October 04, 2010

October 4, 2010 (Stockholm, Sweden) — All people over the age of 40 with diabetes--type 1 or type 2--should be taking statins to reduce their risk of stroke or coronary events, one expert stressed to diabetes doctors at the European Association for the Study of Diabetes (EASD) 2010 Meeting last week. Dr John Betteridge (University College London, UK) outlined the evidence base for statins in diabetes and stressed their safety, as long as they are appropriately used and drug interactions are avoided.

He told the meeting that the plaque burden is increased in diabetes and that LDL cholesterol in diabetics "is particularly atherogenic." Trials such as CARDS have proven the benefit of statins in type 2 diabetics, he explained; in this study, 10 mg of atorvastatin (Lipitor, Pfizer) reduced LDL cholesterol by 40% and was associated with a 37% reduction in cardiovascular events and a "dramatic" halving of the stroke rate over four years, something that came as "a surprise," he noted.

These data were further strengthened by the results from the Cholesterol Treatment Trialists' Collaboration, he noted, which showed that women and type 1 diabetics also benefited equally from statins, although he warned that there is little evidence to guide statin therapy in people under 40 with type 1 diabetes.

"To me, the most important observation from this meta-analysis is that the absolute benefit [of statins] is mainly determined by the absolute reduction in LDL," he noted.

But What Do We Do in Practice?

You have to reassure your patients that the side effects are most unlikely due to the statin and . . . look for other causes.

"What do we do in practice?" he asked. The Joint British Society (JBS2) guidelines give a target LDL cholesterol of 2 mmol/L (77 mg/dL) in diabetics, he notes, but adds, "Statins only work if people take them." He said he has seen many patients in whom statins have been stopped inappropriately, either by the patient or by their doctor. Patients in particular are bombarded with information about the potential dangers of statins, he said, but he stressed that they are safe if appropriately used and drug interactions are avoided.

"The problem is the person coming in with aches and pains but with normal creatinine kinase," which occurs in about 15% of patients, he said. In CARDS, 23% of those on atorvastatin had adverse reactions, but so did 25% of the placebo group, so "you have to reassure your patients that the side effects are most unlikely due to the drug, and you have to look for other causes and counsel them that this is a very important drug for them to take."

In situations where this still doesn't solve the problem, "our fallback is to use a very low dose of a very potent statin, twice a week, sometimes with ezetimibe [Zetia, Merck]," he said.

Betteridge has received honoraria for lectures and attendance at advisory boards and some research funding from AstraZeneca, Bristol-Myers Squibb, Kowa, Merck Sharp & Dohme, and Pfizer.

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