American College of Cardiology and the American Heart Association aligns with The American Diabetes Association (ADA) Recommending statin therapy in patients with diabetes based on :

• age

• other risk factors for cardiovascular disease( CVD)

• established CVD ( already had an event )

I will reiterate first the statin therapy guidelines in diabetes and then I will make comments on the practicability of applying these guidelines in clinical practice and the way I like to approach lipid management.

Why statin therapy in Diabetes

• Diabetes is considered a cardiovascular (CV) equivalent;A patient with diabetes will have the same risk of future cardiac events as a patient with already established CV disease.

• The reduction in LDL translates into decrease plaque deposition and less CV events.

• Statins affect the quality of cholesterol plaque , making it more stable and less likely to rupture ; the rupture of cholesterol plaque triggers a heart attack. This is why in patients with CV disease or patients with DM , statins are indicated even though the total number of the LDL is not high.

The ADA guidelines for Cholesterol management in Diabetes

Younger than 40 years:

✓ no statins if no CVD risk factors other than diabetes;

✓ moderate intensity or high-intensity statin if additional CVD risk factors (LDL > 70, high blood pressure, smoking, kidney disease , albuminuria , family history of CVD , obesity)

✓ high-intensity statin if overt CVD (previous CVD).

Age 40-75 years

✓ moderate -intensity statins if no additional risk factors,

✓ high-intensity statins if either CVD risk factors or overt CVD.

Older than 75 years:

✓ moderate intensity statins if CVD risk factors

✓ high-intensity statins if overt CVD.

Moderate-intensity statin therapy

Lovastatin 40 mg

Pravastatin 40 mg

Simvastatin 40 mg

Atorvastatin 10-20 mg

Rosuvastatin 5-10 mg

High-intensity statin therapy

Atorvastatin 40-80 mg

Rosuvastatin 20 -40 mg

Other Cholesterol lowering medications available if the above are not tolerated

Other Statins – less effective in reducing the risk of CVD but with less side effects

Fluvastatin( Lescol)

Pitavastatin( Livalo)

Non statin

• Exetimibe ( Zetia)- Different mechanism of action than statins , no statin – related side effects

• PCSK9 inhibitor.

Statin side effects 

• Muscle pain and damage- described as a soreness, tiredness or weakness in your muscles. The pain can be a mild discomfort, or it can be severe enough to make your daily activities difficult. Even though is the most bothersome side effects reported real muscle damage or irreversible damage is very rare. A blood enzyme can detect serious all muscle damage and indicate stopping the therapy. Most of the time however muscle pain is not associated with any muscle damage. If symptoms are interfering with daily life a different approach should be taken . Rhabdomyolysis is a life-threatening muscle damage causing severe muscle pain, liver damage, kidney failure and death.
• Liver damage- Reversible upon this continuation of therapy. Liver enzymes are checked regularly in all patients taking statins
• Increased blood sugar it’s a recognized side effect of statins. However the Benefit of statins in reducing cardiac events outweight the risk of mild increase in sugar level

My approach in treating cholesterol and diabetes

• My goal is to have every patient with diabetes on Statin therapy. However cholesterol lowering medications should not trigger bothersome daily side effects.

A trial of all major statins should be done before labeling yourself statin intolerant

The next step would be alternating days or even once a week statin therapy

If side effects still persist, move on to weaker statins or non statin lipid lowering medications( fluvastatin, pitavastatin , zetia or PCSK9 inhibitor.)

Start therapy with low doses and increase over 3 to 6 months. Stick with the lowest dose that does not trigger side effects even though it may not be the most effective does

To reach the desirable LDL goal may combine a lower dose of statins with Zetia