LDL-lowering medications
Statins
Statins are medications that inhibits LDL-cholesterol production in the body. They include atorvastatin, rosuvastatin, and simvastatin. Statins are one of most well-studied treatment for preventing cardiovascular events, and have been unequivocally shown to be effective in people with and without diabetes. The benefits of statins are more pronounced in people with higher risk of cardiovascular diseases, especially in those with existing heart disease or stroke. Given the wealth of scientific data on the benefits of statin treatment, as well as the low cost and relative safety of statins, they are recommended as the first-line treatment for cholesterol lowering in people with diabetes. Most people with diabetes aged 40 years old or older should receive statin treatment, with the dose and intensity of treatment depending on their cardiovascular risks.
The American Heart Association listed cardiovascular risk enhancers in people with diabetes to include:
1. Type 2 diabetes > 10 years or type 1 diabetes > 20 years of duration
2. Moderately-increased or severely-increased albuminuria
3. Diabetic kidney disease with eGFR < 60 ml/min
4. The presence of diabetic retinopathy or diabetic neuropathy
5. Ankle/brachial index of < 0.9
Assessment of cardiovascular risk in people with diabetes may differ from country to country, and with different guidelines. Additionally, people with diabetes who are less than 40 years old may also consider statin treatment after discussion with their diabetes care providers.
Side effects of statins are uncommon, with the most frequent side effects being muscle symptoms and liver derangement. Statin-associated muscle symptoms (SAMS) are usually mild, and rarely severe. Liver derangements can also be seen in people taking statins, however clinical experience suggest that these are more often caused by an underlying metabolic-associated fatty liver disease (MAFLD).
Statins should not be taken by pregnant women. The decision to take or not to take statins during childbearing age should be discussed with the diabetes care providers.
Ezetimibe
Ezetimibe is an LDL-cholesterol lowering treatment that works by blocking intestinal absorption of dietary cholesterol. It is often used when a person is unable to reach LDL targets despite statin treatment. When combined with statin treatment, ezetimib has been shown to further reduce the risks of cardiovascular events.
PCSK-9 inhibitors
PCSK-9 inhibitors are the latest LDL-lowering treatment that have been shown to reduce the risk of cardiovascular events. They work by increasing LDL-cholesterol removal from the body via the liver cells, and have been shown to reduce LDL-cholesterol to even lower levels than with other treatments. Given the current high cost of PCSK-9 inhibitors, they are recommended in selective people with very high risk of cardiovascular events, particularly those with multiple episodes of heart attack or stroke.
Triglyceride-lowering medications
Fibrates
Icosapent ethyl (not available in Malaysia)