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S80 Cardiovascular Disease and Risk Management Diabetes Care Volume 40, Supplement 1, January 2017

Table 9.1Recommendations for statin and combination treatment in people signicant, reduction in risk as patients
with diabetes with type 2 diabetes (47). Even though
Recommended the data are not denitive, similar statin
Age Risk factors statin intensity* treatment approaches should be consid-
,40 years None None ered for patients with type 1 or type 2
ASCVD risk factor(s)** Moderate or high diabetes, particularly in the presence of
ASCVD High other cardiovascular risk factors. Please
4075 years None Moderate refer to Type 1 Diabetes Mellitus and
ASCVD risk factors High Cardiovascular Disease: A Scientic
ASCVD High Statement From the American Heart As-
ACS and LDL cholesterol $50 mg/dL (1.3 mmol/L) Moderate plus sociation and American Diabetes Associ-
or in patients with a history of ASCVD who ezetimibe ation (60) for additional discussion.
cannot tolerate high-dose statins High-intensity statin therapy is rec-
.75 years None Moderate ommended for all patients with diabe-
ASCVD risk factors Moderate or high
tes and ASCVD. Treatment with a
moderate dose of statin should be con-
ACS and LDL cholesterol $50 mg/dL (1.3 mmol/L) Moderate plus
or in patients with a history of ASCVD who ezetimibe
sidered if the patient does not have
cannot tolerate high-dose statins ASCVD but has additional ASCVD risk
*In addition to lifestyle therapy. **ASCVD risk factors include LDL cholesterol $100 mg/dL
(2.6 mmol/L), high blood pressure, smoking, chronic kidney disease, albuminuria, and family
history of premature ASCVD. Ongoing Therapy and Monitoring
With Lipid Panel
In adults with diabetes, it is reasonable
use for assessing cardiovascular risk in based on risk prole. High-intensity sta- to obtain a lipid prole (total choles-
individuals with diabetes. tins, if well tolerated, are still appropri- terol, LDL cholesterol, HDL cholesterol,
Age 4075 Years ate and recommended for older adults and triglycerides) at the time of diagno-
In low-risk patients with diabetes aged with ASCVD. High-intensity statin ther- sis, at the initial medical evaluation, and
4075 years, moderate-intensity statin apy may also be appropriate in adults at least every 5 years thereafter. A lipid
treatment should be considered in addi- with diabetes .75 years of age with ad- panel should also be obtained immedi-
tion to lifestyle therapy. Clinical trials in ditional ASCVD risk factors. However, ately before initiating statin therapy.
high-risk patients with increased cardio- the riskbenet prole should be rou- Once a patient is taking a statin, testing
vascular risk (e.g., LDL cholesterol $100 tinely evaluated in this population, for LDL cholesterol may be considered
mg/dL [2.6 mmol/L], high blood pres- with downward titration (e.g., high to on an individual basis (e.g., to monitor
sure, smoking, albuminuria, and family moderate intensity) performed as for adherence and efcacy). In cases
history of premature ASCVD) and with needed. See Section 11 Older Adults where patients are adherent but the
ASCVD (5759) have demonstrated that for more details on clinical consider- LDL cholesterol level is not responding,
more aggressive therapy with high ations for this population. clinical judgment is recommended to
doses of statins led to a signicant re- Age <40 Years and/or Type 1 Diabetes determine the need for and timing of
duction in cardiovascular events. High- Very little clinical trial evidence exists lipid panels. In individual patients, the
intensity statins are recommended in all for patients with type 2 diabetes under highly variable LDL cholesterollowering
such patients. the age of 40 years or for patients with response seen with statins is poorly un-
Age >75 Years type 1 diabetes of any age. In the Heart derstood (61). When maximally tolerated
For adults with diabetes .75 years of Protection Study (lower age limit 40 doses of statins fail to substantially lower
age, there are limited data regarding years), the subgroup of ;600 patients LDL cholesterol (,30% reduction from
the benets and risks of statin therapy. with type 1 diabetes had a proportion- the patients baseline), there is no strong
Statin therapy should be individualized ately similar, although not statistically evidence that combination therapy should
be used. Clinicians should attempt to
nd a dose or alternative statin that is tol-
Table 9.2High-intensity and moderate-intensity statin therapy*
erable, if side effects occur. There is evi-
High-intensity statin therapy Moderate-intensity statin therapy
(lowers LDL cholesterol by $50%) (lowers LDL cholesterol by 30% to ,50%)
dence for benet from even extremely
low, less than daily, statin doses (62).
Atorvastatin 4080 mg Atorvastatin 1020 mg
Increased frequency of LDL choles-
Rosuvastatin 2040 mg Rosuvastatin 510 mg
terol monitoring should be considered
Simvastatin 2040 mg
for patients with new-onset ACS. In-
Pravastatin 4080 mg
Lovastatin 40 mg
creased frequency of LDL cholesterol
Fluvastatin XL 80 mg monitoring may also be considered in
Pitavastatin 24 mg adults with heterozygous familial hyper-
cholesterolemia who require additional
*Once-daily dosing. XL, extended release.
lowering of LDL cholesterol.