Should a patient with diabetes be on a statin?

Statin Therapy for Patients with Diabetes

Yes, patients with diabetes should be on statin therapy as it significantly reduces cardiovascular morbidity and mortality regardless of baseline LDL cholesterol levels. 1

Primary Prevention Recommendations (No Existing ASCVD)

Age-Based Recommendations

• Ages 40-75 years: Moderate-intensity statin therapy should be added to lifestyle therapy 1
• Ages 20-39 years: Consider statin therapy if additional ASCVD risk factors are present 1
• Ages >75 years:
  • Continue statin therapy if already taking it 1
  • Consider initiating statin therapy after discussing potential benefits and risks 1

Risk-Based Intensification

• For patients with multiple ASCVD risk factors or aged 50-70 years, high-intensity statin therapy is reasonable to reduce LDL cholesterol by ≥50% 1
• For patients with 10-year ASCVD risk ≥20%, consider adding ezetimibe to maximally tolerated statin therapy 1

Secondary Prevention Recommendations (Existing ASCVD)

• All ages with diabetes and ASCVD: High-intensity statin therapy should be added to lifestyle therapy 1
• If LDL cholesterol remains ≥70 mg/dL despite maximally tolerated statin dose, consider adding ezetimibe or PCSK9 inhibitor 1
  • Ezetimibe is generally preferred due to lower cost 1

Clinical Benefits and Evidence

• Meta-analyses of 14 randomized trials show that for each 1 mmol/L (39 mg/dL) reduction in LDL cholesterol, statins provide: 1

  • 9% reduction in all-cause mortality
  • 13% reduction in vascular mortality

• The cardiovascular benefits of statins in diabetes significantly outweigh the small increased risk of new-onset diabetes (which is only relevant for non-diabetic patients) 2

• Even patients with diabetes and relatively normal lipid profiles benefit from statin therapy 3

Recommended Statin Intensities

High-Intensity Options (LDL reduction ≥50%)

• Atorvastatin 40-80 mg
• Rosuvastatin 20-40 mg 1

Moderate-Intensity Options (LDL reduction 30-49%)

• Atorvastatin 10-20 mg
• Rosuvastatin 5-10 mg
• Simvastatin 20-40 mg
• Pravastatin 40-80 mg 1

Monitoring Recommendations

• Obtain baseline lipid profile before initiating therapy 1
• Check LDL cholesterol 4-12 weeks after initiation or dose change 1
• Monitor annually thereafter to assess response and adherence 1

Common Pitfalls and Caveats

• Tolerability issues: If side effects occur with intended intensity, use the maximally tolerated statin dose rather than discontinuing therapy completely 1

  • Even extremely low or less-than-daily statin doses provide benefit 1

• Statin selection in patients with poor glycemic control: Consider that high-intensity atorvastatin may worsen glycemic control, while moderate-intensity pitavastatin may have more favorable effects on glycemic parameters 4

• Pregnancy: Statin therapy is contraindicated during pregnancy 1

• Medication adherence: Regular monitoring of LDL response can help identify adherence issues 1