What is the best management approach for a 45-year-old male with a 10-year history of type 2 diabetes (T2D), hypertension, and a 10-year atherosclerotic cardiovascular disease (ASCVD) risk of 10.5%, currently taking aspirin, metformin (metformin hydrochloride), and Januvia (sitagliptin), with an elevated LDL (low-density lipoprotein) and normal HDL (high-density lipoprotein)?

From the Guidelines

The best management approach for this patient should include starting a moderate-intensity statin therapy, such as atorvastatin 20 mg daily or rosuvastatin 10 mg daily, to address his elevated LDL cholesterol and reduce his cardiovascular risk. Given his 10-year ASCVD risk of 10.5%, which exceeds the 7.5% threshold, statin therapy is strongly indicated, as supported by the 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease 1. His diabetes management appears reasonable with metformin and sitagliptin, but he should have his HbA1c monitored to ensure it's below 7%. For hypertension, his blood pressure target should be less than 130/80 mmHg, and if not at goal, adding an ACE inhibitor like lisinopril 10-20 mg daily or an ARB would be appropriate, as these medications offer renal protection in diabetic patients.

Some key points to consider in his management include:

• The use of statin therapy in patients with diabetes mellitus and elevated LDL-C levels, as recommended by the 2024 standards of care in diabetes 1
• The importance of lifestyle modifications, including a healthy diet, regular physical activity, weight management, and smoking cessation, as emphasized in the 2019 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol 1
• The need for regular monitoring, including quarterly diabetes follow-ups with HbA1c measurements, annual lipid panels, regular blood pressure checks, and screening for diabetic complications, to ensure optimal management of his condition.

Overall, the management of this patient should focus on reducing his cardiovascular risk through the use of statin therapy, lifestyle modifications, and optimal management of his diabetes and hypertension, with regular monitoring to ensure the best possible outcomes.

From the FDA Drug Label

The JUPITER study was stopped early by the Data Safety Monitoring Board due to meeting predefined stopping rules for efficacy in rosuvastatin-treated subjects The primary end point was a composite end point consisting of the time-to-first occurrence of any of the following major CV events: CV death, nonfatal myocardial infarction, nonfatal stroke, hospitalization for unstable angina or an arterial revascularization procedure. Rosuvastatin significantly reduced the risk of major CV events (252 events in the placebo group vs. 142 events in the rosuvastatin group) with a statistically significant (p<0. 001) relative risk reduction of 44% and absolute risk reduction of 1. 2%

The best management approach for a 45-year-old male with a 10-year history of type 2 diabetes, hypertension, and a 10-year atherosclerotic cardiovascular disease (ASCVD) risk of 10.5%, currently taking aspirin, metformin, and Januvia, with an elevated LDL and normal HDL, is to consider adding a statin, such as rosuvastatin, to reduce the risk of major CV events, given the patient's high ASCVD risk.

• The patient's LDL level of 90 and 10-year ASCVD risk of 10.5% indicate a need for more aggressive lipid management.
• Rosuvastatin has been shown to significantly reduce the risk of major CV events, including nonfatal myocardial infarction, nonfatal stroke, and arterial revascularization procedures, in patients with similar risk profiles 2.

From the Research

Management Approach for a 45-year-old Male with Type 2 Diabetes and Hypertension

The patient in question has a 10-year history of type 2 diabetes, hypertension, and a 10-year atherosclerotic cardiovascular disease (ASCVD) risk of 10.5%. He is currently taking aspirin, metformin, and Januvia, with an elevated LDL and normal HDL.

Current Medications and ASCVD Risk

• Aspirin: used for primary prevention of cardiovascular events in patients with diabetes 3
• Metformin: first-line treatment for type 2 diabetes, also has benefits for cardiovascular risk reduction 4
• Januvia (sitagliptin): a dipeptidyl peptidase-4 inhibitor used to improve glycemic control in patients with type 2 diabetes 4
• Elevated LDL: increases the risk of ASCVD, high-intensity statins are recommended for patients with ASCVD or high-risk primary prevention patients 4

Recommendations for Management

• High-intensity statins: recommended for patients with ASCVD or high-risk primary prevention patients, with a goal of reducing LDL by 50% or greater 4
• Non-statin drugs: may be added to high-intensity statins in very high-risk patients, such as ezetimibe, bile acid sequestrant, or proprotein convertase subtilisin/kexin type 9 inhibitor 4
• Coronary artery calcium scoring: may be used to assess ASCVD risk in patients with a 10-year risk of 7.5% to less than 20% 4
• Lifestyle modifications: importance of controlling risk factors, including blood pressure, body mass index, exercise habits, and smoking status, to reduce ASCVD event rates 5

Estimating ASCVD Risk

• The 2013 ACC/AHA 10-year ASCVD risk algorithm: better than SCORE and QRisk II in detecting high cardiovascular risk in patients with rheumatoid arthritis, but may still fail to identify some high-risk patients 6
• The Predicting Risk of Cardiovascular Disease Events (PREVENT) equations: updated equations for estimating 10-year ASCVD risk, which may result in fewer adults being eligible for primary prevention statin therapy 7
• Temporal change in 10-year ASCVD risk: reflects success or failure in controlling major cardiovascular risk factors and indicates the risk of future ASCVD events 5