COMMENTARY

How Do New Statin Guidelines Affect Diabetes Care?

Anne L. Peters, MD

Disclosures

November 21, 2013

In This Article

A Review of the Guidelines

The guidelines create 4 different groups. The first group consists of individuals who have already had an event and who have cardiovascular disease, whether it be a myocardial infarction, unstable angina, stroke, or peripheral vascular disease. Those patients become the secondary prevention patients, those at highest risk.

Basically, we don't care about what their numbers are. They need to be on intensive statin therapy. They need to be on a high dose of a statin, and we don't need to measure what their lipids are because we know that giving them the maximum dose of a statin will maximally reduce their risk for having another event. Those are the sickest ones, the ones at highest risk.

The individuals in the next group are based on a lipid panel. If the low-density lipoprotein (LDL) cholesterol level is ≥ 190 mg/dL, those individuals are also considered to be at very high risk. It is recommended that they are also treated with intensive statin therapy at the high dose.

The third group consists of individuals with diabetes. The authors actually lumped together patients with type 1 and type 2 diabetes, which, as I'll discuss in a minute, may not be quite fair. But regardless, patients with diabetes are considered to be at high risk. Depending on their 10-year risk for an event, whether or not it's greater than or equal to 7.5%, they are put on either a moderate-intensity statin regimen or the high-intensity statin regimen. But they are all put on statins if they are between the ages of 40 and 75 years.

Finally, the fourth category is basically everybody else who ranges in age from 40 to 75 years. It is recommended that patients are fit into a pooled risk equation in order to assess the 10-year risk for a cardiovascular disease event. If the risk is greater than or equal to 7.5%, treatment with a statin is recommended.

These guidelines are basically completely focused on statins, and this is because of the lack of data on other therapies. Either the other nonstatin treatments are considered to be less effective than statins, or they don't have the same types of outcome data that we have for statins.

I think that one of the reasons for moving away from just looking at LDL targets is that there are treatments that we know can make LDL targets better, but they don't necessarily improve outcomes. We know this from such studies as AIM-HIGH[2] with niacin. We know that when you give estrogen, you can improve the lipid profile but not improve outcomes.[3] So really, these guidelines say that if you are at high risk -- and they define it in a number of different ways -- you need to be on statin therapy regardless of your LDL cholesterol.

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