Diabetes
9
3. Type 2 Diabetes Mellitus
➤ 3.1 In adults with T2D and other CV risk factors, we recommend statin therapy
in addition to lifestyle modification in order to reduce CV risk. (1|⊕⊕⊕⊕)
Technical Remarks:
▶ High intensity statins should be chosen in patients with ASCVD or those with risk
factors for ASCVD or risk enhancing factors.
▶ Statins should not be used in women who are pregnant or trying to become pregnant.
▶ In patients over the age of 75, continuation of statin treatment or initiation of statin
treatment depends upon ASCVD risk, prognosis, potential interacting medications,
polypharmacy, mental health and the wishes of the patient.
➤ 3.2 In adults with T2D and other CV risk factors, we suggest lowering
LDL-C to achieve a goal of LDL-C <70 mg/dL (< 1.8 mmol/L) in order to
reduce CV risk. (2|⊕
)
Technical Remarks:
▶ A statin should be added to lifestyle modifications if LDL-C is >70 mg/dL (1.8
mmol/L).
▶ LDL-C should be <55 mg/dL(1.4 mmol/L) in patients with established CVD or
multiple risk factors.
▶ Additional LDL-lowering therapy (ezetimibe, proprotein convertase subtilisin/kexin
type 9 inhibitor [PCSK9]) may be needed if the LDL-C goal is not reached with
statins.
▶ Risk factors include traditional risk factors and risk-enhancing factors.
➤ 3.3 In adults with T2D on a statin at LDL goal with residual TG over 150 mg/
dL (1.7 mmol/L) and with two additional traditional risk factors or risk-
enhancing factors, we suggest adding EPA ethyl ester to reduce CV risk.
(2|⊕⊕⊕
)
Technical Remarks:
▶ Consider 4 g/d of EPA ethyl ester.
▶ If EPA ethyl ester is not available or accessible, then it is reasonable to consider a
fibrate such as fenofibrate.
➤ 3.4 In adults with T2D with chronic kidney disease stages 1–4 and post
renal transplant, we suggest statin therapy, irrespective of the CV risk
score, to reduce CV risk. (2|⊕
)
Technical Remarks:
▶ When selecting the statin, consider the renal clearance of the statin. Pitavastatin,
pravastatin and rosuvastatin all have at least partial clearance through the kidney
whereas atorvastatin, fluvastatin, lovastatin, and simvastatin are cleared via the liver.
▶ All statins require dose adjustments in CKD except for atorvastatin and fluvastatin.
➤ 3.5 In adults with T2D and diabetic retinopathy, we suggest fibrates in
addition to statins to reduce retinopathy progression. (2|⊕
)
Technical remarks:
▶ This recommendation applies regardless of TG levels.
▶ The preferred fibrate is fenofibrate.
