Make Cholesterol Control a Greater Priority in Diabetes

Marlene Busko

December 02, 2021

Clinicians need to pay more attention to high levels of lipoprotein cholesterol (LDL-C) — a marker of cardiovascular disease (CVD) risk — in patients with type 2 diabetes, a new population-based study in Finland suggests.

In the study, recently published online in Scientific Reports, the authors showed that LDL-C control and statin prescriptions remain suboptimal in this patient population in clinical practice.

They identified four 5-year trajectories of LDL-C along with concurrent levels of statin treatment. The percentages of patients in each group were:

  • Moderately stable LDL-C: 2.3 mmol/L (90 mg/dL): 86%  

  • High stable LDL-C: 3.9 mmol/L (152 mg/dL): 7.7%

  • Decreasing LDL-C: 3.8%

  • Increasing LDL-C: 2.5% 

"The second-largest group consisted of predominantly untreated patients (7.7%) with alarmingly 'high stable' LDL-C levels around 3.9 mmol/L," the researchers highlight.

And among patients with "increasing" LDL-C cholesterol, statin treatment "declined drastically."

Moreover, 42% of patients had no statins prescribed at the end of follow-up.

These findings show that "efforts to control LDL-C should be increased — especially in patients with continuously elevated levels — by initiating and intensifying statin treatment earlier and re-initiating the treatment after discontinuation, if possible," lead author Laura Inglin, MPH, told Medscape Medical News in an email.

Discuss Risks vs Benefits of Statins With Patients

Patients may not understand the benefits versus potential side effects of statins, pointed out Inglin, of the Institute of Public Health and Clinical Nutrition, University of Eastern Finland, in Kuopio.

To improve management of cholesterol levels, she said, "clinician-patient discussions are crucial, addressing risk/benefits and treatment goals, and offering reputable sources" of information about statins.

When patients discontinue statin treatment, Inglin continued, "physicians should try to re-initiate another statin or to lower the dose if possible, following guidelines on how to do that," as other research has reported that more than 70% of patients who stopped a statin due to side effects tolerated it when it was restarted.

The study also identified gender differences, she continued. Compared with men, women had significantly higher average LDL-C levels, but were less likely to be prescribed a statin or were prescribed a lower-dose statin, and they were more likely to discontinue statin therapy. 

Four LDL-C Trajectories With Statin Treatment Differences

Suboptimal lipid profiles, especially elevated LDL-C, are strongly associated with atherosclerotic CVD in individuals with type 2 diabetes, Inglin and colleagues write.

"To prevent or at least delay complications, regular follow-up visits and good control of A1c, LDL-C, blood pressure, and other CVD risk factors are vital in diabetes management," they continue. "Guidelines have consistently identified statins as the principal lipid-lowering therapy, recommended particularly at moderate- to high-intensity." 

The researchers aimed to identify LDL-C level trajectories and concomitant statin treatment in patients with type 2 diabetes.

They identified 8592 patients — 4622 men (54%) and 3970 women (46%) — with type 2 diabetes seen by primary care physicians or specialists in North Karelia, Eastern Finland in 2011-2017.

During this time, like other international guidelines, the Finnish Current Care Guideline recommended assessing LDL-C levels every 1 to 3 years in patients with type 2 diabetes, with LDL-C treatment targets of < 2.5 mmol/L (< 100 mg/dL) for those at high CVD risk due to diabetes, and targets of < 1.8 mmol/L (< 70 mg/dL) or a 50% reduction from baseline in those at very high CVD risk due to additional risk factors.

At baseline, on average, men in the current study were age 66 years and had had diabetes for 8 years; 60% were receiving a statin and 56% had an LDL-C < 2.5 mmol/L.

Women were, on average, age 69 years and had had diabetes for 8 years; 56% were receiving a statin and 51% had an LDL-C < 2.5 mmol/L.

The researchers identified the four distinct LDL-C trajectories, each with differences in statin treatment.

In the "moderate-stable" LDL-C group, 67% of men and 64% of women were receiving a statin, and the rates of high-intensity statin increased in both men and women.

In the "high-stable" LDL-C group, rates of statin use decreased from 42% to 27% among men and from 34% to 23% among women.

In the "decreasing" LDL-C group, the proportion of patients who received a statin increased; the percentage of patients who received a high-intensity statin also increased among men (6.2% to 29%) and women (7.7% to 14%).

In the "increasing" LDL-C group, the percentage of patients receiving a statin decreased from more than 64% to less than 43%.

"Physicians should increase efforts to achieve the LDL-C treatment targets — especially in the patient group with constantly elevated LDL-C levels — by paying attention to earlier initiation of statin treatment, intensification of treatments when necessary, and re-initiating if possible," the researchers reiterate.

"The results of our study may support physicians to identify patients who need to be monitored more closely beyond a single time point measurement," they conclude.

The study was partly funded by the Strategic Research Council of the Academy of Finland (project IMPRO), the Finnish Diabetes Association, and the Research Committee of the Kuopio University Hospital Catchment Area for the State Research Funding (project QCARE). The authors have reported no relevant financial relationships.

Sci Rep. Published online November 19, 2021. Article

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