LDL Cholesterol Goals for Individuals with Diabetes Aged 40-75
For people with diabetes aged 40-75 years at higher cardiovascular risk, including those with one or more atherosclerotic cardiovascular disease risk factors, the target LDL cholesterol goal is <70 mg/dL with a recommendation to reduce LDL cholesterol by ≥50% from baseline. 1
Primary Prevention Recommendations (No Established ASCVD)
Standard Risk Patients with Diabetes (40-75 years)
- For people with diabetes aged 40-75 years without atherosclerotic cardiovascular disease (ASCVD), moderate-intensity statin therapy is recommended in addition to lifestyle therapy 1
- Moderate-intensity statin therapy typically lowers LDL cholesterol by 30-49% 1
Higher Risk Patients with Diabetes (40-75 years)
- For those with additional ASCVD risk factors (such as hypertension, smoking, dyslipidemia, or family history of premature CHD), high-intensity statin therapy is recommended 1
- The goal is to reduce LDL cholesterol by ≥50% from baseline and achieve an LDL cholesterol level of <70 mg/dL 1
- If this goal is not achieved with maximum tolerated statin therapy, adding ezetimibe or a PCSK9 inhibitor may be reasonable, especially in those with multiple risk factors and LDL ≥70 mg/dL 1
Secondary Prevention Recommendations (Established ASCVD)
- For people with diabetes and established ASCVD, high-intensity statin therapy is recommended 1
- The target LDL cholesterol goal is <55 mg/dL with a reduction of ≥50% from baseline 1
- Addition of ezetimibe or a PCSK9 inhibitor is recommended if the goal is not achieved on maximum tolerated statin therapy 1
Medication Selection and Monitoring
High-Intensity Statin Options (LDL reduction ≥50%)
Moderate-Intensity Statin Options (LDL reduction 30-49%)
- Atorvastatin 10-20 mg daily 1
- Rosuvastatin 5-10 mg daily 1
- Simvastatin 20-40 mg daily 1
- Pravastatin 40-80 mg daily 1
- Lovastatin 40 mg daily 1
Monitoring
- Lipid levels should be assessed 4-12 weeks after initiating statin therapy or after any dose change 1
- For individuals who do not tolerate the intended intensity, the maximum tolerated statin dose should be used 1
- In those intolerant to statin therapy, bempedoic acid is recommended as an alternative cholesterol-lowering option 1
Additional Considerations
- Lifestyle modification remains foundational and should focus on weight management, Mediterranean or DASH eating patterns, reducing saturated and trans fats, and increasing physical activity 1
- Intensify lifestyle therapy and optimize glycemic control for those with elevated triglycerides (≥150 mg/dL) and/or low HDL cholesterol 1
- For very high-risk patients, achieving LDL <70 mg/dL may be challenging, with approximately 25% requiring more than two lipid-lowering medications at maximal doses 2
- The SANDS trial demonstrated that reducing LDL-C to lower targets resulted in regression of carotid intima-media thickness in individuals with type 2 diabetes 3
Special Populations
- For people with diabetes aged 20-39 years with additional ASCVD risk factors, statin therapy may be reasonable in addition to lifestyle therapy 1
- In adults with diabetes aged >75 years already on statin therapy, it is reasonable to continue treatment 1
- For those >75 years not yet on statin therapy, initiating moderate-intensity statin therapy may be reasonable after discussing potential benefits and risks 1
Remember that these recommendations prioritize reducing morbidity and mortality through aggressive management of cardiovascular risk factors in people with diabetes.