Does a patient with diabetes and borderline low Low-Density Lipoprotein (LDL) cholesterol need a statin (HMG-CoA reductase inhibitor)?

From the Guidelines

A statin is generally recommended for diabetic patients regardless of their LDL level, as diabetes is considered a cardiovascular risk equivalent. The most recent and highest quality study, 1, published in 2023, supports the use of statins in diabetic patients to reduce cardiovascular risk by 30-50%, beyond just lowering LDL levels. According to this study, high-intensity statin therapy is recommended for all people with diabetes and ASCVD to target an LDL cholesterol reduction of ≥50% from baseline and an LDL cholesterol goal of <55 mg/dL. Some key points to consider when prescribing statins include:

• Common statins prescribed include atorvastatin (10-20 mg daily), rosuvastatin (5-10 mg daily), or simvastatin (20-40 mg daily) 1.
• The statin should be taken daily, typically in the evening for most statins.
• Regular monitoring of liver function tests and checking for muscle symptoms is important, as some patients may experience side effects like muscle pain or liver enzyme elevations, which should be reported to their healthcare provider.
• The decision to add a nonstatin agent, such as ezetimibe or a PCSK9 inhibitor, should be made following a clinician-patient discussion about the net benefit, safety, and cost of combination therapy 1. Overall, the use of statins in diabetic patients is supported by strong evidence and should be considered a key component of cardiovascular risk management.

From the Research

Statin Therapy for Diabetic Patients with Borderline Low LDL Cholesterol

• The use of statins in patients with diabetes is a well-established practice for reducing cardiovascular risk, as evidenced by multiple clinical trials 2, 3.
• Statins have been shown to reduce the risk of mortality and morbidity in diabetic patients by lowering blood low-density cholesterol levels 2.
• Current guidelines recommend statin therapy for diabetic patients with LDL cholesterol levels above 70 mg/dL, especially those at high or very high risk of cardiovascular disease 4, 3.
• Even patients with borderline low LDL cholesterol levels may benefit from statin therapy, as the risk of cardiovascular disease is still present in diabetic patients with LDL levels below 100 mg/dL 5, 6.
• The decision to prescribe statin therapy should be based on individual patient risk factors, including age, smoking status, and presence of other cardiovascular risk factors 4, 6.

LDL Cholesterol Targets for Diabetic Patients

• The target LDL cholesterol level for diabetic patients is generally considered to be below 70 mg/dL, although some studies suggest that even lower levels (below 40 mg/dL) may be beneficial in reducing cardiovascular risk 4.
• Achieving very low LDL cholesterol levels (below 30 mg/dL) has been shown to be safe and effective in reducing cardiovascular risk, without a significant increase in adverse events 4.
• However, the use of high-intensity statin therapy to achieve these low LDL levels may be associated with a higher risk of adverse events, such as transaminase elevations and myopathy 4, 6.

Adherence to Clinical Guidelines

• Adherence to clinical guidelines for statin prescribing in diabetic patients is crucial for reducing cardiovascular risk and preventing complications 5.
• Studies have shown that a significant proportion of diabetic patients are not prescribed statin therapy, despite being at high risk of cardiovascular disease 5, 3.
• Healthcare providers should strive to adhere to established guidelines and recommend statin therapy to diabetic patients who are at high risk of cardiovascular disease, regardless of their LDL cholesterol level 5, 3.