The European Association for the Study of Diabetes
Statins and diabetes
MedWire News – European Association for the Study of Diabetes (Lisbon, Portugal), September 16th, 2011: In a symposium on the last day of the 47th European Academy for the Study of Diabetes, the lipid hypothesis was revisited and the issue of statin treatment in patients with diabetes addressed.
The presenters concluded that individual risk for cardiovascular disease (CVD) should guide statin prediction in patients with diabetes rather than pretreatment blood cholesterol level, and that statins should be used for secondary, but not primary, prevention of CVD in patients who are diabetic.
Individual risk should guide statin prescription
Peter Sawicki, University of Cologne, Germany
In the first talk of the symposium, Sawicki tackled the question of “does the benefit of statins in diabetic patients depend on the pretreatment level of blood cholesterol?” He argued that it should not and said that instead the prescribing of statins in individuals with diabetes should be based on actual risk rather than the “artificial” marker of blood cholesterol levels.
“Statins are the most frequently prescribed drugs worldwide,” said Sawicki.
“They are effective in lowering the risks for myocardial infarction, stroke and cardiovascular (CV) mortality, which is a major burden in Type 2 diabetes. An effective lowering of this so called macrovascular morbidity and mortality is a still unmet need in diabetic patients.”
There is good evidence that statin therapy is equally beneficial for patients with diabetes as for those without the condition [1].
It has also been shown that initial cholesterol concentration and prior CVD do not appear to have a major effect on the degree of benefit gained by diabetic patients taking statins [1,2]. In fact, in the Collaborative AtoRvastatin Diabetes Study (CARDS) study the researchers showed that atorvastatin 10 mg/day is effective for reducing CVD events even in patients without high cholesterol levels at baseline [3].
Sawicki explained that, in his opinion, it is very unlikely that the beneficial effects of statins in patients with and without diabetes is only due to their cholesterol lowering effects. He believes that the positive CV effects observed in patients who are prescribed these drugs are largely because of a direct effect on blood vessel walls and atherosclerotic plaques.
“These results call for a change of the prescription strategies and may be of particular importance in diabetic patients,” he said.
“The indication for statin treatment should be determined according to the overall risk for CV events rather than by the transgression of an artificial threshold value of blood cholesterol.”
Of concern, a recent study in the USA showed that in a cohort of 125,464 patients with Type 2 diabetes, 98.5% of whom were eligible for statin therapy, only 62.9% were actually prescribed statins [4], he said.
A Danish study published a few years earlier demonstrated similar findings [5]. Sawicki said that a strategy based on risk should result in fewer patients being treated unnecessarily with statins, such as those with high blood cholesterol, but low overall CVD risk, as well as fewer patients being left untreated who could benefit from such treatment.
He said that the overall probability of a diabetic patient having coronary heart disease should be assessed by their physician, and the resulting risk estimation should then be used to guide a treatment decision.
“The main question before prescription of statins is: does this patient have a high risk for coronary events, and not does he have high blood cholesterol?” concludes Sawicki.
Statins useful for secondary but not primary CVD prevention
Miles Fisher, Royal Infirmary, Glasgow, UK
Fisher presented the last talk of the symposium. He discussed the recent debate about how low cholesterol targets should be for patients with diabetes.
He explained that of the possible ways of reducing CVD risk in patients with Type 2 diabetes, such as blood pressure reduction, glycemic control, prescription of antiplatelet drugs, and lifestyle intervention, cholesterol reduction using statins has the most evidence to support it.
“Statins were one of the first proven interventions to reduce CV risk in people with diabetes,” said Fisher.
“Multiple studies have compared statins with placebo in people with diabetes, and have demonstrated reductions in coronary and cerebrovascular events, including CV deaths.”
He added that recent studies have compared low- with high-dose statins in patients with diabetes and have demonstrated a greater reduction in events with high-dose statins [5].
Patients with acute coronary syndromes and those with chronic kidney disease seemed to derive particular benefit from such treatment. In contrast to the conclusions made by Sawicki, Fisher said: “Epidemiological analysis has demonstrated a direct correlation between the amount of reduction in cholesterol and the reduction in events, suggesting that the reduction in vascular events is caused by the reduction in cholesterol by the statins, and not any cholesterol independent mechanism.”
He added that this theory is further supported by the results of the recent Study of Heart And Renal Protection (SHARP), where the addition of ezetimibe to simvastatin further reduced vascular events in diabetic patients with renal failure compared with simvastatin alone [6].
References
1. Cholesterol Treatment Trialists’ (CTT) Collaborators. Efficacy of cholesterol-lowering therapy in 18,686 people with diabetes in 14 randomised trials of statins: a meta-analysis. Lancet 2008;371:117–125.
2. Collins R, Armitage J, Parish S, et al. MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5963 people with diabetes: a randomised placebo-controlled trial. Lancet 2003;361:2005–2016.
3. Colhoun HM, Betteridge DJ, Durrington PN, et al. Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo-controlled trial. Lancet 2004;364:685–696.
4. Fu AZ, Zhang Q, Davies MJ, Pentakota SR, Radican L, Seck T. Underutilization of statins in patients with type 2 diabetes in US clinical practice: a retrospective cohort study. Curr Med Res Opin 2011;27:1035–1040.
5. Dominguez H, Schramm TK, Norgaard ML, et al. Initiation and persistence to statin treatment in patients with diabetes receiving glucose-lowering medications 1997–2006. Open Cardiovasc Med J 2009;3:152–159.
6. AhmedS, Cannon CP, Murphy SA, Braunwald E. Acute coronary syndromes and diabetes: Is intensive lipid lowering beneficial? Results of the PROVE IT-TIMI 22 trial. Eur Heart J 2006;27:2323–2329.
7. Baigent C, Landray MJ, Reith C, et al. The effects of lowering LDL cholesterol with simvastatin plus ezetimibe in patients with chronic kidney disease (Study of Heart and Renal Protection): a randomised placebo-controlled trial. Lancet 2011;377:2181–2192.
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Publicerad: |2011-09-21|