Should You Take a Statin?
New statin guidelines include controversy about diabetes and heart health
The rebellion was a polite one. During an informal poll of health care professionals at the 2014 American Diabetes Association (ADA) Scientific Sessions, people raised their hands to show their disagreement with certain aspects of new guidelines on the treatment of blood cholesterol. The new guidelines are from the American College of Cardiology (ACC) and the American Heart Association (AHA).
The debate about how to treat abnormal cholesterol levels is particularly important for people with diabetes, who are at an elevated risk for heart attack and stroke. Abnormal cholesterol is another risk factor for these types of cardiovascular problems.
You Say Statin
The debate is less about the favored drugs for improving abnormal cholesterol—statins—than about who, exactly, needs the medication and at what doses. For people with diabetes who have cardiovascular disease or additional risk factors for heart disease, such as high blood pressure or high LDL cholesterol, the ACC/AHA and ADA essentially agree: Give them a statin. Statins are prescription pills that are very effective at lowering levels of LDL (“bad”) cholesterol.
With lower risk diabetes patients—a minority because diabetes itself is a substantial risk factor for heart attacks and strokes—the organizations’ paths diverge. The ADA currently recommends that health care providers consider treating lower-risk people with diabetes (such as a healthy 30-year-old with type 1 diabetes) with statins if LDL cholesterol is 105 mg/dl and doesn’t get lower with lifestyle changes. The ACC/AHA guidelines, by contrast, recommend statins for all people with diabetes between the ages of 40 and 75 with LDL cholesterol of 70 mg/dl and above.
These differences may not greatly alter who gets a statin prescription. “My sense is it really isn’t going to change things all that much, at least in terms of the number of people on statin therapy,” says Jill Crandall, MD, professor of clinical medicine at Albert Einstein College of Medicine. What may change, though, is the statin dose. The ACC/AHA recommendations base statin doses on the results of a risk calculator, which Crandall thinks will lead to higher doses in general for people with diabetes. The ADA guidelines recommend using LDL cholesterol targets to guide dose decisions. The issue of targets, in particular, is a point of debate.
Goal, No Goal
For people who take statins, the ADA recommends tailoring treatment based on the results of regular LDL cholesterol tests. The LDL target is less than 100 mg/dl for people who have diabetes but no heart disease and less than 70 mg/dl for people with diabetes and heart disease. On the other hand, the ACC/AHA guidelines don’t recommend targets for making treatment decisions.
The lack of targets had health care providers at the ADA meeting raising their hands—it turns out, they like goals. “As a clinician, I will have a hard time not measuring LDL cholesterol in patients treated with statins,” says Crandall, to see if a person is taking medication as directed, whether the medications are effective, and to make sure LDL cholesterol doesn’t drop too low.
Though not everyone agrees with the ACC/AHA guidelines, the recommendations certainly weren’t made lightly. “It took four and a half years to dig into 60,000 papers to come up with the guidelines,” said Robert H. Eckel, MD, a professor of medicine at the University of Colorado, Anschutz Medical Campus, who worked on the guidelines. “The process that ACC/AHA went through was a substantial effort to get into the depths of the literature.” The organizations had strict definitions of what sort of evidence they could use, relying only on randomized clinical trials (RCT) to make their recommendations. Many other organizations, including the ADA, include expert opinion when crafting their recommendations. However, health care providers often use expert opinion to help make clinical decisions because there isn’t data on everything. “Are we going to stop using parachutes because there’s no RCT?” asks Eckel, to make the point.
An abundance of evidence on statins exists, which is why the ACC/AHA guidelines focus on these medications, but there are other treatments that target blood fats, such as fibrates and bile acid binders. Studies on these medications are smaller and the results less compelling, says Crandall, though they may still be helpful in a subset of patients. For example, some evidence suggest that fibrates may be beneficial for people with diabetes with high triglycerides and low HDL.
Even though the ACC/AHA guidelines do make recommendations, they also encourage health care providers to individualize treatment. “These are guidelines and they don’t tell you necessarily what you have to do or should do for any individual patients,” says Crandall. “These act as a reference point, but don’t substitute for decision making.”
The ADA releases its annual guidelines for people with diabetes in January. The question remains on whether the ADA will align its recommendations with those of the ACC/AHA, whether it will stick with its current criteria, or go in a new direction.
Talk to Your Doc
To reduce your risk of cardiovascular disease, such as heart attack and stroke, your doctor may recommend a statin. Here’s how to talk about it:
- What about lifestyle? Exercise for at least 30 minutes on most days. Limit foods with saturated fat, trans fats, and cholesterol. Eat foods with omega-3s (such as salmon and sardines). Don’t spend your money on fish oil supplements and omega-3 pills, which don’t appear to protect against heart disease. Quit smoking.
- Should I be on a statin? The American Diabetes Association, the American College of Cardiology, and the American Heart Association agree that almost all people with diabetes who are 40 years or older should be on at least a moderate dose of a statin if they tolerate it.
- What is the cost of statin therapy? Some generic statins are available for $4 through retail discount programs. Consumer Reports found that statin costs vary widely, from $36 to $600 a month.
- Are there any side effects? Some people using statins experience muscle aches and pains, which can be a sign of rare but serious muscle breakdown. Report aches and pains to your health care provider. Possible adverse effects on the liver are almost always reversible by stopping statin use.
- How will we monitor the statin? While optimizing the dose with a treat-to-target approach, monitoring will occur about every six weeks. Then, the American Diabetes Association recommends a fasting blood test for adults with diabetes at least once a year to measure lipids, including HDL (“good”) and LDL (“bad”) cholesterol and triglycerides.