At what level of fasting blood glucose would you initiate statin therapy in a patient with prediabetes?

From the Guidelines

I would recommend initiating statin therapy in a patient with prediabetes when their fasting blood glucose level indicates an increased risk of cardiovascular disease, regardless of the specific glucose level, as the decision to start statin therapy should be based on overall cardiovascular risk factors. The American Diabetes Association recommends statin therapy for patients with diabetes aged 40–75 years without atherosclerotic cardiovascular disease (ASCVD), in addition to lifestyle therapy 1. For patients with prediabetes, the decision to initiate statin therapy should consider their overall cardiovascular risk factors, including age, blood pressure, lipid profile, and family history of cardiovascular disease. Key factors to consider when deciding to initiate statin therapy include:

• Age: Patients aged 40–75 years are at higher risk of cardiovascular disease and may benefit from statin therapy 1
• Blood pressure: Patients with hypertension are at higher risk of cardiovascular disease and may benefit from statin therapy
• Lipid profile: Patients with elevated LDL cholesterol or low HDL cholesterol are at higher risk of cardiovascular disease and may benefit from statin therapy
• Family history: Patients with a family history of cardiovascular disease are at higher risk and may benefit from statin therapy Before initiating statin therapy, baseline liver function tests and lipid panel should be obtained, with follow-up testing in 4-12 weeks to assess efficacy and tolerability 1. A shared decision-making approach with the patient is essential, discussing the potential cardiovascular benefits versus the burden of adding another medication and possible side effects. The benefit of statins in patients with prediabetes must be balanced against potential side effects like myalgias, risk of drug interactions, and impact on quality of life. In patients with prediabetes, lifestyle modification focusing on weight loss, application of a Mediterranean style or Dietary Approaches to Stop Hypertension (DASH) eating pattern, reduction of saturated fat and trans fat, increase of dietary n-3 fatty acids, viscous fiber, and plant stanols/sterols intake, and increased physical activity should be recommended to improve the lipid profile and reduce the risk of developing atherosclerotic cardiovascular disease 1. Statin therapy is recommended for patients with diabetes aged 40–75 years at higher cardiovascular risk, including those with one or more additional ASCVD risk factors, to reduce LDL cholesterol by ≥50% of baseline and to target an LDL cholesterol goal of <70 mg/dL (<1.8 mmol/L) 1. In adults with diabetes aged >75 years already on statin therapy, it is reasonable to continue statin treatment 1. In adults with diabetes aged >75 years, it may be reasonable to initiate moderate-intensity statin therapy after discussion of potential benefits and risks 1. Statin therapy is contraindicated in pregnancy 1. The most recent and highest quality study recommends statin therapy for patients with diabetes aged 40–75 years without ASCVD, in addition to lifestyle therapy 1. This study provides the most up-to-date guidance on the use of statin therapy in patients with prediabetes and diabetes. Therefore, initiating statin therapy in a patient with prediabetes should be based on their overall cardiovascular risk factors, rather than a specific fasting blood glucose level.

From the Research

Fasting Blood Glucose and Statin Therapy

• The provided studies do not directly address the specific fasting blood glucose level at which to initiate statin therapy in patients with prediabetes 2, 3, 4, 5, 6.
• However, study 4 defines prediabetes as a fasting glucose level of 100 to 125 mg/dL, and notes that intensive lifestyle modification and metformin can decrease the incidence of diabetes in these patients.
• Study 3 suggests that statin therapy may have a diabetogenic effect, particularly with certain statins such as simvastatin and high-dose atorvastatin, which may be associated with greater impairment in glucose metabolism.
• Studies 2, 5, 6 discuss the benefits and risks of statin therapy in reducing LDL cholesterol and cardiovascular events, but do not provide specific guidance on initiating statin therapy based on fasting blood glucose levels.

Statin Therapy and LDL Cholesterol

• Study 2 suggests that driving down LDL cholesterol to a range of about 30 to 50 mg/dL can halt atherosclerosis progression and minimize coronary heart disease events.
• Study 5 recommends an LDL cholesterol target of 70 mg/dL for patients at high or very high risk, and notes that very low LDL cholesterol levels (lower than 70 mg/dL) are associated with a very low risk of cardiovascular disease.
• Study 6 demonstrates that switching to a more efficacious statin can improve lipid goal achievement in patients requiring lipid-lowering therapy.

Prediabetes and Cardiovascular Risk

• Study 4 notes that prediabetes is associated with increased risk of diabetes, cardiovascular events, and mortality, and that first-line therapy for prediabetes is lifestyle modification or metformin.
• Study 3 suggests that statin therapy may be necessary for patients with prediabetes, but that the choice of statin and dose should be carefully considered to minimize the diabetogenic effect.