3.3.2.0 Ini­ti­at­ing Statin Ther­a­py Based on Risk

Pa­tients with type 2 di­a­betes have an in­creased preva­lence of lipid ab­nor­malities, con­tribut­ing to their high risk of ASCVD. Mul­ti­ple clin­i­cal tri­als have demon­strat­ed the beneficial ef­fects of statin ther­a­py on ASCVD out­comes in sub­jects with and with­out CHD (77,78). Sub­group anal­y­ses of pa­tients with di­a­betes in larg­er tri­als (79-83) and tri­als in pa­tients with di­a­betes (84,85) showed significant pri­ma­ry and sec­ondary pre­ven­tion of ASCVD events and CHD death in pa­tients with di­a­betes. Meta-‍anal­y­ses, in­clud­ing data from over 18,000 pa­tients with di­a­betes from 14 ran­dom­ized tri­als of statin ther­a­py (mean fol­low-‍up 4.3 years), demon­strate a 9% pro­por­tion­al re­duc­tion in all-‍cause mor­tal­i­ty and 13% re­duc­tion in vas­cu­lar mor­tal­i­ty for each mmol/‍L (39 mg/dL) re­duc­tion in LDL choles­terol (86). Ac­cord­ing­ly, statins are the drugs of choice for LDL choles­terol low­er­ing and car­dio­pro­tec­tion. Table 10.2 shows rec­om­mend­ed lipid-‍low­er­ing strate­gies, and Table 10.3 shows the two statin dos­ing in­ten­si­ties that are rec­om­mend­ed for use in clin­i­cal prac­tice: high-‍in­ten­si­ty statin ther­a­py will achieve ap­prox­i­mate­ly a 50% re­duc­tion in LDL choles­terol, and mod­er­ate-‍in­ten­si­ty statin reg­i­mens achieve 30–50% re­duc­tions in LDL choles­terol. Low-‍dose statin ther­a­py is gen­er­ally not rec­om­mend­ed in pa­tients with di­a­betes but is some­times the only dose of statin that a pa­tient can tol­er­ate. For pa­tients who do not tol­er­ate the in­tend­ed in­ten­si­ty of statin, the max­i­mal­ly tol­er­at­ed statin dose should be used.

As in those with­out di­a­betes, ab­so­lute re­duc­tions in ASCVD out­comes (CHD death and non­fa­tal MI) are great­est in peo­ple with high base­line ASCVD risk (known ASCVD and/‍or very high LDL choles­terol lev­els), but the over­all bene- fits of statin ther­a­py in peo­ple with di­a­betes at mod­er­ate or even low risk for AS­CV­D are ­con­vinc­ing (87,88). The rel­a­tive benefit of lipid-‍low­er­ing ther­a­py has been uni­form across most sub­groups test­ed (78,86), in­clud­ing sub­groups that var­ied with re­spect to age and other risk fac­tors.