Treating Type 2 Diabetes: Looking Ahead - Episode 3

Cholesterol-Lowering Therapies for CVD Prevention in T2DM

January 4, 2022

Considerations that factor into decisions for reducing LDL levels in patients with diabetes with statin therapy or options, such as PCSK9 inhibitors and ezetimibe.

Davida Kruger, NP: Let’s talk about cholesterol, lipids, and lipid lowering medications and what are the guidelines in terms of what are we looking for these patients, and how does it affect them cardiovascular?

Margo B. Minissian, PhD, ACNP: I love lipids. I love them because we can treat them and very similar to the diabetes world, we finally have medications that truly work and it’s so empowering as a provider to have hard outcomes for our patients in our community. Our guidelines are quite set in the sense that there are 4 different groups of individuals that qualify for cholesterol lowering therapy and the class 1A recommendation is the statin lowering drug. Those individuals are people who have established coronary artery disease [CAD], for those patients with diabetes 40-59 years of age, the age limitations there are simply because that’s what the randomized clinical control trials were, that they might have familial hyperlipidemia, which is you know, very high cholesterol—can’t eat your way at McDonald’s enough to get your LDL [low-density lipoprotein] over 190 mg/dL. And then the trickiest categories are those primary prevention patients that are either borderline, which is greater than 5% risk using the atherosclerotic cardiovascular disease [CVD] risk calculator, [ASCVD] that’s a mouthful, we call it ASCVD. If you are over 5% is a deeper discussion. If they’re over 7.5% then we are strongly recommending that they consider a cholesterol lowering medication.

Davida Kruger, NP: When you talk about the cholesterol lowering medications and I know each one lowers a certain percentage, when you maximum out 1 of the medications or when do you add Zetia [ezetimibe]. That would be my question to you, when do you add Zetia?

Margo B. Minissian, PhD, ACNP: Our guidelines suggest that you would add zetimide [Ezetrol], which is our first-line non-statin. You can also prescribe simultaneously a PCSK9 inhibitor, those usually take weeks, maybe a month to get into your patients’ hands so you can prescribe them together, get going on the zetimide. That’s if somebody hasn’t reached a 50% reduction in their LDL, or they’re not meeting the LDL threshold that you set for them. And for our patients currently it’s about 70 mg/dl. If they’re aggressive, if they’re lying down flat quickly, they have a very strong family history, I’m trying to prevent a second heart attack, then I’m driving that LDL well below 70. And we’ll watch our guidelines reflect that in the future as they’re being currently updated as we are speaking.

Davida Kruger, NP: Right. Now I’ve heard more and more that we should all be using a risk calculator with our patients to help guide some of these decisions. Do you have a favorite that you recommend?

Margo B. Minissian, PhD, ACNP: I do. I use that ASCVD calculator. It’s validated. It’s a pulled cohort risk equation, they have pulled in these different variables that they know can help move the needle towards the confidence interval that helps us decide as clinicians, do we really need to start a therapy or not, and that’s what we care about, right? It’s the best validated tool that we have. It has been endorsed by the American College of Cardiology and the American Heart Association amongst other organizations and that is the tool that I use. There is an App. There is always an App for that. If you put in ASCVD calculator into your App store it will pop up and you’ll see it there. I find that very helpful. I also find that it’s helpful for patients because it gives them something quantifiable to look at and it seems to be more concrete for them. Now, we’re talking about diabetes today, do we need that ASCVD calculator if we are talking about a patient with diabetes? The answer is no, you just jump right into treatment almost every time. There are a few that you wouldn’t, but for the most, you would, and you would have to have strong documentation why your diabetic is not on a cholesterol lowering pill, specifically a statin.

Davida Kruger, NP: You’re saying that this is news because everywhere I go they are taking about using these calculators is, if I have an elevated lipid profile on a patient with diabetes, which I actually do, I do jump right in [to] treat it, that I don’t have to use a risk calculator I should just be starting a statin?

Margo B. Minissian, PhD, ACNP: I’m going to take it further than that. I’m going to say if they have diabetes, I don’t care if they are healthy all of 75, you are going to hopefully start them on a statin medication. Now, the intensity of the statin may be less. Maybe you’re using rosuvastatin [Crestor] 5 mg and not rosuvastatin 20 mg, but if they have diabetes with a normal LDL but they’ve had a heart attack or they have plaque then I am putting them on a high intensity statin, which is either atorvastatin [Lipitor] 40 [mg] or 80 mg or a rosuvastatin 20 [mg] or 40 mg and that’s all good national guidelines recommendation. It’s the dose that is important, not that LDL number because remember that’s just 1 type of low density lipoprotein we are measuring, as we know there are several of these particles circulating in our system.

Davida Kruger, NP: Exactly. And I usually tell my patients the greatest risk in your life is going to be cardiovascular disease. We’re going to put you on medication to control your blood sugar and I agree with you, no matter where you are on the spectrum give yourself a statin. But I get up against a wall on a lot of patients because they’re going to eat themselves out of cardiovascular disease. I’ll get my LDL where I want it, even though I’m saying that that’s not the issue, and I’m saying your food intake isn’t necessarily what’s causing and elevated LDL.

Margo B. Minissian, PhD, ACNP: Correct, and you are absolutely right, and the food piece is important because remember we are combating inflammation, a systemic inflammation so Mediterranean style nutrition is the way to go, carb [carbohydrate] counting if need it to help manage their diabetes, these are all good things but honestly if I could start a business and somehow be able to coin these lifesaving therapies we know, you know ACE [angiotensin-converting enzyme] inhibitors, ARBs [angiotensin receptor blockers] statins, these medications reduce heart attacks, strokes, and death, and if I could re-coin them as a cardiovascular prevention vitamin that just happens to be FDA approved I would because they are so vitally important. People will put all kinds of supplements into their body but many times they have this barrier especially if the med sounds like something their parents or their grandparents have taken in the past. If it’s associated with maybe a poor outcome in a family member, they will have certain stigmas around the medication. It’s trying to change those stigmas that sometimes come with these vitally important medications.

Davida Kruger, NP: I want to thank our audience for watching HCPLive® Peers and Perspectives. If you enjoyed the content, please subscribe for our new e-newsletter to receive upcoming Peers and Perspectives and other great content right in your inbox. I receive it and I really love it when I see it in there. Take some time to enjoy it. Thank you again for joining us.

Transcript edited for clarity.