in the June, October and December 2023 issues of our provider e-newsletter, we featured a succession of articles promoting medication adherence. Part four in this series addresses statin therapy, which is especially important for patients with diabetes.
According to evidence-based guidelines, statin therapy is recommended for all patients with diabetes between the ages of 40 to 75.1,2 Despite this, some members with diabetes who may benefit from statin therapy are either not on one or don’t adhere to the one they are prescribed.
What providers can do for patients with diabetes
- For patients who are not currently on statin therapy, consider initiating a statin in those who may benefit.
- For patients who are currently prescribed statin therapy, promote medication adherence by writing for 90-day fills, synchronizing all prescriptions for chronic conditions to be renewed during one yearly visit and educating patients about the benefits of statin therapy.
Use these resources to effectively prescribe and promote statin therapy for your patients:
- American Diabetes Association (ADA) Summary of Recommendations for Statin Use
- Moderate-Intensity and High-Intensity Statin Therapy Regimens
- Statin Use Barriers and Solutions
ADA Summary of Recommendations for Statin Use
| Presence of Atherosclerotic Cardiovascular Disease (ASCVD) | Recommended Statin Intensity |
| No | Moderate-intensity statin |
|
Yes |
High-intensity statin |
High-intensity statin is recommended for patients with ≥1 ASCVD risk factors, such as LDL cholesterol ≥ 100 mg/dL, high blood pressure, smoking, chronic kidney disease, albuminuria and family history of premature ASCVD.
Moderate-Intensity and High-Intensity Statin Therapy Regimens
| Medication | Moderate-Intensity Statin Therapy (Lowers LDL by <50%) |
High-Intensity Statin Therapy
(Lowers LDL by ≥50%) |
|
Atorvastatin |
10-20 mg |
40-80 mg |
|
Rosuvastatin |
5-10 mg |
20-40 mg |
|
Simvastatin |
20-40 mg |
-- |
|
Lovastatin |
40 mg |
-- |
|
Fluvastatin XL |
80 mg |
-- |
|
Pravastatin |
20-40 mg |
-- |
|
Pitavastatin |
2-4 mg |
Statin Use Barriers and Solutions
| Barrier | Solution |
|
Patient has type 1 diabetes |
The American Diabetes Association and the American College of Cardiology/American Heart Association guidelines recommend statin therapy for primary prevention of ASCVD for both type 1 and type 2.1,2 |
|
Patient’s LDL is within normal range |
Statin therapy is recommended for all patients with diabetes between the ages of 40 to 75, regardless of LDL levels.1 |
|
Patient has myalgia or is at risk for myalgia (e.g., female gender, advanced age, hepatic dysfunction, kidney dysfunction, medication interactions) |
Consider if the benefits still outweigh the risks. A brief period of discontinuation may resolve the myalgia. You may then consider initiating the same or a different statin.3 Myalgia is common and may not be medication related. Some statins are more hydrophilic and may be less likely to cause myalgia (such as pravastatin, rosuvastatin or fluvastatin).4,5 Try lower or less frequent dosing (such as every-other-day simvastatin or once-weekly rosuvastatin).4,5,6 Vitamin D levels are associated with myalgia in patients with statin therapy, and correcting this may improve statin tolerance.7,8 |
|
Patient’s ACC/AHDA ASCVD Risk Calculator estimates a < 7.5% 10-year atherosclerotic ASCVD risk |
This tool has limited use in patients with diabetes since those with diabetes between the ages of 40 and 75 should be on a statin independent of the calculated 10-year ASCVD risk.1 |
|
Medication interaction concerns |
Simvastatin, lovastatin and atorvastatin are susceptible to many medication interactions. Consider switching to rosuvastatin, pravastatin or fluvastatin.9 |
|
Patient has elevated liver enzymes |
Elevated liver enzymes in diabetes may be due to fatty liver, which may improve with better glycemic control. Once liver function returns to normal, it is reasonable to re-initiate the same statin at a lower dose or try a different statin, which can be done safely with routine liver function test monitoring.10 |
|
Statins increase A1c |
Although increased A1c and fasting glucose have been reported with statin use, the risk is considered minimal compared to the cardiovascular benefits.1,11-13 |
|
Statins cause dementia |
There is no definitive data to support the claim that statins cause dementia. In fact, some studies have shown that statins may reduce the incidence of dementia.14-16 |
References
1. Diabetes Care 2023;46(Suppl. 1):S158–S190 | https://doi.org/10.2337/dc23-S010
2. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2019 Jun 25;73(24):3168-3209. doi: 10.1016/j.jacc.2018.11.002. Epub 2018 Nov 10. Erratum in: J Am Coll Cardiol. 2019 Jun 25;73(24):3234-3237. PMID: 30423391.
