Lipid Guidelines for Diabetes Debated at ADA

New guidelines for the treatment of patients with high cholesterol may, or may not, be appropriate for persons with type 2 diabetes mellitus (DM), according to researchers who debated the topic at the American Diabetes Association (ADA) 74^th Scientific Sessions in San Francisco.

The newest guidelines jointly issued by the American College of Cardiology and American Heart Association in November 2013 do not provide specific target levels for lowering cholesterol, only the recommendation that statins be used to reduce it.

The new guidelines recommend statin treatment for 4 groups of patients: (1) those with cardiovascular disease (CVD); (2) those with low-density lipoprotein cholesterol (LDL-C) levels higher than 190 mg/dL; (3) those with DM, between age 40 and 75 years, with LDL-C levels 70 to 189 mg/dL; and (4) those without DM or CVD, with LDL-C levels 70 to 189 mg/dL and an estimated risk of CVD greater than 7.5%.

Under the new guidelines, statin therapy would be recommended for the vast majority of patients with type 2 DM. Some experts, but not all, think this is appropriate.

At the ADA meeting, Robert H. Eckel, MD, Professor of Medicine and Charles A. Boettcher Chair in Atherosclerosis at the University of Colorado, Anschutz Medical Campus, said he agrees with the guidelines. “Almost all people with diabetes should be on a statin,” he said. “That’s what the evidence tells us. You may not like the new guidelines, but these are evidence-based and this is what the evidence says.”

On the other hand, Henry Ginsberg, MD, Irving Professor of Medicine and Director of the Irving Institute for Clinical and Translational Research at Columbia University in New York, said: “The guideline committee used the evidence-based construct much too narrowly.” He agreed with the recommendation to examine a person’s risk of CVD as well as cholesterol level when determining whether to prescribe a statin. But he did not agree with the removal of target LDL-C goals once a person is being treated with medication or with the lack of recommendations for additional or alternative therapies.

“There are people who can’t take a high dose of a statin or who won’t respond as well to a high dose,” Dr Ginsberg said. “In that case, you should be adding another medication. The new guidelines try to make it too simple.”

Dr Ginsberg, who has critiqued the new guidelines in print, said they actually ignore evidence that shows the lower a patient’s LDL-C level the better. “How do you get to those lower levels if statins alone aren’t enough?" he asked. "You add a non-statin.”

Dr Eckel, a member of the guidelines committee, said that exceptions, which often come up in patients with DM, are addressed in the new guidelines by suggesting that physicians make a judgment call. “It should be an educated judgment, though, based on an understanding of the increased risk of heart disease and stroke for people with diabetes,” he said.

The ADA recommends that patients with DM keep LDL-C levels at or below 100 mg/dL or, if they also have CVD, under 70 mg/dL, and recommends using high-dose statin therapy to reach those goals.