People with diabetes often have multiple abnormalities in their lipids, including high low-density lipoprotein (LDL) cholesterol, low high-density lipoprotein (HDL) cholesterol and elevated triglycerides. And of these three, it is most important to reduce the LDL cholesterol to lower one’s risk for heart disease and stroke. With several of the leading organizations releasing cholesterol recommendations over the past two years, it can be confusing to interpret the various guidelines.
In an effort to help mitigate this confusion among both providers and patients, Om P. Ganda, M.D., Director of the Lipids Clinic at Joslin Diabetes Center and Associate Professor of Medicine at Harvard Medical School, authored a perspective paper released last month in JAMA, which explains and provides recommendations regarding the new cholesterol guidelines.
The previous cholesterol guidelines utilized specific targets for LDL cholesterol for patients at risk, which were characterized as having a LDL cholesterol lower than 100 mg/dL for adult patients with diabetes and greater than 70 mg/dL for those with cardiovascular disease. When the American College of Cardiology (ACC) and the American Heart Association (AHA) set forth new guidelines in 2013, they eliminated numerical targets for LDL cholesterol and HDL cholesterol. These regulations also introduced a new risk calculator for preventative treatment.
“There are two points of contention with the recommendations from the ACC and the AHA,” said Dr. Ganda. “The first is that removing numerical goals for LDL cholesterol makes it more difficult for patients and providers to establish proper treatment and adherence protocols. The next is that the new risk calculator for primary prevention may overestimate or underestimate the need for statin therapies.”
In response to these changes in treatment guidelines, Dr. Ganda and his Joslin colleagues adopted a more proactive cholesterol treatment plan.
“At Joslin, we treat people under the age of 40 with multiple risk factors, which we implemented before the ADA recommendations were released,” commented Dr. Ganda. “And I am glad to see the ADA agrees with that stance, as reflected in their new guidelines.”
The American Diabetes Association (ADA), the UK National Institute for Health and Care Excellence (NICE) and the National Lipid Association (NLA) also released additional cholesterol treatment guidelines over the past year, some of which differ from the ACC and AHA’s recommendations.
Despite these differences, all five organizations agree on the need for more aggressive statin therapy in high risk people. High-risk people are classified as having preexisting cardiovascular disease, multiple risk factors or whose LDL cholesterol is greater than 190 mg/dL.
“In the past, many people have been prescribed low dose statins and they have not progressed to high dose statins, meaning a majority of the high risk people remained at high risk for heart disease,” explained Dr. Ganda. “One of the major advantages of these guidelines is they emphasize the intensification of statin therapies for high risk people.”
There is also a consensus that in primary prevention, lifestyle changes, including lowering your blood pressure, quitting smoking, adopting a healthy diet and exercising regularly, are essential in averting cardiovascular complications.
The organizations diverge on screening and risk assessment as well as recommendations for lipid targets. Part of the reason for this is the clinical trials used to form these recommendations only evaluated people between the age ranges of 40 to 75.
“I disagree with the notion that people under the age of 40 or over the age of 75 should be not treated just because there is no clinical trial evidence,” commented Dr. Ganda. “We have a lot of other evidence that younger and older patients with cardiovascular risk factors, such as diabetes, can benefit from early detection and treatment.”
Dr. Ganda also notes that the conflicting guidelines are causing confusion among providers, especially when it comes to prescribing statin therapies.
“There needs to be a better combined approach,” said Dr. Ganda. “All of the organizations need to get together and reassess their guidelines because this controversy is frustrating for the primary care physicians as well as specialists.”
A more uniformed approach would be advantageous for people with diabetes, who are two to three more times more likely to develop heart disease, according to Dr. Ganda.
“It is generally agreed upon that people with diabetes should receive more aggressive cholesterol lowering treatment,” he said.
Joslin’s cholesterol guidelines include the following:
- All adults with any form of cardiovascular disease, or a LDL cholesterol 190 mg/dl should be treated with high dose statins
- All patients with diabetes (age 40-75 years) with a LDL cholesterol between 70-189 mg/dl, and without any evidence of cardiovascular disease should receive a moderate dose of statin therapy
- However, you should consider high dose statin as above if 10-yr risk by new risk calculator >7.5 %
- For patients under 40, they should consider statin therapies if their LDL cholesterol is greater than 100 mg/dL and they have multiple CVD risk factors.
- If you are take a high or moderate dose of statins as described above, then a specific target LDL cholesterol is not recommended.
- As before, all patients must receive intensive lifestyle management