Should a statin be initiated in a 62-year-old patient with diabetes (Diabetes Mellitus) and hypertension (High Blood Pressure) who has good control and low-density lipoprotein (LDL) levels below target?

From the Guidelines

Starting a statin is recommended for a 62-year-old patient with diabetes and well-controlled hypertension, even if their LDL cholesterol is already below target, due to their high cardiovascular risk profile. This recommendation is based on the patient's multiple risk factors, including age over 60, diabetes, and hypertension, which increase their risk for atherosclerotic cardiovascular disease (ASCVD) events 1. According to the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol, in patients with diabetes mellitus at higher risk, especially those with multiple risk factors or those 50 to 75 years of age, it is reasonable to use a high-intensity statin to reduce the LDL-C level by ≥50% 1. Additionally, the 2022 standards of medical care in diabetes recommend that for patients of all ages with diabetes and atherosclerotic cardiovascular disease, high-intensity statin therapy should be added to lifestyle therapy 1. Some key points to consider when initiating statin therapy include:

• Starting with a moderate-intensity statin such as atorvastatin 10-20 mg daily or rosuvastatin 5-10 mg daily
• Monitoring liver function tests at baseline and after 3 months, then annually
• Periodic checks for muscle symptoms
• Considering the potential benefits of statin therapy, including reduced cardiovascular event risk by 25-35% in diabetic patients regardless of baseline LDL levels 1. The benefits of statin therapy in this high-risk patient significantly outweigh potential side effects, making it a crucial component of their treatment plan to reduce the risk of ASCVD events 1.

From the FDA Drug Label

To reduce the risk of: Myocardial infarction (MI), stroke, revascularization procedures, and angina in adults with multiple risk factors for coronary heart disease (CHD) but without clinically evident CHD MI and stroke in adults with type 2 diabetes mellitus with multiple risk factors for CHD but without clinically evident CHD.

The patient has diabetes and hypertension, which are considered multiple risk factors for coronary heart disease (CHD).

• The patient's LDL levels are below target, but the label does not specify that statin initiation is dependent on LDL levels being above a certain threshold in patients with diabetes and multiple risk factors for CHD.
• The label indicates that atorvastatin is indicated to reduce the risk of MI and stroke in adults with type 2 diabetes mellitus and multiple risk factors for CHD. Therefore, a statin should be initiated in this patient, considering their diabetes and hypertension as multiple risk factors for CHD 2.

From the Research

Patient Profile

• Age: 62 years
• Diabetes Mellitus (diabetes)
• Hypertension (high blood pressure)
• Low-density lipoprotein (LDL) levels below target

Statin Initiation

• According to 3, the US Preventive Services Task Force recommends statin use for the primary prevention of cardiovascular disease in adults aged 40 to 75 years with no history of cardiovascular disease and who have one or more cardiovascular disease risk factors (such as diabetes, hypertension, or dyslipidemia) and an estimated 10-year cardiovascular disease event risk of 10% or greater.
• The patient's profile suggests they have multiple risk factors, including diabetes and hypertension, which may increase their cardiovascular disease risk.
• However, the patient's LDL levels are below target, which may affect the decision to initiate statin therapy.

LDL Targets and Statin Therapy

• 4 suggests that lowering LDL cholesterol with statins decreases cardiovascular risk, and the amount of risk reduction is greater with lower LDL-C values achieved by statin therapy.
• The study recommends an LDL-C target of < 70 mg/dl in patients at very high risk of cardiovascular events.
• 5 discusses the use of rosuvastatin and ezetimibe for the treatment of dyslipidemia and hypercholesterolemia, and suggests that the combination of these drugs is safe and effective in patients with hypercholesterolemia or dyslipidemia, with or without diabetes and cardiovascular disease.

Statin Effects on Glycemic Control

• 6 found that statins were associated with an increase in HbA1c compared to placebo in patients with type 2 diabetes mellitus.
• However, moderate-intensity pitavastatin improved glycemic control, while high-intensity atorvastatin worsened it.
• The study suggests that appropriate statins should be administered for patients with diabetes mellitus.

Intensive Lipid-Lowering Therapy

• 7 evaluated the effectiveness and safety of different rosuvastatin-based regimens for patients at high cardiovascular disease risk.
• The study found that the combination of a statin and a PCSK9 inhibitor was safe and more effective for the treatment of high-risk cardiovascular disease patients.
• The addition of ezetimibe was unable to significantly lower lipid levels further.