Dr. K. here, your War on Diabetes pharmacist, with a new lesson for a new year. I was at work the other day reviewing the new cholesterol guidelines. New guidelines? Yes. Every few years, the American Heart Association and American College of Cardiology publish new guidelines that are used as a recommendation for treating patients with high cholesterol. Since I have been doing a series of posts here on cholesterol recently, I wanted to see if the guidelines said anything about treatment for cholesterol in diabetics. What I found in the changes made me stop and take a step back – the new guidelines are a complete revamping of the way that we have been treating all patients with high cholesterol, which is why I thought it was so important to make a formal post about these changes.
At the end of this posting I will provide a link to the full cholesterol guidelines, for the sake of completeness and because I know we have friends of diabetics that read our blog and should know how the recommendations affect them.
The ‘Old’ Way
Up to this point, the treatment of high cholesterol was based on numbers. You got a blood test for lipids. The doctor received a report with your numbers and, based on those numbers, developed a treatment plan. It was a pretty cut and dried approach that everyone could understand. Those were the past guidelines.
If you have read my previous cholesterol posts, you might remember words like LDL, HDL, triglycerides, good cholesterol, bad cholesterol, and so on. In fact, if you’ve been on cholesterol medications for awhile, you might even know what your goals are based on your many blood tests through the years. Well, what I’m about to say could effectively wipe all of the things you’ve learned off of the chalkboard. If you’ve looked for my simvastatin and lovastatin posts recently, you’ll notice we’ve taken them down – that’s because the changes are significant enough to make me rewrite portions of my articles in order to keep them accurate relative to the new model.
Have I kept you on the edge of your seat long enough? Well, let’s end the suspense now. The newest recommendations from the American Heart Association/American College of Cardiology abandon the standard LDL goal numbers in favor of giving an appropriate statin medication at the correct dose based on a patients risk of developing heart disease or complications. You will notice that I said a statin medication – the new guidelines focus more on treating with statins only, saving non-statin medications as last-ditch options or for particular patients with high trigylcerides alone.
This should come as no surprise to you from reading my posts – statins have always been known as the best cholesterol-lowering medications with some of the lowest amount of side effects and greatest benefits on improving overall health. I have not, and will continue to not recommend over-the-counter products such as fish oil for the majority of patients with high cholesterol. Contrary to what has been reported on medical shows on television and in the news recently, adding medications like fish oil, krill oil, flax seed, niacin, or even prescription fibrates (gemfibrozil, fenofibrate) has not been shown to have any effect on decreasing strokes, heart attacks, or death from heart-related causes. Remember, if it sounds too good to be true, it probably is.
The old days of starting on a low dose of a statin and working your way up to a dose that gets you to your goal cholesterol levels are over. As a diabetic, you will know that we treat diabetes that way – start at one dose mg/and work your way up until your A1C is where we want it. The treatment of high cholesterol is now a whole different ballgame. It has been found that there is no need to start a patient on a low dose of a cholesterol medication and work up to a higher dose, so from now on we will start you at the recommended dose for your risk factors (which I will discuss later) and lower the dose if muscle aches become a problem. Starting at a low dose and increasing slowly has not been shown to decrease the muscle aches that some experience with statins.
The new guidelines rank cholesterol medications and doses based on how “strong” they are (what percentage of cholesterol-lowering you can expect from them): high intensity, moderate intensity, and low intensity. Which category of statin you will be taking is based upon how much benefit you are expected to receive from taking a statin. How do they determine that? A new risk calculator has been developed which will help predict if you are likely to have in the next ten years a stroke, heart attack, or death from heart related problems. The more at risk you are, the more benefits you will receive from statins (because they have been shown to decrease the risk of these health events), so the stronger the medication you should receive.
To try the risk calculator for yourself, follow this link.
There are four groups of people who are classified as “statin benefit groups” because these groups have been found to have more of the heart related problems that I just discussed and statins can help prevent these problems, if given at the proper dose. People in these groups should be on a statin medication. If you are a diabetic between the ages of 40 and 75 with LDL between 70 and 189 mg/dL (1.8 to 4.9 mmol/L), you fall into one of the statin benefit groups. If you are outside of those age ranges, you might fall into one of the groups if you have other conditions (such as very high cholesterol, heart disease, or if your risk on the risk calculator is greater than 7.5%). Essentially, they recommend that almost all diabetics between the ages of 40 and 75 should now be on a statin.
The recommended statin is based on how “strong” it is, or how much cholesterol-lowering potential it has been proven to display. High-intensity statins (those that can lower LDL by over 50%) should be used for diabetics who receive 7.5% risk or higher on the risk calculator above. High-intensity statins are:
- Atorvastatin (Lipitor) 80 mg once daily (40 mg if 80 mg not tolerated)
- Crestor 20 mg to 40 mg once daily
Moderate-intensity statins (those that lower LDL by 30-50% on average) should used for diabetics who receive less than a 7.5% risk on the risk calculator. The moderate-intensity statins are:
- Atorvastatin 10 to 20 mg once daily
- Fluvastatin 40 mg twice daily or 80 mg (XL) once daily
- Lovastatin 40 mg once daily
- Pitavastatin 2 to 4 mg once daily
- Pravastatin 40 to 80 mg once daily
- Rosuvastatin 5 to 10 mg once daily
- Simvastatin 20 to 40 mg once daily
There is another category of low-intensity statins (lower your LDL by less than 30%), but these are specifically reserved as last-choice options because they have not been proven as effective at lowering your risk of heart attacks, stroke, and death. They should be only used if you have tried all of the options in the high or moderate-intensity categories and are still having muscle problems. The low-intensity statins are:
- Fluvastatin 20 to 40 mg once daily
- Lovastatin 20 mg once daily
- Pitavastatin 1 mg once daily
- Pravastatin 10 to 20 mg once daily
- Simvastatin 10 mg once daily
Notice, there are very specific doses given on some of these medications. These are the doses that have been shown, in clinical studies, to have the desired risk-lowering benefits necessary for diabetic patients. If you are taking one of these medications, but at a lower dose than is recommended above, you might not be receiving the necessary benefit your medication. Talk with your doctor about the new guidelines and go over your risk assessment at your appointment. Remember, the risk assessment shows how likely you are to have a stroke, heart attack, or death from a heart-related condition within the next ten years. The right dose really could save your life (remember, heart disease tops the list as the number one killer of American adults, stroke is number four).
The guidelines also stress that medication alone should not be the solution to fending off heart attacks and stroke. Proper nutrition and exercise, as they are in the War on Diabetes, are two of your weapons when trying to lower your risk of heart disease.
Another note, these guidelines are called recommendations for a reason. They cannot be considered an across-the-board standard for all patients. Every person is different, which is why you and your doctor should be the ones to determine whether or not you should start a statin. A good thing about new guidelines is, it keeps the conversation fresh and pushes us to develop the best plans based on the current research available.
If you are a prediabetic or a non-diabetic, the guidelines address you as well. You can read all about them here.
For a more lively discussion, and to hear about the criticisms that the guidelines have faced so far, visit this article.
As a disclaimer, I am your “virtual” pharmacist, here to provide you with information and answers to questions. However, I am not your local pharmacist and could, in no way, be aware of your specific medical needs. Remember to always check with your medical provider and pharmacist before stopping or starting any new medications. My posts are based on general pharmacy principles and should not considered as your “first opinion” when it comes to your health. Please consult with your doctor and pharmacist about anything regarding your health.