Should a patient with diabetes mellitus be on a statin (HMG-CoA reductase inhibitor) if their low-density lipoprotein (LDL) cholesterol level is below 100 milligrams per deciliter (mg/dL), indicating normolipidemia or borderline hyperlipidemia?

From the Guidelines

Diabetic patients with LDL below 100 mg/dL should still be considered for statin therapy, as the benefits of statins in reducing cardiovascular risk extend beyond LDL lowering, and diabetes itself is a significant risk factor for cardiovascular disease. When considering statin therapy for diabetic patients, it's essential to assess their overall cardiovascular risk profile, including factors such as age, presence of atherosclerotic cardiovascular disease (ASCVD), and other risk factors like hypertension, smoking, and kidney disease 1. For diabetic patients aged 40-75 years without established ASCVD, moderate-intensity statin therapy is recommended, as it has been shown to reduce the risk of major vascular events 1. The choice of statin and dose should be individualized based on the patient's risk profile, potential for drug interactions, and tolerance to the medication. Some studies suggest that the benefits of statins may be derived from their effects on plaque stabilization, improved endothelial function, or effects on C-reactive protein, in addition to LDL cholesterol lowering 1. Key considerations in statin therapy for diabetic patients include:

• Starting with a moderate-intensity statin, such as atorvastatin 10-20 mg daily or rosuvastatin 5-10 mg daily, for patients without established ASCVD
• Using high-intensity statins, such as atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily, for patients with existing ASCVD or multiple risk factors
• Monitoring liver enzymes and muscle symptoms regularly, and adjusting the statin dose based on individual tolerance and response
• Considering the potential benefits and risks of statin therapy, including the increased risk of developing diabetes, and discussing these with the patient to make an informed decision 1.

From the Research

Statin Therapy for Diabetics with LDL Below 100

• The standards of medical care in diabetes recommend that statin therapy is added to lifestyle therapy for diabetic patients with overt cardiovascular disease (LDL cholesterol goal <70 mg/dl), or without cardiovascular disease who are over the age of 40 years and who have one or more other cardiovascular disease risk factors (LDL cholesterol goal <100 mg/dl) 2.
• Current guidelines recommend an LDL cholesterol target of 70 mg/dL for patients at high or very high risk, and epidemiologic studies have shown that very low LDL cholesterol levels are associated with a very low risk of cardiovascular disease 3.
• In diabetic patients, current treatment guidelines target low-density lipoprotein cholesterol (LDL-C) <or= 100 mg/dL with statins, and non-HDL-C is considered a secondary target of therapy in patients with elevated triglycerides 4.
• Studies have shown that statin therapy can be effective in reducing LDL-C levels in patients with diabetes, and that the benefits of statin therapy far outweigh any real or perceived risks 5, 6.
• The decision to prescribe statin therapy for a diabetic patient with an LDL level below 100 should be based on individual risk factors and guidelines, and should take into account the potential benefits and risks of therapy 2, 3, 6.

Key Considerations

• The presence of other cardiovascular disease risk factors, such as age, smoking, and indices of inflammation, should be considered when determining the need for statin therapy 3.
• The potential for statin-associated adverse effects, such as muscle pain and liver enzyme elevations, should be monitored and managed appropriately 2, 6.
• The use of non-statin therapies, such as ezetimibe and PCSK9 inhibitors, may be considered in addition to statin therapy in individuals whose LDL-cholesterol and non-HDL-cholesterol levels remain above certain thresholds after statin treatment 6.