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ADA’s Revised Diabetes Standards Increase Statin Use

New guidelines call for giving the cholesterol-lowering drugs to almost all people with diabetes to help prevent heart disease…

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Most patients with diabetes should receive at least a moderate statin dosage regardless of their cardiovascular disease risk profile, according to the American Diabetes Association’s (ADA) annual update to standards for managing patients with diabetes.

“Standards of Medical Care in Diabetes – 2015″ also shifts the ADA’s official recommendation on assessing patients for statin treatment from a decision based on blood levels of low density lipoprotein (LDL) cholesterol to a risk-based assessment. That change brings the ADA’s position in line with the approach advocated in late 2013 by guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) (J. Am. Coll. Cardiol. 2014;63:2889-934).

The ADA released the revised standards online Dec. 23.

The statin use recommendation is “a major change, a fairly big change in how we provide care, although not that big a change in what most patients are prescribed,” said Dr. Richard W. Grant, a primary care physician and researcher at Kaiser Permanente Northern California in Oakland and chair of the ADA’s Professional Practice Committee, the 14-member panel that produced the revised standards. “We agreed [with the 2013 ACC and AHA lipid guidelines] that the decision to start a statin should be based on a patient’s cardiovascular disease risk, and it turns out that nearly every patient with type 2 diabetes should be on a statin,” Dr. Grant said in an interview.

The revised standards recommend a “moderate” statin dosage for patients with diabetes who are aged 40-75 years, as well as those who are older than 75 years even if they have no other cardiovascular disease risk factors (Diabetes Care 2015;38:S1-S94).

The dosage should be intensified to “high” for patients with diagnosed cardiovascular disease, and for patients aged 40-75 years with other cardiovascular disease risk factors. For patients older than 75 years with cardiovascular disease risk factors, the new revision calls for either a moderate or high dosage.

However, for patients younger than 40 years with no cardiovascular disease or risk factors, the revised standards call for no statin treatment, a moderate or high dosage for patients younger than 40 years with risk factors, and a high dosage for those with cardiovascular disease.

Grant said in a statement, “The big change here is to recommend starting either moderate- or high-intensity statins based on the patient’s risk profile rather than on low-density lipoprotein level.” “It turns out that patients with diabetes have the same risk as people with heart disease, so (almost) all of our patients need to be on statins,” he said. However, Grant said some people with diabetes may not need statins. These include younger, healthier patients and very old patients who have other medical conditions that shorten their life expectancy.

Heart disease is the No. 1 killer of people with diabetes, Grant said. People with diabetes are two to four times more likely to have a heart attack or stroke than people without diabetes, he said.The increased risk of heart disease in people with diabetes is what was behind the rationale for this year’s recommendations on statins, blood pressure and exercise, according to Grant.

“In the old days, all we thought about was sugar, and nowadays we recognize that the leading killer in diabetes is heart disease,” he said. “You have to be aggressive in controlling risks.”

Practice Pearls:

  • The new standards bring the association in line with the American College of Cardiology and American Heart Association.
  • For patients younger than 40 years with no cardiovascular disease or risk factors, the revised standards call for no statin treatment
  • A moderate or high dosage for patients younger than 40 years with risk factors, and a high dosage for those with cardiovascular disease.
     

Research, chairman, professional practice committee, American Diabetes Association; Spyros Mezitis, M.D., endocrinologist, Lenox Hill Hospital, New York City; January 2015 Diabetes Care supplement.

Watch Richard Grant, M.D., M.P.H., research scientist, Kaiser Permanente Division as he introduces himself and describes his current research into whether patients can be motivated to better diabetes management if they are aware of their risk factors.