Is Your Patient on Target? Optimizing Diabetes Management

Statin use is widely recommended

In 2008, the ADA and the American College of Cardiology Foundation (ACCF) produced a joint consensus statement regarding lipoprotein management for patients with diabetes and multiple CVD risk factors.²⁵ Target LDL was recommended at <100 mg/dL for moderately high-risk primary prevention patients, including those with diabetes. For patients with diabetes and ≥1 other risk factors, the ADA/ACCF recommended an LDL goal <70 mg/dL. The 2011 AACE guideline has the same treatment goals,¹³ while the 2012 IDF guidelines are more aggressive.¹² For primary prevention, the AACE endorses an LDL goal <80 mg/dL, and <70 mg/dL for those with known CVD.¹³

The updated standards released by the ADA in January 2013 recommend statin therapy regardless of LDL level for patients who have diabetes and known CVD, as well as for those ages 40 years and older who do not have CVD but have ≥1 other risk factors. Specific risk factors include hypertension, dyslipidemia, albuminuria, and a family history of CVD.¹¹

The latest statin guideline. In November 2013, the American College of Cardiology and American Heart Association (ACC/AHA) published a new guideline for the treatment of cholesterol to reduce cardiovascular risk,²⁶ but said nothing for or against specific LDL or non-HDL cholesterol targets. The ACC/AHA recommends that all patients who have diabetes and are between the ages of 40 and 75 years be treated with a moderate dose of a statin—a target supported with strong (strength of recommendation: A) evidence.

Patients with diabetes and an estimated 10-year risk of CVD >7.5% should be considered for high-intensity statin therapy, according to the ACC/AHA.²⁶ For patients younger than 40 or older than 75, the decision to initiate statin therapy should be made by weighing the potential cardiovascular benefits, the risk of adverse effects, and the potential for drug-drug-interactions, as well as patient preference.

CASE › You discuss the need for moderate-dose statin therapy with Mr. D. He is hesitant at first, referring to a coworker who had “leg cramps” when he was taking a statin. You emphasize the importance of prevention in the care of his diabetes and convince the patient to begin a trial of atorvastatin 40 mg daily.

The ACC and AHA published a new guideline for the treatment of cholesterol to reduce cardiovascular risk, but said nothing for or against specific LDL or non-HDL cholesterol targets.You warn Mr. D of the possibility of an allergic reaction, rash, or cough from lisinopril and loose stools from metformin, and advise him to call if he develops muscle cramps that could be associated with the statin. Finally, you stress the importance of lifestyle modification, including diet and weight loss, and schedule a follow-up visit in 3 months.

At Mr. D’s next visit, you will check his HbA1c and BP. If his HbA1c is still >7.0%, you may increase the dose of metformin or add a sulfonylurea. The dose of lisinopril could be increased if the patient’s BP continues to be elevated. There will be no need to recheck Mr. D’s cholesterol levels, however, because the purpose of the statin therapy is to improve overall outcomes, rather than to achieve a target goal.

CORRESPONDENCE
Kathryn M. Harmes, MD, Department of Family Medicine, University of Michigan Medical School, 1150 West Medical Center Drive, M7300 Med Sci I, SPC 5625, Ann Arbor, MI 48109-5625; jordankm@med.umich.edu