From the Guidelines
High-intensity statin therapy is recommended for diabetic patients aged 40-75 years with additional cardiovascular risk factors or established atherosclerotic cardiovascular disease (ASCVD), as stated in the most recent guidelines 1.
Key Points to Consider
- Diabetic patients with a history of myocardial infarction, stroke, coronary artery disease, peripheral arterial disease, or other clinical manifestations of ASCVD should receive high-intensity statins.
- Diabetic patients with multiple cardiovascular risk factors such as hypertension, smoking, family history of premature ASCVD, chronic kidney disease, or persistent elevated LDL-C levels (≥70 mg/dL) should be considered for high-intensity statin therapy.
- High-intensity statins include atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily, which work by inhibiting HMG-CoA reductase, reducing LDL cholesterol levels by ≥50% 1.
- The rationale for this approach is that diabetes significantly increases cardiovascular risk, and high-intensity statins have demonstrated substantial risk reduction for cardiovascular events in these high-risk populations.
- Before initiating therapy, baseline liver function tests should be obtained, and patients should be monitored for muscle symptoms, which are the most common side effects.
Additional Considerations
- For patients with diabetes and ASCVD, if LDL cholesterol is ≥70 mg/dL on maximally tolerated statin dose, consider adding additional LDL-lowering therapy (such as ezetimibe or PCSK9 inhibitor) after considering the potential for further ASCVD risk reduction, drug-specific adverse effects, and patient preferences 1.
- In adults with diabetes aged >75 years already on statin therapy, it is reasonable to continue statin treatment, while initiation of statin therapy in this age group may be considered after discussion of potential benefits and risks 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Eligibility Criteria for High-Intensity Statin Therapy in Diabetic Patients
The following criteria qualify diabetic patients for high-intensity statin therapy:
- Patients with type 2 diabetes without high concentrations of LDL-cholesterol, as evidenced by the Collaborative Atorvastatin Diabetes Study (CARDS) 2
- Patients with diabetes who have a high risk of cardiovascular disease, as identified by the presence of risk factors such as retinopathy, albuminuria, current smoking, or hypertension 2
- Patients with diabetes who have a history of cardiovascular disease or are at high risk of developing cardiovascular disease, as suggested by the study on cardiovascular disease in diabetic patients 3
High-Intensity Statin Therapy Benefits
High-intensity statin therapy has been shown to:
- Reduce the risk of major cardiovascular events, including acute coronary heart disease events, coronary revascularisations, and stroke, by 37% in patients with type 2 diabetes 2
- Lower the death rate by 27% in patients with type 2 diabetes 2
- Prevent at least 37 major vascular events per 1000 patients treated for 4 years 2
Considerations for Statin Therapy
When considering statin therapy for diabetic patients, the following factors should be taken into account:
- The type of statin used, as some studies suggest that rosuvastatin may have a different effect on new-onset diabetes mellitus compared to atorvastatin 4
- The achieved LDL-C level, as a level below 70 mg/dL may increase the risk of new-onset diabetes mellitus with rosuvastatin therapy 4
- The importance of timely lipid-lowering therapy, as delaying statin therapy can increase the risk of cardiovascular events in patients with diabetes 5