A new clinical practice guideline from the Endocrine Society provides guidance on lipid management in patients with endocrine disorders, including diabetes.
The guideline, which will appear in the December Journal of Clinical Endocrinology and Metabolism and was posted online in October, addresses the use of statin and other medical therapies in addition to lifestyle modification.
For adults with type 2 diabetes and other risk factors for ASCVD, statins and lifestyle modification is recommend to lower risk. High intensity statins are recommended for those with known ASCVD or risk factors and the guideline suggests a goal for low-density lipoprotein (LDL) cholesterol of less than 70 mg/dL. Also, if triglyceride levels are greater than 150 mg/dL, eicosapentenoic acid ethyl ester is recommended. In adults with type 2 diabetes and diabetic retinopathy, adding a fibrate to a statin is recommended to reduce retinopathy progression.
In those with borderline or intermediate risk, defined as 10-year ASCVD risk from 5% to 19.9%, additional risk-enhancing factors should be considered and coronary artery calcium can inform shared decision making. Initiation or continuation of statin treatment in patients older than age 75 years should depend on ASCVD risk, prognosis, potential interacting medications, polypharmacy, mental health, and the wishes of the patient.
The guideline suggests statin therapy regardless of a cardiovascular risk score in adults with type 1 diabetes who are age 40 years and older and who have had diabetes for more than 20 years and/or have microvascular complications. LDL cholesterol should be the primary target for lipid-lowering therapy, and therapy should be considered if LDL is over 70 mg/dL.
The guideline recommends measuring triglyceride levels and LDL cholesterol and said that nonfasting lipid panels are acceptable for initial screening. Clinicians should repeat a fasting lipid panel when triglyceride levels are elevated or if genetic dyslipidemia is suspected. If lipoprotein(a) levels are measured, fasting or nonfasting samples can be used.
Lipoprotein(a) testing does not need to be repeated if it has been assessed in childhood or early adulthood. It is not yet known whether reducing lipoprotein(a) reduces atherosclerotic cardiovascular disease risk, the guideline said.
For more on lipoprotein(a), read ACP Internist's May article, “Why Internists Should Care about Lipoprotein(a).”