Interpreting the results: The experts disagree
The ADA recommends that patients with diabetes and hypertension be treated to a goal <140 mm Hg systolic and <80 mm Hg diastolic pressure11—more lenient than the recommendations of either the AACE or the IDF. It is not clear whether these recommendations will change, however, given the recent JNC 8 report.1 A lower systolic target may be appropriate for certain patients, if it can be achieved without undue adverse effects from antihypertensive medication. Older patients in particular may be at risk for orthostasis or falls as a result of more aggressive treatment.
CASE › Mr. D’s most recent BP is 145/95. Given that his goal is <140/90, you elect to start lisinopril 10 mg daily, advise him to monitor his BP at home, and refer him to a dietician to discuss the Dietary Approaches to Stop Hypertension diet.
Lipid levels: When to add statin therapy
Like glucose and BP control, lipid control and, concomitantly, the benefit of statin therapy for patients with type 2 diabetes has been studied extensively (TABLE 3).19-24
The Scandinavian Simvastatin Survival Study (4S) recruited participants with a history of MI or angina, and included a small diabetes subgroup.19 Participants were randomized to simvastatin 20 mg daily, with blinded titration up to 40 mg/d, or placebo. Among those with diabetes, patients on simvastatin had a 55% reduction in risk for major coronary heart disease events and a 43% reduction in total mortality. The risk reduction did not depend on baseline levels of total cholesterol, LDL cholesterol, HDL cholesterol, or triglycerides.
Cholesterol and Recurrent Events (CARE), which studied participants with a history of MI 3 to 20 months prior to the start of the study and also included a diabetes subgroup, had a similar outcome.20 Compared with placebo, treatment with pravastatin 40 mg/d reduced the risk of both coronary events and revascularization procedures by 25%.
The Heart Protection Study randomized patients with either diabetes or a history of occlusive arterial disease to receive simvastatin 40 mg daily or placebo.21 In the treatment group, the risk of major vascular events was reduced in patients with diabetes by 27%. Improvements were seen in patients with LDL cholesterol levels both above and below 116 mg/dL.
Multiple studies have evaluated the benefits of atorvastatin for patients with diabetes. All have demonstrated a significant reduction in the risk of MI and death in those on statin therapy. The Treating to New Targets study showed a 25% reduction in major cardiovascular events in those treated with 80 mg atorvastatin daily (mean LDL, 77 mg/dL) vs those treated with 10 mg of the drug (mean LDL, 86 mg/dL).22 The Anglo-Scandinavian Cardiac Outcomes Trial–Lipid-Lowering Arm (ASCOT-LLA)23 and the Collaborative Atorvastatin Diabetes Study (CARDS)24 were both terminated early due to the magnitude of benefit seen with statin therapy. In contrast to LDL, evidence for non-LDL treatment goals is lacking in the diabetes literature. Also, there is little evidence to support nonstatin cholesterol-lowering therapy for the management of diabetes patients.
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.