3. Bitzur R, Cohen H, Kamari Y, et al. Intolerance to Statins: Mechanisms and Management. Diabetes Care. 2013; 36(Supplement 2): S325-S330. doi: 10.2337/dcS13-2038.
4. Mancini GB, Baker S, Bergeron J, et al. Diagnosis, Prevention, and Management of Statin Adverse Effects and Intolerance: Canadian Consensus Working Group Update (2016). Can J Cardiol. 2016 Jul;32(7 Suppl):S35-65.
5. Rosenson RS, Baker SK, Jacobson TA, et al. An assessment by the Statin Muscle Safety Task Force: 2014 update. J Clin Lipidol. 2014 May-Jun;8(3 Suppl):S58-71.
6. Pramanik S, Das AK, Chakrabarty M, et al. Efficacy of alternate-day versus everyday dosing of atorvastatin. Indian J Pharmacol. 2012 May;44(3):362-5.
7. Taylor B, Lorson L, et al. Low vitamin D does not predict statin associated muscle symptoms but is associated with transient increases in muscle damage and pain. Atherosclerosis. 2017 Jan; 256:100-104. doi: 10.1016/j.atherosclerosis.2016.11.011.
8. Michalska-Kasiczak M, Sahebkar A, et al. Analysis of vitamin D levels in patients with and without statin-associated myalgia - a systematic review and meta-analysis of 7 studies with 2420 patients. Int J Cardiol. 2015 Jan 15; 178: 111-6. doi: 10.1016/j.ijcard.2014.10.118
9. Zhelyazkova-Savova M, Gancheva S, Sirakova V.Potential statin-drug interactions: prevalence and clinical significance. SpringerPlus. 2014; 3:168. doi: 10.1186/2193-1801-3-168.
10. Calderon RM, Cubeddu LX, Goldberg RB, Schiff ER. Statins in the Treatment of Dyslipidemia in the Presence of Elevated Liver Aminotransferase Levels: A Therapeutic Dilemma. Mayo Clinic Proceedings. 2010; 85(4): 349-356. doi:10.4065/mcp.2009.0365
11. Rajpathak SN, Kumbhani DJ, Crandall J, Barzilai N, Alderman M, Ridker PM. Statin therapy and risk of developing type 2 diabetes: a metaanalysis. Diabetes Care. 2009; 32: 1924–1929
12. Sattar N, Preiss D, Murray HM, et al. Statins and risk of incident diabetes: a collaborative meta-analysis of randomised statin trials. Lancet. 2010; 375: 735–742
13. Ridker PM, Pradhan A, MacFadyen JG, Libby P,Glynn RJ. Cardiovascular Benefits and Diabetes Risks of Statin Therapy in Primary Prevention. Lancet. 2012; 380(9841): 565-571. doi:10.1016/S0140-6736(12)61190-8.
14. Cramer C, Haan M N, Galea S, et al. Use of statins and incidence of dementia and cognitive impairment without dementia in a cohort study. Neurology. 2008 Jul 29; 71(5): 344–350. doi: 10.1212/01.wnl.0000319647.15752.7b.
15. Jick H, Zomberg G L, Jick S S, et al. Statins and the risk of dementia. Lancet. 2000 Nov 11; 365: 1627-1631.
16. Wanamaker, B. L., Swiger, K. J., Blumenthal, R. S. and Martin, S. S. (2015), Cholesterol, Statins, and Dementia: What the Cardiologist Should Know. Clin Cardiol, 38: 243–250. doi:10.1002/clc.22361.