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4.2.5. Diabetes in Adults Without Established ASCVD
COR LOE
Recommendations
1 A
1. In adults 40 to 75 years of age with diabetes and without
clinical ASCVD, moderate-intensity statin therapy is
indicated to achieve a ≥30% to 49% reduction in LDL-C
and a goal of LDL-C <100 mg/dL (2.6 mmol/L) and non–
HDL-C <130 mg/dL (3.4 mmol/L) to reduce ASCVD risk.
1 B-R
2. In adults with diabetes who have statin-attributed side effects,
initiation of ezetimibe and/or bempedoic acid or a PCSK9 mAb
is recommended to lower LDL-C and reduce ASCVD risk.
2a B-R
3. In adults 40 to 75 years of age with diabetes who have multiple
ASCVD risk factors, it is reasonable to prescribe high-intensity
statin therapy to achieve a ≥50% reduction in LDL-C and a
goal of LDL-C <70 mg/dL (1.8 mmol/L) and non–HDL-C
<100 mg/dL (2.6 mmol/L) to reduce ASCVD risk.
2b B-R
4. In adults with diabetes without ASCVD but with additional
ASCVD risk factor(s)* on a statin with an LDL-C
<100 mg/dL (2.6 mmol/L) and elevated fasting TG
(150–499 mg/dL [1.7–5.6 mmol/L]), the addition of IPE
may be considered to reduce ASCVD risk.
2b C-LD
5. In adults with diabetes and 10-year ASCVD risk of ≥10% by
the PREVENT-ASCVD equations, it may be reasonable to
add ezetimibe or a PCSK9 mAb to maximally tolerated statin
therapy to achieve an LDL-C goal of <70 mg/dL (1.8 mmol/L)
and non–HDL-C <100 mg/dL (2.6 mmol/L) to reduce
ASCVD risk.
2b C-LD
6. In adults >75 years of age with diabetes and an estimated life
expectancy of at least 2.5 years, it may be reasonable to initiate
moderate-intensity statin therapy after a clinician-patient
discussion of potential benefits and risks to reduce ASCVD risk.
2b C-LD
7. In adults 20 to 39 years of age with diabetes of long duration
(≥10 years of type 2 diabetes, ≥20 years of type 1 diabetes),
albuminuria (≥30 µg of albumin/mg creatinine), estimated
glomerular filtration rate (eGFR) <60 mL/min/1.73 m
2
,
retinopathy, neuropathy, or ankle-brachial index (ABI) <0.9,
it may be reasonable to initiate moderate-intensity statin
therapy to reduce ASCVD risk.
* As per REDUCE-IT inclusion criteria, high-risk features include men ≥55 years or women
≥65 years, cigarette smoking or stopped smoking within 3 months; hypertension (blood
pressure ≥140 mm Hg systolic or ≥90 mm Hg diastolic) or on antihypertensive medication;
high-density lipoprotein-cholesterol ≤40 mg/dL for men or ≤50 mg/dL for women; high-
sensitivity C-reactive protein >3.0 mg/L (if measured); renal dysfunction: creatinine clearance
>30 and <60 mL/min; retinopathy; albuminuria (≥30 µg of albumin mg creatinine); ankle-
brachial index <0.9 without symptoms of intermittent claudication (if measured).
