ACP Says That Many Diabetics Should Be Taking Statins

May 2004 - All people with type 2 diabetes mellitus and coronary artery disease (CAD), and all people with diabetes and any other risk for cardiovascular disease, should be taking cholesterol-lowering drugs called statins, the American College of Physicians (ACP) said in new guidelines published in the April 20, 2004, issue of Annals of Internal Medicine.

This is the second ACP guideline on aggressive management of risk factors for cardiovascular disease in people with type 2 diabetes. In April 2003, ACP called for tight control of blood pressure for people with diabetes.

An estimated 80 percent of people with type 2 diabetes will develop or die of complications of heart and vessel disease, and about 65 percent of deaths among people with diabetes are due to heart disease and stroke, according to the American Diabetes Association.

"We want both physicians and patients to know that when treating diabetes, controlling cardiovascular risk factors, particularly cholesterol levels and high blood pressure, is as important as controlling blood sugar," said Vincenza Snow, MD, FACP, senior medical associate in the department of scientific policy at the American College of Physicians.

"This is life-saving information," Dr. Snow said "In addition to controlling blood sugar levels, people with diabetes may be surprised to know that they must also be vigilant about controlling their blood pressure and cholesterol levels."

The numbers of people with type 2 diabetes is growing rapidly in the United States. An estimated 18.2 million Americans, or about six percent of the population, have type 2 diabetes, and an additional 1.3 million people aged 20 or older are diagnosed with the disease each year, according to the American Diabetes Association. Some call this increase an epidemic.

The new ACP guidelines are targeted at both patients and primary care physicians. For patients, ACP is issuing a video news release to alert people with type 2 diabetes and their families about the importance of controlling cholesterol. For ACP physician members, evidence-based guidelines on all aspects of diabetes treatment are important. Diabetes is the seventh most common reason patients visit their internists and the second most common diagnosis made by internists, according to 2001 data from the National Center for Health Statistics.

ACP says that to control cholesterol in people with diabetes:

• All adults with type 2 diabetes and known CAD should be taking statins, regardless of their cholesterol levels.
• All adults with type 2 diabetes and another risk factor for coronary artery disease, such as high blood pressure, high cholesterol, smoking, physical inactivity or obesity, should be taking statins or the non-statin drug gemfibrozil, regardless of cholesterol levels. This group includes premenopausal women with diabetes and another risk factor.
• Once started on cholesterol-lowering therapy, patients with type 2 diabetes should remain on at least moderate doses of a statin.
• Physicians should not delay starting statin treatment until cholesterol reaches a certain level and should not "treat to a target" level of cholesterol.
• Routine monitoring of liver function or muscle enzymes is probably not needed for those patients with type 2 diabetes who are taking statins, except if they also have a liver abnormality or muscle pain or are taking drugs that interact with statins.

The ACP guidelines call special attention to premenopausal women with diabetes. "Women with diabetes who have not reached menopause may think their female hormones protect them from CAD," said Dr. Snow. "But statistics show that premenopausal women with type 2 diabetes and at least one other cardiovascular risk factor are as likely as men to develop CAD. So ACP says that women with diabetes and other risk factors for CAD should take a statin."

Diabetes is itself a major risk factor for heart disease. Other risk factors are high blood pressure, high blood cholesterol, physical inactivity, obesity and overweight, smoking, and older age.

The guidelines, "Lipid Control in the Management of Type 2 Diabetes Mellitus: A Clinical Practice Guideline from the American College of Physicians," and the background paper, "Pharmacologic Lipid-Lowering Therapy in Type 2 Diabetes Mellitus," were published in the April 20, 2004, issue of Annals of Internal Medicine. They are also available to the public at http://www/annals.org.

The guidelines are based on a systematic review of evidence about cholesterol-lowering drug therapy in people with diabetes who have coronary disease already or who have risk factors for coronary disease. In these studies, the authors looked at:

• The benefits of tight lipid control in primary prevention (in patients without known coronary disease) and in secondary prevention (in patients with established CAD).
• The evidence for the benefit of lowering cholesterol to a target level of low-density lipoprotein (LDL, the dangerous cholesterol).

The ACP authors concluded that statins are extremely safe, except for patients who have liver problems or are taking drugs that interact with statins.

The American College of Physicians is the largest medical specialty organization and the second-largest physician group in the United States. ACP members include more than 115,000 internal medicine physicians (internists), related subspecialists, and medical students. Internists specialize in the prevention, detection and treatment of illnesses in adults.

Source: American College of Physicians