From the Guidelines
For patients with diabetes, the goal LDL cholesterol target is generally less than 70 mg/dL (or less than 1.8 mmol/L). This more aggressive target is recommended because diabetes is considered a cardiovascular disease equivalent, meaning diabetic patients have a similar risk of cardiovascular events as those who have already experienced a heart attack 1. The 2016 ESC/EAS guidelines for the management of dyslipidaemias recommend an LDL-C goal of < 1.8 mmol/L (70 mg/dL), or a reduction of at least 50% if the baseline LDL-C is between 1.8 and 3.5 mmol/L (70 and 135 mg/dL) for patients at very high CV risk, which includes those with diabetes 1.
Some key points to consider in managing LDL cholesterol in diabetic patients include:
- Using LDL-C as the primary target for treatment 1
- Starting treatment with high-intensity statins such as atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily
- Considering additional medications like ezetimibe 10 mg daily if LDL goals aren't met with statins alone
- Possibly using PCSK9 inhibitors (evolocumab or alirocumab) for very high-risk patients who still don't reach targets
- Focusing on lifestyle modification, including reduction of saturated fat, trans fat, and cholesterol intake, and increased physical activity to improve the lipid profile in patients with diabetes 1
It's worth noting that the 2014 standards of medical care in diabetes recommend a lower LDL cholesterol goal of <70 mg/dL (1.8 mmol/L) with a high dose of a statin as an option for individuals with overt CVD, and an LDL cholesterol goal of <100 mg/dL (2.6 mmol/L) for individuals without overt CVD 1. However, the more recent 2016 ESC/EAS guidelines provide a clearer and more aggressive target for LDL cholesterol management in diabetic patients 1.
From the Research
LDL Target for Patients with Diabetes
The goal LDL target for patients with diabetes is a topic of discussion in several studies.
- According to 2, the National Cholesterol Education Program recommends an optional LDL goal of <70 mg/dl for very-high-risk patients, which includes those with diabetes and cardiovascular disease.
- A study published in 3 compared the efficacy and safety of an ezetimibe/simvastatin combination with other intensified lipid-lowering treatment strategies in diabetic patients with symptomatic cardiovascular disease, and found that significantly more subjects reached LDL-C <70 mg/dL with ezetimibe/simvastatin.
- Another study 4 evaluated the consistency of effect with ezetimibe/simvastatin combination therapy, atorvastatin, or rosuvastatin in patients with diabetes, metabolic syndrome, or neither condition, and found that NCEP LDL-C goal attainment was lowest in the high-risk group with atherosclerotic vascular disease.
- A more recent study 5 found that targeting an LDL cholesterol of <70 mg/dL compared with 100 ± 10 mg/dL consistently reduced the risk of subsequent stroke and other major vascular events in patients with and without diabetes.
- Additionally, a review 6 discussed the benefits of combining rosuvastatin and ezetimibe for the treatment of hypercholesterolemia and mixed dyslipidemia, particularly in high-risk patients such as those with diabetes.
Key Findings
- The recommended LDL target for patients with diabetes is <70 mg/dl for very-high-risk patients and <100 mg/dl for high-risk patients 2.
- Ezetimibe/simvastatin combination therapy can help achieve LDL-C <70 mg/dL in a significant proportion of diabetic patients with symptomatic cardiovascular disease 3.
- The choice of lipid-lowering therapy should be individualized based on the patient's risk profile and response to treatment 4, 5, 6.