Healthgrades for Professionals

Treating High Cholesterol in Patients With Type 2 Diabetes

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Treating high cholesterol is about assessing risk for cardiovascular disease. We know there’s a causal link between elevated LDL cholesterol and the development of atherosclerosis, the process that leads to heart attack and stroke. Patients with no underlying conditions may be able to lower cholesterol with lifestyle modifications, like diet changes and increased exercise. But those with cardiovascular risk factors, like type 2 diabetes, require higher levels of treatment. And while each patient is different, in general I find it’s important to be aggressive when treating high cholesterol in those with diabetes.

There’s a strong relationship between type 2 diabetes and macrovascular outcomes, like coronary artery disease, heart attack, and stroke. And people with diabetes tend to have more severe coronary artery disease that’s more likely to require bypass. The American Heart Association and American College of Cardiology guidelines highlight four main patient groups as eligible and recommended to treat their cholesterol with statin medications. People with type 2 diabetes are one of these groups, so if a patient with diabetes and high cholesterol comes to see me, I will prescribe a statin, regardless of their age, glycemic control, or the duration of their diabetes. Plus, some diabetes medications are known to cause weight gain, which can make control of cholesterol a little more difficult–another reason why it’s key to treat cholesterol early and aggressively in patients with type 2 diabetes.

Cholesterol and Diabetes

If a patient has diabetes and high cholesterol, I’ll look at their other risk factors to decide if they should get a moderate-intensity or high-intensity statin. There are two commonly used high-intensity statins available today–atorvastatin (Lipitor) and rosuvastatin (Crestor). The rest on the market are considered moderate-intensity, like pravastatin (Pravachol) and lovastatin (Altoprev), among others. We measure their intensity level in relation to the percentage of LDL lowered per dose. A high-intensity statin can bring a 30 to 55% reduction in LDL levels. Moderate-intensity statins typically lower LDL by less than 30%, which may be all that’s needed for some patients.

In some cases, statins won’t be enough to reach our cholesterol goal for a patient. If they are on the maximally tolerated statin but LDL levels are still high, I’ll turn to add-ons, including ezetimibe, bempedoic acid, or PCSK9 inhibitors. And new medications are coming down the pipeline that may offer more significant benefits to patients who require a higher level of treatment.

In addition to medication, lifestyle is a big component of diabetes and cholesterol management. I encourage anyone with diabetes to work with a certified diabetes educator, who can advise about dietary changes, foods to avoid, appropriate portion sizes, and even when to eat meals in conjunction with taking insulin. They can also help with introducing exercise into your daily routine and provide guidance about virtually any other aspect of diabetes management–which of course includes lowering cholesterol.

With type 2 diabetes, LDL cholesterol is not the only number considered; triglycerides are very important as well, as they’re often elevated in people with uncontrolled diabetes. We typically address the diabetes before addressing the triglycerides, because once A1C is lowered, triglycerides tend to lower as well. They might not be exactly where we want them, though, so the next step is treating triglycerides based upon that residual level. If further triglyceride reduction is necessary, I’ll typically turn to a medication called icosapent ethyl (Vascepa). It’s a high dose fish oil with clinical trial data behind it showing it reduces risk of cardiovascular events–the only fish oil to show any benefit. More trials are ongoing to determine if other fish oils provide the same outcomes, but for now it’s the only one backed up with data.

The Bottom Line

When it comes to diabetes and cholesterol, I want patients to know that yes, these conditions put them at high risk of heart attack or stroke–but they should also remember we have effective therapies out there and their healthcare team is available to guide and support them every step of the way. And it’s important for my cardiology colleagues to keep in mind that old chant from high school: “Be aggressive, be, be aggressive!” Patients with diabetes and high cholesterol have unique challenges, but don’t be afraid to dive in with them. And try to take a more holistic view of the patient, rather than focusing solely on the heart. To be a good cardiovascular specialist, you need to understand that all the common diabetes-related problems are vascular; nephropathy, retinopathy, and neuropathy are vascular complications, just in other organs. Lastly, it’s important for cardiologists to know treating cholesterol with diabetes is not as easy as simply prescribing medication. A lot more goes into it, including lifestyle changes that require expert support. The patient has to dive in with us, so we must provide the support and education they need to feel confident rather than intimidated.

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