In part 5, the conclusion of this Exclusive Interview, Kathleen Wyne talks with Diabetes in Control Medical Editor Joy Pape during the AACE 2018 convention in Boston, MA about starting statins in adults with type 1.
Kathleen Wyne MD, PhD, FACE, MACP, FNLA is an endocrinologist and Director of the OSU Adult Type 1 Diabetes Program at The Ohio State University.
Transcript of this video segment:
Pape: And when do you start statins on an adult-onset type 1?
Wyne: (Laughs) The statins are a big question. Patients with type 1 diabetes tend to be very tech-savvy, science-savvy, medical-savvy, so they already have some thoughts when they come in. So here is the challenge with statins: Everybody says when you have diabetes you must be on a statin. Well, the majority of that data is in people with type 2 diabetes. And I would say that the standard-of-care for people with type 2 diabetes is everybody gets a statin. Doesn’t matter what their lipids are, their A1C, their age, well not totally, the teenagers, you might wait a little bit depending on their situation – their A1C, their comorbidities. Type 2 diabetes, again, it’s going to go back to age and comorbidities. If I have a 25-year-old who is slender, healthy and active, that type 1 diabetes does not automatically get them a statin, OK? That 58-year-old man probably needs to be on one anyway, irregardless of the diabetes, right? So, the issue becomes age 40. So, for the general population, age 40 is kind of the break point of when you should start thinking about statins. So, the challenge becomes, if the person is 38-years-old and newly diagnosed, should they be on a statin? And the short answer is: You have to look at their comorbidities and risk factors. So that’s the newly diagnosed person. What about the person who was diagnosed at age 20 and they’re now 40-years-old? Does that person now need to go on a statin? This is where it gets difficult. There’s data from Europe and from the Untied States and some of the data suggests that after 15 or 20 years of type 1 diabetes, maybe you should be on a statin. One thing to me that is pretty clear from the data is if you have had the diabetes for five years and your A1C is still uncontrolled, you need to be on a statin. I don’t think anyone is going to have any problems with that. If you are still running an A1C of 9 to 12 after five years, you’re probably not going to come under control and it’s probably a good idea to be on a statin. What about the person who has had it for 20 years, maybe had some rough times in the late teens, early 20s, but has been doing well, and maybe has been doing well for 10 years. Their BMI is below 21, their systolic blood pressure is 110, they are physically active, their A1C is in the low 6s, does that person really need to be on a statin? That’s the big question right now in type 1 diabetes.
The standard risk calculators don’t account for the difference between type 1 and type 2. One of the things we did in the AACE lipid guidelines, the update in 2017, is we made a point of pulling type 1 and type 2 apart, which no other guideline has done, to try and give people those tools. What we’ve found was there actually is a risk calculator that’s dedicated to type 1 diabetes; it’s been developed in Denmark, it’s available free online, it’s actually published in Circulation, I think in 2016. We use that to estimate CV risk in our patients and document the risk and track it. If you take that risk calculator and just kind of put in different possibilities, what comes through very clearly is, as soon as the evidence of kidney disease, cardiovascular disease escalates. This was also shown with the MACES study. But, microalbuminuria alone doesn’t escalate your cardiovascular disease. The moment the estimated GFR starts to drop, then your cardiovascular disease risk goes up. So macroalbuminuria with preserved GFR, I’m going to treat those people, I’m scared that their GFR is still preserved. With micro, I am going to give it some time to see if we can make it go away; if we can’t make it go away, I am going to probably put them on medication. But duration of disease alone isn’t necessarily enough to me in the context of glucose control and also asking the questions, “Do they have hypertension, do they smoke, do they have any other complications?” If they’re developed retinopathy, I’m going to give them a statin. If they’ve developed significant neuropathy, I’m going to give them a statin. I’m talking the person who has trace neuropathy, maybe has one red dot in their eye after 20 years, they may not need a statin. It’s complicated, isn’t it?
Pape: Yes, it’s complicated! (Laughs) I feel like we just got a bite of a lot more that we can learn about and we hope to learn more from you, I can’t thank you enough.
Wyne: Well, thank you!