Diabetes, LDL-C 70-180mg/dL, age 40 to 75 years LDL-C в‰Ґ190mg/dL (if LDL-C <190mg/dl, move to No. Statin Therapy Recommendation Algorithm, per the ACC/AHAДЈ. Patients with diabetes (age 40 to 75, LDL-C 70-180mg/dl) are automatically considered for moderate-intensity statin, but when he or she has an estimated 10-year ASCVD risk factor of в‰Ґ7.5%, is a candidate for high-intensity statin. If a patient does not meet either of the 2 criteria, diabetes would be considered. Before considering diabetes as a determining factor for the intensity of statin therapy, we must review other factors such as *clinical ASCVD (ACS, myocardial infarction, angina, coronary revascularization, PAD due to atherosclerosis, stroke or transient ischemic attacks 6) and LDL-C level в‰Ґ190mg/dl. Statin therapy initiation follows a four-step process in the ACC/AHA guideline (Table 2).

6 The ACC/AHA guidelines recognize lifestyle modification as a crucial component to reduce the ASCVD risk factor, and they publish a separate guideline for it: the 2013 ACC/AHA Guideline on Lifestyle Management to Reduce Cardiovascular Risk. в‰Ґ40 years with ACS and LDL cholesterol в‰Ґ50mg/dl or in patients with a history of ASCVD who cannot tolerate high-intensity statinДЄCC/AHA: The 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults focus on the treatment to reduce ASCVD risk, rather than targeting a certain LDL level. Statin Therapy Recommendations for Patients with Diabetes, per the ADA Primary composite end points were cardiovascular death, major coronary events, or nonfatal stroke. The simvastatin and ezetimibe combination group resulted in a 2-percentage-point lower rate of primary composite end point cardiovascular death (hazard ratio 0.936). 5 The combination of simvastatin and ezetimibe resulted in a significantly lower risk of cardiovascular events than that of simvastatin mono-therapy for post-ACS patients who are 50 or older. Supporting evidence for the addition of ezetimibe to moderate-intensity statin originates from the results of ezetimibe added to statin therapy after the ACS (IMPROVE-IT) trial. Patients younger than 40 without CVD risk factors are not a candidate for statin therapy. Ezetimibe may be combined with moderate-intensity statin for patients 40 and older with a history of acute coronary syndrome (ACS) who cannot tolerate high-intensity statin or with LDL-C в‰Ґ50 mg/dl. Who would be considered a good candidate for either high-intensity or moderate-intensity statin? Patients under 40 or over 75 carrying ASCVD risk factor. 3,4 Which individuals are candidates for high-intensity statin? Any diabetic patient with a history of ASCVD and individuals from 40 to 75 with ASCVD risk factors (LDL cholesterol в‰Ґ100mg/dl, high blood pressure, smoking, chronic kidney disease, albuminuria, and family history of premature ASCVD 4) may be considered for high-intensity statin therapy. As a result, patients with diabetes are less likely to benefit from ERK-5, KLF-2, and PPARg mediated cardio-protection compared with patients without diabetes.ДЄDA: The 2017 American Diabetes Association Standards of Medical Care in Diabetes recommends statin therapy (Table 1) based on *atherosclerotic cardiovascular disease (ASCVD) * cardiovascular disease (CVD) risk factors, rather than low-density lipoproteins (LDL) levels by itself for patients with diabetes.

KLF-2 and PPARg are known to block the activity of pro-inflammatory immune cell activity in blood vessels. 2 ERK-5 functions by signaling endothelial nitric oxide synthase to produce more nitric oxide for vasodilation. It is believed that increased production of advanced glycation end product (AGE) in patients with diabetes interferes with extracellular signal-regulated kinase 5 (ERK-5), krup-pel-like factor 2 (KLF-2), and peroxisome proliferator-activated receptor-g (PPARg). LetвЂ™s take a look at the role of statin therapy in patients with diabetes, referencing the most widely used guidelines. 1 Because statin medications are commonly prescribed, different guidelines acknowledge the importance of statin therapy and describe how it should be used. From 2011 to 2012, 93% of adults using cholesterol-lowering medication took a statin, also known as an HMG-CoA reductase inhibitor. The CDC estimates that from 2003 to 2012, the percentage of adults 40 and older who took a cholesterol-lowering medication increased to 28%, from 20%.

High intensity statins