Statin use with diabetes: is it for everyone?

Statin use with diabetes: is it for everyone?

Looking at benefits and risk factors of statin use for people with type 1 diabetes.

Cardiovascular risks are a major long-term complication risk for people with type 1 diabetes. Blood sugar control is certainly a piece to reducing this risk. However, even with “perfect blood sugar control” we are still at a higher risk of cardiovascular injury or illness simply due to the underlying factors that come with a diabetes diagnosis (such as inflammation, unknown autoimmune impact, unknown genetic links, hyperinsulinemia) For this reason it is important for people with diabetes and their healthcare team to do what we can to reduce other risk factors for cardiovascular complications. For this reason, reducing LDL lipid values and total cholesterol has been a focus of treatment for people with diabetes. Reducing these values reduces the risk of blockages that can lead to elevated blood pressure, heart attack and stroke.

Statin medications reduce cholesterol by blocking the production of cholesterol by the liver, which, in turn, causes the liver to uptake more dietary cholesterol form the bloodstream.  There has been some question in recent years as to the direct preventative impact of statins on cardiovascular disease, but the majority of literature still points to the benefits of cholesterol reduction as a risk factor for cardiac events. This has led to many prescribers, particularly cardiologists making the broad statement “all adult patients with diabetes should be on statins”. But, statin medications do carry side effects.

What are the side effects of statin medication?

• Muscle pain/weakness/ damage: This is the most commonly reported effect of Statin use present in about 5% of use. These feelings of soreness, fatigue, heaviness or tightness of muscles can be reduced by slowly titrating medications, and by trying a different statin medication if you experience side effects from one. There is an extremely rare side effect called rhabdomyolysis that can cause severe muscle pain that can lead to permanent muscle damage, liver or kidney damage. This side effect presents in fewer than 3 in 1million cases.
• Liver damage: As with any medication that works on the liver, statin medications can cause an increase in liver enzymes by causing inflammation. Patients using stains should have a liver enzyme test (A standard blood test) before starting and follow up after starting the medication. Some statins are indicated to have ongoing liver function screenings done throughout use, while others have been able to get approval without the follow up lab indication.
• Neurological Impact: Some studies have shown a link to statin use and loss of memory of confusion. Though these appear to reverse when statins are discontinued the mechanism that causes the issue is not clear so discussing this risk with your prescriber is important. There is ongoing research as to whether there is a connection between long term statin use and neurological changes related to dementia and Alzheimer’s. However, there is also some evidence that statin use can improve brain function ins people with dementia

Talking about your risk factors for statin side effects is important, and the risk of side effects should be balanced against your cardiovascular risks. For example, if you have a moderate risk of stroke or heart attack, but minimal risk of statin side effects it would be advisable to give them a try since the vast majority of side effects are temporary and stop when we stop using statins.

Who are at risk for cardiovascular issues with statin use?

The American Diabetes Association identifies the following groups as having cardiovascular risks that indicate the start of statin medications:

1. Patients with current Cardiovascular disease diagnoses over the age of 18
2. Patients over the age of 40 with LDL >100 mg/dl
3. Patients over the age of 40 with multiple additional cardiac risk factors such as obesity, hypertension, family history of stroke or heart attack
4. Statin therapy is contraindicated in pregnancy

What would put you at higher risk of statin side effects?

• Polypharmacy: there are medications that raise the risks of side effects. Such as Amiodarone, Gemfibrozil, Protease inhibitors,  Clarithromycin, Itraconazole, and clyclosporines. There are many others so be sure to share a full medication list with all your prescribers to prevent interactions.
• Patients over the age of 80 should use caution before starting statin therapy
• Persons with a smaller body frame and women are also at higher risk of side effects and may want to be more cautious in dosing.
• Patients who have secondary medical or lifestyle concerns that effect kidney or liver function would use caution before starting stain therapy. This includes persons on other medications that impact kidney or liver function, persons with nephropathy, persons who routinely consume alcohol, and patients with ALS

Side effects of Statin use can be reduced by:

• Using the lowest possible dose of statin medications
• Changing statins – just because one statin causes side effects does not mean that all will.
• Don’t make multiple medication/lifestyle changes at the same time- If we change multiple medications or start a medication and a workout regimen at the same time it is difficult to identify the cause of a side effect, or whether it is even a side effect at all. So, making one change at a time is advised.
• Taking CO-Q 10 supplements have also been shown to reduce statin side effects for some people.

What are alternatve options to using Statin LDL lowering medications?

• If side effects are a concern for you, discussing alternate LDL lowering options.
• There are non statin cholesterol lowering medications available such as fibrates, Bile acid sequestrants, ezetimbe, PCSK9 inhibitors and discussing these medications and their potential side effect profiles with your prescriber can help you find the right medication options for you.
• Niacin has also been shown to reduce LDL, and triglycerides, however they have not been shown to reduce cardiovascular injury or deaths. This may be an appropriate option for persons who’s LDL levels are less elevated or who have lower over all cardiovascular risk beyond lipid levels.
• It is possible that statin use may not need to be forever. Some persons may be able to use statins to more quickly lower LDL cholesterol while building lifestyle adjustments and alternate medication regimens to reduce to eliminate stain use eventually.

As always, it is important that we, as people with T1D, are educated and empowered to have these discussions with our prescribers. Ask what medication and therapy options are available, establish your goals and plans based on your personal/ family history, health needs, and priorities.