Is your patient on target? Optimizing diabetes management

Patients with diabetes and an estimated 10-year risk of CVD >7.5% should be considered for high-intensity statin therapy, according to the ACC/AHA.²⁶ For patients younger than 40 or older than 75, the decision to initiate statin therapy should be made by weighing the potential cardiovascular benefits, the risk of adverse effects, and the potential for drug-drug-interactions, as well as patient preference.

CASE › You discuss the need for moderate-dose statin therapy with Mr. D. He is hesitant at first, referring to a coworker who had “leg cramps” when he was taking a statin. You emphasize the importance of prevention in the care of his diabetes and convince the patient to begin a trial of atorvastatin 40 mg daily.

The ACC and AHA published a new guideline for the treatment of cholesterol to reduce cardiovascular risk, but said nothing for or against specific LDL or non-HDL cholesterol targets.You warn Mr. D of the possibility of an allergic reaction, rash, or cough from lisinopril and loose stools from metformin, and advise him to call if he develops muscle cramps that could be associated with the statin. Finally, you stress the importance of lifestyle modification, including diet and weight loss, and schedule a follow-up visit in 3 months.

At Mr. D’s next visit, you will check his HbA1c and BP. If his HbA1c is still >7.0%, you may increase the dose of metformin or add a sulfonylurea. The dose of lisinopril could be increased if the patient’s BP continues to be elevated. There will be no need to recheck Mr. D’s cholesterol levels, however, because the purpose of the statin therapy is to improve overall outcomes, rather than to achieve a target goal.

CORRESPONDENCE
Kathryn M. Harmes, MD, Department of Family Medicine, University of Michigan Medical School, 1150 West Medical Center Drive, M7300 Med Sci I, SPC 5625, Ann Arbor, MI 48109-5625; jordankm@med.umich.edu