Using Statins for Patients with Diabetes without CVD

Seven randomized controlled trials of statin– vs. control–therapy in patients with diabetes were reviewed. A total number of 12 711 patients were involved and the outcomes of interest were major adverse cardiovascular and cerebrovascular events (MACCE), including myocardial infarction, stroke, all–cause mortality and coronary revascularization.

A total of 1 376 MACCE occurred during follow–up, with 9.54% (605 patients) in the statin therapy group and 12.10% (771 patients) in control group. Statin therapy was associated with a significant reduction in the incidence of MACCE (0.79, 95%CI 0.66–0.95; P=0.01).

Meanwhile, the risk of stroke and coronary revascularization were reduced 29 and 26% in statin therapy group. However, there was no statistical difference of all–cause mortality between statin– and control–therapy group (3.73 vs. 4.65%, P=0.13).

Both in primary prevention and in the very-high-risk patients, it seems that statins reduce major cardiovascular events irrespective (at least in part) of the baseline and post-therapy LDL levels achieved. Should statins be generally prescribed in a fixed-dose manner? We would not go so far as to suggest that, but indeed, in the diabetic individual whose LDL cholesterol is seemingly within normal limits, this should be considered. The indication for statin therapy in diabetic individuals should not rely solely on LDL levels but on the inherent cardiovascular risk that accompanies this disease (even if goal LDL levels are met).

The standards of care for individuals with diabetes should mirror the evidence. Replacing a fixed-dose statin trial scheme with a treat-to-target LDL guideline is controversial. This inherent problem of the current guidelines should be amended. Evidence based on "hard" outcome trials of statin use should guide our treatment goals and considerations, not epidemiologic or extrapolated LDL-based data.

Diabetes Care November 2009 vol. 32 no. suppl 2 S384-S391