KEYWORDS:
Q:
Should we reconsider/revise the guidelines at some stage to include more patients with T2DM who should be started earlier on a statin? Is it a time for more individualization of treatment? We would appreciate the expert opinion of Khalil et al. [Citation1] on this controversial issue.
We read with great interest the letter from Katsiki et al. commenting on our article that discussed the role of statin in diabetes mellitus (DM) patients [Citation2]. The authors raised a very important point related to the statin initiation in diabetic patients. We are in agreement that high-intensity statin should be initiated for diabetic patients < 40 years of age with atherosclerotic cardiovascular disease (ASCVD) risk > 20% [Citation3]. We also agree that lower is better and lower for a longer period of time is better as well. Katsiki et al. also allude to the fact that we should be more aggressive in lowering LDL serum levels in DM patients seeking lower long-term cardiovascular (CV) event rates in DM patients. Although we have tools that are endorsed by the ACC/AHA guidelines such as the 10 year ASCVD risk assessment calculator to guide the statin therapy for the primary prevention of CVD in diabetic patients [Citation3,Citation4], the calculator benefit is limited to asymptomatic adults of age 40–75 years [Citation2,Citation5]. The current guidelines recommend following healthy lifestyle for DM patients between 20 and 39 years and consider using statin therapy in selected patients with LDL-C (≥160 mg/dL) and family history of premature ASCVD [Citation4]. However, ‘routine’ statin use in DM patients who have low ASCVD score or 40 years or younger with no CV events is still controversial because of the lack of evidence or properly design trial that studied this cohort of patients [Citation6]. Therefore, the current (2019) ADA and ACC/AHA guidelines still do not support the use of statin therapy for primary prevention in patients with type 2 diabetes under the age of 40 years or for patients with type 1 diabetes of any age [Citation3,Citation4,Citation5]. Definitely, there are benefits from statin as lipid-lowering agent as well as anti-inflammatory agent; however, our current practice is dictated by the most recent guidelines that do not recommend routine use of statin for DM who are younger than 40 years with no cardiovascular event [Citation6,Citation7]. This argument is also applicable for PCSK agents who have shown significant lower LD levels as well as CV events in high-risk patients.
We thank Katsiki et al. again for their thoughtful comments and agree that based on more recent studies, the current guideline should consider incorporating more guidance on the primary prevention of CV events in DM patients.
Correction Statement
This article has been republished with minor changes. These changes do not impact the academic content of the article.
References
- Khalil S, Khayyat S, Al-Khadra Y, et al. Should all diabetic patients take statin therapy regardless of serum cholesterol level? Expert Rev Cardiovasc Ther. 2019 Apr;17(4):237–239. Epub 2019 Mar 11. PubMed PMID: 30856356.
- Katsiki N, Kotsa K, Athyros VG, et al. Statin use in patients with diabetes: one drug, multiple benefits. Expert Rev Cardiovasc Ther. 2019 Nov;17(11):839–840. Epub 2019 Aug 14.
- American Diabetes Association. Cardiovascular disease and risk management: standards of medical care in diabetes-2019. Diabetes Care. 2019;42(Suppl 1):S103–S123.
- ASCVD. 2108 [cited 2019 Jun 28]. Available from: http://www. cvriskcalculator.com/
- 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: A report of the American college of cardiology/American heart association task force on clinical practice guidelines.
- Collin R, Armitage J, Parish S, et al. Heart protection study collaborative group. MRC/BHF heart protection study of cholesterol-lowering with simvastatin in 5963 people with diabetes: a randomized placebo-controlled trial. Lancet. 2003 Jun 14;361(9374):2005–2016. PubMed PMID: 12814710.
- Ebrahim S, Taylor F, Ward K, et al. Multiple risk factor interventions for primary prevention of coronary heart disease. Cochrane Database Syst Rev. 2011 Jan 19;(1):CD001561. doi:https://doi.org/10.1002/14651858.CD001561.pub3. PubMed PMID: 21249647.
- Trialists CTJTL. Efficacy of cholesterol-lowering therapy in 18 686 people with diabetes in 14 randomized trials of statins: a meta-analysis. Lancet. 2008;371(9607):117–125.