Do we always start diabetic patients on high-intensity statins (HMG-CoA reductase inhibitors)?

From the Guidelines

No, we do not always start diabetic patients on high-intensity statins, and the decision should be based on the patient's age, cardiovascular risk factors, and individual risk profile, as recommended by the most recent guidelines 1. The decision to start a diabetic patient on high-intensity statins depends on several factors, including the patient's age, presence of cardiovascular risk factors, and individual risk profile.

• For diabetic patients aged 40-75 with additional cardiovascular risk factors, such as hypertension, smoking, family history of premature cardiovascular disease, or albuminuria, high-intensity statins like atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily are typically recommended 1.
• For diabetic patients aged 40-75 without additional risk factors, moderate-intensity statins such as atorvastatin 10-20 mg, rosuvastatin 5-10 mg, simvastatin 20-40 mg, or pravastatin 40-80 mg daily may be sufficient 1.
• For diabetic patients under 40 or over 75 years of age, statin therapy should be individualized based on their specific risk profile and potential benefits versus side effects 1. The rationale for statin therapy in diabetes is that diabetes is considered a cardiovascular disease equivalent, significantly increasing the risk of atherosclerotic cardiovascular disease.
• Statins reduce this risk by lowering LDL cholesterol and providing pleiotropic effects, including anti-inflammatory and plaque-stabilizing properties 1.
• Before initiating statin therapy, baseline liver function tests should be checked, and patients should be monitored for muscle symptoms, which are the most common side effects 1. It is essential to consider the potential benefits and risks of statin therapy in each patient and to individualize treatment based on their unique needs and circumstances, as recommended by the most recent guidelines 1.

From the FDA Drug Label

Adults with type 2 diabetes mellitus with multiple risk factors for CHD but without clinically evident CHD Recommended starting dosage is 10 or 20 mg once daily; dosage range is 10 mg to 80 mg once daily. Patients requiring LDL-C reduction >45% may start at 40 mg once daily.

The answer is no, we do not always start diabetic patients on high-intensity statins. The starting dosage for adults with type 2 diabetes mellitus is 10 or 20 mg once daily, which may not be considered high-intensity. High-intensity statin therapy is typically defined as a daily dose of atorvastatin 40-80 mg or equivalent. The decision to start with a high-intensity statin should be based on the patient's individual risk factors and LDL-C reduction goals, such as those requiring LDL-C reduction >45% 2.

From the Research

Statin Therapy in Diabetic Patients

• Not all diabetic patients are started on high-intensity statins, as the decision to prescribe high-intensity statins depends on the patient's risk factors and medical history 3.
• High-intensity statins are recommended for patients with atherosclerotic cardiovascular disease (ASCVD) or those at high risk for ASCVD, including diabetic patients with associated risk factors 3.
• The American College of Cardiology and the American Heart Association guidelines recommend moderate-intensity or high-intensity statin therapy for primary prevention in individuals with diabetes mellitus, aged between 40 and 75 years, and with low-density lipoprotein cholesterol (LDL-C) from 70 to 189 mg/dL 4.

Situations Where High-Intensity Statins May Not Be Started

• If the patient has already achieved a low-density lipoprotein cholesterol (LDL-C) level <100 mg/dL with low-dose statin treatment, switching to a high-intensity statin may not be necessary 5.
• In patients with type 2 diabetes, moderate-intensity pitavastatin may be a better option than high-intensity atorvastatin, as it has been shown to improve glycemic control 4.
• The risk-benefit ratio of statin therapy should be considered, particularly in patients with major type 2 diabetes risk factors, as high-intensity statins may increase the risk of new-onset type 2 diabetes mellitus (T2D) 6.

Alternative Treatment Options

• A single-pill combination of moderate-intensity rosuvastatin plus ezetimibe may be a viable alternative to high-intensity rosuvastatin in patients with atherosclerotic cardiovascular disease (ASCVD) and type 2 diabetes (T2D), with a non-inferior LDL-C lowering efficacy and a good safety profile 7.
• Combining a moderate-intensity statin with ezetimibe may be a reasonable approach if high-intensity statin treatment is not tolerated in high-risk patients 3.