• Moderate-intensity statin therapy, on the other hand, may have a more favorable effect on glycemic control, with some studies suggesting that it can improve insulin sensitivity and reduce the risk of diabetes 2, 4.
• The benefits of high-intensity statin therapy in reducing cardiovascular risk may outweigh the potential risks of diabetes, especially in patients with high cardiovascular risk 3, 4.
• The choice of statin therapy should be individualized, taking into account the patient's specific risk factors and medical history 2, 3, 5, 4, 6.

Factors Influencing the Choice of Statin Therapy

• The patient's cardiovascular risk profile, including factors such as age, blood pressure, and lipid levels 3, 4.
• The patient's glycemic control, including factors such as HbA1c levels and insulin sensitivity 2, 4.
• The presence of major risk factors for diabetes, such as obesity and family history 3, 4.
• The potential benefits and risks of high-intensity statin therapy, including the reduction in cardiovascular risk and the increased risk of diabetes 3, 4.

Specific Statins and Their Effects on Glycemic Control

• Pitavastatin has been shown to have a favorable effect on glycemic control, with improvements in HbA1c and fasting plasma glucose levels 2.
• Atorvastatin, particularly at high intensities, has been associated with an increased risk of diabetes and worsening glycemic control 2, 3, 4.
• Rosuvastatin has been shown to have a modest effect on glycemic control, with some studies suggesting that it can improve insulin sensitivity and reduce the risk of diabetes 5, 6.
• Simvastatin has been associated with a favorable effect on glycemic control, with improvements in HbA1c and fasting plasma glucose levels 2.