Statins and LDL goal in DM

Question 1

What are the lipid profiles in DM patients?
*Insulin resistance profile

Answer 1

Low HDL-C
Marginally increased LDL-C
Increased TG

Question 2

The lipid profile in DM pts are thought to represent a higher risk of ____________

Answer 2

Thought to represent a higher risk of atherosclerosis than an isolated elevated LDL-C

Question 3

What is the role of therapeutic lifestyle changes in normalizing DM lipid profiles?

Answer 3

Negative impacts:

• Saturated and Trans fatty acid => incr LDL
• Alcohol + Carbs + Fructose (>10% of daily energy) => incr TG and abdominal obesity

Positive impacts (marginal):

• Unsaturated fat-rich oil => marginally dcr LDL
• Weight loss + exercise => marginally dcr LDL (10kg weight loss, 0.2mmol/L dcr in LDL)
  (weight loss have even smaller impact)
• BW and regular exercise => dcr TG, incr HDL

Question 4

Which lipid profile does not have drug therapy option, and must rely on TLC?

Answer 4

HDL
- If HDL <1mmol/L, most effective strategy is exercise

Question 5

Following MOH 2016 guidelines, target LDL levels for high risk patients is ______, and very high risk patients is _______

What constitutes ‘high risk’ and ‘very high risk’ for DM patients?

Answer 5

High risk <2.6mmol/L

• DM (including new onset) is considered a cardiovascular risk equivalent

Very high risk <2.1mmol/L

• DM with target organ damage (microalbuminuria, retinopathy, neuropathy)

Question 6

What is the difference between LDL goals in DM and LDL goals in hyperlipidemia?

Answer 6

In hyperlipidemia, follow stricter ESC/EAS 2019 guidelines

• To classify as ‘very high risk’, must have established ASCVD that includes history of PAD, stroke, ACC, IHD etc. or severe CKD => goal <1.8mmol/L

Question 7

If DM patient has concomitant CVD / CKD, how does the LDL goal change?

Answer 7

Classified as ‘very high risk’, may choose to follower CVD targets <1.8mmol/L

Question 8

5 year treatment with statin lowers LDL by ______ and hence prevents major CVD events

Answer 8

2mmol/L

Question 9

Statins is first line for LDL lowering, but Ezetimibe may be added if LDL still not at goal. Ezetimibe provides additional _____% LDL lowering when added to statins

Answer 9

Additional 20% LDL lowering

Question 10

What are some examples of moderate intensity statins, and how much do they reduce LDL by?

Answer 10

Moderate intensity statins (30-49%)

• Simvastatin 20-40mg
• Atorvastatin 10-20mg
• Rosuvastatin 5-10mg

*Low intensity (<30%)
*High intensity (>50%)

Question 11

Doubling the dose of statins gives _____ reduction in LDL

Answer 11

6-7% reduction in LDL

Question 12

When to monitor and consider Ezetimibe add on to statins?

Answer 12

When high intensity statin unable to bring LDL levels to goal, repeat LDL and consider adding Ezetimibe

Question 13

Why is statin still used in the management of LDL for DM patients despite the controversy a/w its use?

Answer 13

Controversy:

• Statin initiation a/w 10% incr risk of DM
• More intensive statin dosing a/w 10% incr risk of DM
• Chiefly amongst those with raised BMI, impaired fasting glucose (alr have metabolic syndrome)

However,

• Risk did not incr as treatment continued (risk only occur at the start when statin first initiated)
• No evidence that deterioration of glycemic control is due to statin use

=> CVD benefits > initial risk of DM development

Question 14

Apart from being the first line to reduce LDL levels, Statins are also first line to treat TG > ___ mmol/L, to reduce CVD risk.

When is fibrates considered?

Answer 14

Statins are also first line to treat TG >2.3 mmol/L

Fibrates can be considered:
1. Consider as monotherapy first when TG >4.5mmol/L (risk of pancreatitis)
2. When on optimal statin but TG still >2.3 mmol/L (add on fibrate) - [for primary prevention or high risk patients]

Question 15

Which fibrate should be avoided and why?

Answer 15

Gemfibrozil - incr risk of myopathy, rhabdomyolysis with statins

Consider Fenofibrate, or Bezafibrate instead