The buzz in family medicine or other outpatient practices is statins. Practitioners have been waiting for updated guidelines, particularly the anticipated Adult Treatment Panel IV (ATP-IV). However, the American College of Cardiology (ACC) and American Heart Association (AHA) released joint guidelines on the treatment of blood cholesterol to reduce atherosclerosis cardiovascular risk in the adult population; these guidelines were published online on November 12, 2013 in Circulation. These guidelines specifically address the patient populations who would benefit from statin; it does not address non-statin therapies (e.g., niacin, fibrates, ezetimibe) since there is insufficient evidence to support their use.
The Adult Treatment Panel III (ATP-III) guidelines categorized patients with diabetes as “high-risk.” Diabetes is considered a coronary heart disease risk equivalent, meaning these patients are at high-risk for a coronary heart event within 10 years. These guidelines also determined a desired low-density lipoprotein (LDL) goal, which was less than 100 mg/dL. If the patient had overt cardiovascular disease or multiple, uncontrolled risk factors, then a LDL goal of less than 70 mg/dL would be optional.
The new ACC / AHA guidelines identify four patient populations who would benefit from a statin. One of the populations includes patients with diabetes. A practitioner should ask the following question: is the patient between 40 and 75 years of age AND does s/he have type 1 or type 2 diabetes? If so, then statin therapy would be beneficial for the individual. This set of guidelines does not promote a specific goal, but favors a percentage change in LDL from baseline. No randomized controlled trial has treated to a specific LDL target. A moderate-intensity statin would provide 30 to 40 percent reduction, whereas a high-intensity statin would provide a 50 percent reduction in LDL level. Percentage reductions with a fixed-dose statin have been shown to significantly reduce cardiovascular events.
As I write this blog, the American Diabetes Association (ADA) has released the 2014 standards for medical care in diabetes. This set of guidelines has not changed its recommendations for the use of statins. The ADA recommends statin therapy, regardless of baseline LDL level, with lifestyle modifications. Statin therapy should be considered among patients with diabetes who also have overt cardiovascular disease (CVD) OR who are over the age of 40 years with one or more CVD risk factors. These risk factors include family history of cardiovascular disease, hypertension, smoking, dyslipidemia, or albuminuria.
As the saying goes, “out with the old and in with the new,” so let us know which guidelines you and your practitioners are following. What are you recommending for patients with diabetes? Which statin and dose? What are your thoughts of these recommendations?