Friday, February 17, 2012

Pre-Diabetes treatment with Glucophage ? Statins ?

 This is a continuation of our discussion of our 48y/o man with Pre - diabetes.


 He has been very successful at reducing his risk of progression to type 2 diabetes with his life style change efforts.


Should he consider adding a medication such as glucophage or a* GLP-1 agonist ?


There is good evidence that glucophage slows the progression to Type 2 Diabetes.
This is worth further discussion with his doctor.
 The use of a GLP-1 Agonist  makes sense on paper. This group of medication have been shown to correct the problem of sluggish insulin release and preserve function and survival of Beta cells , but I am not aware of any studies supporting their use for pre-diabetes yet.


His problem with elevated Triglycerides has been successfully managed with Omega  -3 - Fatty acids and life style change. He is left with an elevation of his LDL at 131 mg/dl ( 3.4mm/l ) and an HDL of 36mm/dl ( .9mm/l )


 Should he consider adding a *"Statin " to treatment program ?


American Diabetes Association 2012 guidelines 


Lifestyle modification focusing on the 
reduction of saturated fat, trans fat, and cholesterol intake; increase of n-3 fatty acids, viscous fiber and plant stanols/ sterols; weight loss (if indicated); and increased physical activity should be recommended to improve the lipid profile in patients with diabetes. (A)


 Statin therapy should be added to life- style therapy, regardless of baseline lipid levels, for diabetic patients:


          *with overt CVD.     
          * without CVD who are over the age of 40 years and have one or more other CVD risk factors. 
          * For lower-risk patients than the above (e.g., without overt CVD and under the age of 40 years), statin therapy should be
        considered in addition to lifestyle therapy if LDL cholesterol remains .100 mg/dL or in those with multiple CVD risk
        factors. (E)
         * In individuals without overt CVD, the primary goal is LDL cholesterol ,100 mg/dL (2.6 mmol/l). (A)

page3image62840
        S6 DIABETES CARE, VOLUME 35, SUPPLEMENT 1, JANUARY 2012care.diabetesjournals.org

page4image536
        * In individuals with overt CVD, a lower LDL cholesterol goal of ,70 mg/dL (1.8 mmol/l), using a high dose of a statin,is  an option   
       * If drug-treated patients do not reach the above targets on maximal tolerated statin therapy, a reduction in LDL cho- 
       lesterol of ;30–40% from baseline is an alternative therapeutic goal. (A)
       * Triglycerides levels ,150 mg/dL (1.7 mmol/l) and HDL cholesterol .40 mg/ dL (1.0 mmol/l) in men and .50 mg/dL (1.3
       mmol/l) in women, are desirable. However, LDL cholesterol–targeted statin therapy remains the preferred strategy.
        * If targets are not reached on maximally tolerated doses of statins, combination therapy using statins and other lipid-
       lowering agents may be considered to achieve lipid targets but has not been evaluated in outcome studies for either 
       CVD outcomes or safety. (E)
       * Statin therapy is contraindicated in pregnancy. (B) 


Comment:
      I believe it is time to change our approach from trying to find a reason to start a Statin drug  to trying to find a reason not to start a statin. 


 The CARDS  study demonstrated the benefit of of treating people with and without overt heart disease who had one other risk factor .   (for example Diabetes plus an elevated LDL )


 the people taking 10 mgs. of Lipitor demonstrated significant benefit
        Acute coronary event reduced by 36%
        Coronary revascularizations reduced 31 %
        Rate of strokes reduced by 48 %
        Death rate reduced by 27 %

My favorite line from The CARDS study is, “The debate about whether all patients with type 2 diabetes warrant statin treatment should now focus on whether any patient can reliably be identified as sufficiently low risk for this safe, efficacious treatment to be withheld.”


Have fun , Be Smart  and check out my Diabetes Office visit training Video on the above Tab
David Calder,MD


*   GLP-1 agonist . Please the the discussions over the last few days
*  " Statins "       This refers to medications such as Lipitor ( atorvastatin ) and Zocor ( Simvastatin ) and others

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Your comments and questions are appreciated. David Calder,MD