Management of lipids in type 1 and type 2 diabetes

Primary prevention for people with type 1 diabetes

• statin treatment should be considered for the primary prevention of CVD in all adults with type 1 diabetes
  
  
• statin treatment should be offered for the primary prevention of CVD to adults with type 1 diabetes who:
  • are older than 40 years or
  • have had diabetes for more than 10 years or
  • have established nephropathy or
  • have other CVD risk factors
    
    
• start treatment for adults with type 1 diabetes with atorvastatin 20 mg

Primary prevention for people with type 2 diabetes

• offer atorvastatin 20 mg for the primary prevention of CVD to people with type 2 diabetes who have a 10% or greater 10-year risk of developing CVD.
• estimate the level of risk using the QRISK2 assessment tool

Lipid modification therapy for the primary and secondary prevention of CVD

• before starting lipid modification therapy for the primary prevention of CVD, take at least 1 lipid sample to measure a full lipid profile
  • should include measurement of total cholesterol, high-density lipoprotein (HDL) cholesterol, non-HDL cholesterol, and triglyceride concentrations (fasting sample is not required)
• atorvastatin 20 mg should be offered for the primary prevention of CVD to people who have a 10% or greater 10-year risk of developing CVD. Estimate the level of risk using the QRISK2 assessment tool
• if a person has CVD then start statin treatment in people with CVD with atorvastatin 80 mg .A lower dose of atorvastatin if any of the following apply:
  • potential drug interactions
  • high risk of adverse effects
  • patient preference

Target cholesterol level

• measure total cholesterol, HDL cholesterol and non-HDL cholesterol in all people who have been started on high-intensity statin treatment at 3 months of treatment and aim for a greater than 40% reduction in non-HDL cholesterol. If a greater than 40% reduction in non-HDL cholesterol is not achieved:
  • discuss adherence and timing of dose
  • optimise adherence to diet and lifestyle measures
  • consider increasing dose if started on less than atorvastatin 80 mg and the person is judged to be at higher risk because of comorbidities, risk score or using clinical judgement

Notes:

• there is trial evidence that use of a statin did not prevent cardiovascular events or death in patient with type 2 diabetes receiving haemodialysis (2)
• **a non-fasting TG level of > 2mmol/l is not diagnostic as a feature of metabolic syndrome. A non-fasting level of of > 2mmol/l should instead prompt a request for a fasting TG level (3)
• the groups of diabetic patients recommended for statin treatment are based on evidence from randomised controlled trials such as CARDS and HPS (involved diabetic patients aged 40 years old or over), as well as concensus statements (5)
• the NICE guidance regarding management of lipids in diabetic patients is linked

Reference:

1. NICE (July 2014). Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease
2. Wanner C et al. Atorvastatin in patients with type 2 diabetes mellitus undergoing haemodialysis. N Eng J Med 2005;353:238-48.
3. Personal Email Communication. Professor Mike Kirby 13/2/06.