Debate Over Cholesterol Guidelines for Diabetes Patients

Diabetes patients with few exceptions urged to take statins under new guidelines

/ Author:  / Reviewed by: Joseph V. Madia, MD Beth Bolt, RPh

(RxWiki News) Last year, new guidelines on treating high cholesterol placed a focus on overall risk instead of specific cholesterol levels. Those recommendations set off a debate in the medical community. The controversy rages on.

After extensive research, the American Heart Association (AHA) and the American College of Cardiology (ACC) issued new recommendations on how to prevent heart attack and stroke. According to previous guidelines, doctors would prescribe cholesterol-lowering statins with the goal of reaching specific targeted cholesterol levels. The new guidelines urge patients with a high risk of cardiovascular problems to take statins regardless of cholesterol numbers.

Because people with diabetes have a high risk for heart disease, the latest guidelines recommend statins for most people with type 2 diabetes, no matter what their cholesterol levels are.

Doctors will be arguing the pros and cons of this approach at the upcoming American Diabetes Association's 74th Scientific Sessions in San Francisco.

"Lower cardiovascular risk through exercise, diet and weight management."

Robert H. Eckel, MD, professor of medicine and Charles A. Boettcher Chair in Atherosclerosis at the University of Colorado, Anschutz Medical Campus, will defend the new cholesterol treatment policy, while Henry Ginsberg, MD, professor of medicine and director of the Irving Institute for Clinical and Translational Research at Columbia University in New York City, will give the opposing view.

People who are 40 to 75 years old with diabetes and an LDL cholesterol (the "bad" cholesterol) level of 70–189 mg/dL are among those who might reduce their risk of heart disease and cardiovascular events by taking statins to lower LDL cholesterol, according to the AHA and ACC.

"Almost all people with diabetes should be on a statin," said Dr. Eckel in a statement. "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."

Once a person is being treated with these medications, target LDL levels are not considered, according to the new policy.

Dr. Ginsberg argued that this approach disregards evidence showing that the lower a patient's LDL cholesterol level, the better. Without a measure of cholesterol, it can be impossible to tell if patients are responding to statins. Some may need other medication to lower cholesterol.

"There are people who can't take a high dose of a statin, or who won't respond as well to a high dose," he said in a press release. "How do you get to those lower levels if statins alone aren't enough? You add a non-statin."

According to Dr. Eckel, the new guidelines recognize that there can be exceptions to their suggested approach and urge doctors to make their own educated judgment calls regarding treatment.

Dr. Ginsberg agrees with American Diabetes Association policy, advocating that diabetes patients use statins to reach targeted LDL cholesterol levels at or below 100 mg/dL, or under 70 mg/dL if they also have cardiovascular disease.

Commonly used statins include atorvastatin (brand name Lipitor), fluvastatin (Lescol), lovastatin (Mevacor), pravastatin (Pravachol), rosuvastatin calcium (Crestor) and simvastatin (Zocor).

In an interview with dailyRx News, Sarah Samaan, MD, cardiologist and physician partner at the Baylor Heart Hospital in Plano, Texas, said that the new guidelines can be confusing.

“In the past, treating to a specific goal was the name of the game,” said Dr. Samaan. “Now, the latest guidelines advise that numbers are not as important as baseline risk, and that the choice of a low- versus high-dose statin should be made based on whether or not the patient has heart disease or other factors that put them at risk for heart disease and stroke. One of these issues is diabetes. Diabetes triples to quadruples your risk for a heart attack.”

The AHA and ACC guidelines also encourage people to pursue a healthy lifestyle, including eating a healthy diet, exercising regularly and maintaining a healthy body weight.

New guidelines for the treatment of high cholesterol will be debated at a symposium on June 17 at the American Diabetes Association's 74th Scientific Sessions.

Review Date: 
June 13, 2014
Last Updated:
June 14, 2014