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The New Cholesterol Guidelines and Diabetes

Started By: hcsmlm, MD, Internal Medicine, 6:12PM Nov 23, 2013

THe ACC and AHA just put out a new set of cholesterol guidelines that will likely affect clinician's practice in lipid management, especially as it relates to diabetes. There are a few significant changes:

1. Guidelines focus on statin use.  Other agents (fibrates, niacin, omega 3's) are not recommended unless statins can not be tolerated.  This is mainly because outcomes data for these agents are limited or negative. 

2. Guidelines no longer recommend shooting for a target LDL.  Rather they suggest four categories of patients that would receive statin therapy-those with CV disease (high intensity statins), those with LDL's greater than 190 (also high intenstiy statins), diabetics (moderate intensity statins, and those without these 3 conditions that have a 10 year CV risk ofr > 7.5% (moderate statins)

3. For diabetics, they all get moderate dose statins, unless their 10 year risk is >7.5% where high intensity statins should be considered. 

These guidelines may cause clinicans to change their routine care, especially when it comes to using the non-statin cholesterol lowering agents or checking LDL levels after initiating therapy. Other changes include use of certain statins with lower potency. 

For high instensity statin therapy the guidelines recommend 20mg rosuvastatin/40 mg atorvastatin or at higher doses.  Moderate instensity statin are lower doses of rosuvastatin/atorvastatin or simvastatin 20-40mg, pravastatin 40mg, lovatstatin 40mg, or fluvastatin 40mg.  This suggest that if a moderate intensity statin therapy is needed, providers must use higher dosese of less potent statins like simva, lova and pravastatin which are all associated with higher doses (the FDA no longer recommends simvastatin 80mg). 


Poll: Will the new cholesterol guidelines change the way you prescribe statins or monitor therapy in diabetic patients? Yes|No|
Will the new cholesterol guidelines change the way you prescribe statins or monitor therapy in diabetic patients?
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#1 of 1, Added By: mdictu, MD, General Practice, 3:49AM Dec 20, 2013

Is there a limit to how low LDL can be safely lowered? Can the LDL get ‘too low’, raising risk of other problems? (I see mention elsewhere of mood disorders, hemorrhagic stroke, even cancer.) Am particularly interested in this question in male > 60 yo with history of Hypertension (controlled with multiple meds), History of stroke (never established whether hemorrhagic or thrombotic), and treatment (seemingly well tolerated) with statin so LDL < 40. How is too low? Is any low value OK? Do we have evidence based guidelines to support claims of safety of very low LDL levels? Thanks for any response.

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