MRCGP Exam Update: Diabetes and cholesterol

Dr Louise Newson is a GP in the West Midlands and author of 'Hot Topics for MRCGP and General Practitioners' PasTest 2006.

Current situation

  • Patients with type-2 diabetes should be considered high risk for cardiovascular disease. Dyslipidaemia should be a key therapeutic target, irrespective of baseline LDL cholesterol levels or age (Circulation 2004;110:227-39).
  • Many studies have established statins as effective agents in the primary and secondary prevention of CHD in diabetes patients.
  • Many patients with diabetes are still not reaching current therapeutic lipid goals and so remain at an unacceptable level of risk (JAMA 2004;291:335-42).

What is the evidence?

  • The Collaborative Atorvastatin Diabetes Study (CARDS) involved over 2,800 patients with type-2 diabetes (Lancet 2004;364:685-96). It was stopped when patients in the statin group showed reductions in MI, stroke, angina and revascularisation, although they had normal LDL cholesterol levels.
  • A recent meta-analysis of statin trials in diabetes concluded that the NNT to prevent one CHD event was only 13.8 over 4.9 years for secondary prevention and 34.5 over 4.3 years for primary prevention (Ann Intern Med 2004;140:650-8).
  • Results from the Heart Protection Study showed that simvastatin could reduce the risk of MI, stroke or need for revascularisation in diabetes patients by a third, regardless of their baseline cholesterol level (Lancet 2003;361:2005-16).
  • The American College of Physicians recommended statins for diabetes patients over 55 years and for younger patients who have any other risk factors for heart disease, such as high BP or a history of smoking (Ann Int Med 2004;140:644-9). Guidelines are based on the results of six studies of primary prevention and eight trials of secondary prevention in patients with diabetes.

Implications for practice

  • Although CARDS adds support to prescribing statins for patients with type-2 diabetes, it is still recommended that a patient's individual risk and preference should be considered before starting them on long-term statin treatment.
  • Poor compliance still limits the long-term effectiveness of treatment (J Gen Intern Med 2004;19:638-45).
  • Statins should be prescribed for the majority of patients with type-2 diabetes, irrespective of their baseline LDL cholesterol level (Br J Diabetes Vasc Dis 2005;5:55-62).
  • Combination therapy of statins with fibrates or niacin may offer intensive lipid control and greater risk reduction.

Guidelines

  • Updated guidelines from the National Cholesterol Education Program (Circulation 2004;110:227-39).
  • Third Joint Task Force of European and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (Eur Heart J 2003;24:1601-10).
  • NICE guidelines for the management of blood pressure and lipids in patients with type-2 diabetes 2002: www.nice.org.uk.

 

Key points
  • Statins are effective at reducing cholesterol.
  • Statins reduce risk even when cholesterol levels are normal.
  • Compliance with statins is an issue

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