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Experts debate ACC/AHA lipid guidelines
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SAN FRANCISCO — Two researchers argued whether or not the recently issued American College of Cardiology and American Heart Association guidelines for lipids are appropriate for patients with type 2 diabetes, during a press conference at the American Diabetes Association’s 74th Scientific Sessions.
Robert H. Eckel, MD, professor of medicine and Charles A. Boettcher chair in atherosclerosis at the University of Colorado, Anschutz Medical Campus, argued that almost all patients with diabetes should be on a statin.
“Keep in mind that our age range is between 40 and 75 years; we don’t know what to do with the 83-year-old with type 2 diabetes or 35-year-old with 30 years of type 1 diabetes,” Eckel told Endocrine Today. “It is based on clinical judgment; my opinion would be that the guidelines did not address both of these groups, based on understanding their overall health risk and comorbidities. Most patients with diabetes should be on a statin, but not all.”
Eckel said the physician should consider risk of new onset type 2 diabetes when determining whether or not patients should be treated with a statin but the reduction in CVD risk favors a decision to treat most of these patients.
The new guidelines, published in November 2013, divide patients into four groups: those with CVD; those with LDL greater than 190 mg/dL; patients with diabetes aged 40 to 75 years with LDL 70 mg/dL to 189 mg/dL; and patients without diabetes or CVD and an LDL of 70 mg/dL to 189 mg/dL, with an estimated risk for CVD >7.5%.
Currently, the ADA recommends that patients with diabetes keep LDL levels at or below 100 mg/dL or under 70 mg/dL if they also have CVD.
Henry Ginsberg, MD, Irving professor of medicine and director of the Irving Institute for Clinical and Translational Research at Columbia University agrees with the ADA guidelines, and disagrees with Eckel.
“Where I have my largest issue is not so much in not using LDL as a target, but in not going beyond statins when needed. Certainly, if you read the 65 or 75 pages of the document, you’ll find it clear — as a physician — that you can work with your patient and reach conclusions about what that patient’s goals should be. But how can you do that when the guidelines say that there are no goals?” Ginsberg asked during the press conference.
Although he agrees with the recommendation to examine a person’s risk for CVD and their cholesterol level when determining whether or not to prescribe a statin, he disagrees with the removal of target LDL goals once a person is being treated with medications.
“To say that the PROVE IT, Treat to New Targets, IDEAL and SEARCH trials put together don’t support the idea that a lower LDL is better than a less lower LDL, I believe is too narrow a view,” Ginsberg told Endocrine Today.
However, Eckel said that exceptions are addressed in the new guidelines, suggesting that clinicians use their best judgment.
“Physicians can make a decision to set levels they’re comfortable after being informed by the guidelines and having an educated knowledge of patients who may need goals set to create a level of comfort in medical care,” Eckel said. — by Samantha Costa
Disclosure: At the time the guideline process was initiated, Eckel reported financial relationships with Abbott, Merck and Pfizer, but they were no longer relevant soon after the process was initiated.
For more information: CT-CI03: Are the new ACC/AHA Guidelines for Lipids Appropriate for Diabetes? Presented at: American Diabetes Association’s 74th Scientific Sessions; June 13-17, 2014; San Francisco.
Perspective
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Robert E. Ratner, MD
We have multiple debates going on at this conference on controversial issues in which there is an honest disagreement on how to interpret the data and how to apply the data. One of the goals of the ADA is to take new data, interpret it and integrate it into our clinical practice recommendations which we produce on an annual basis every January.
The recent lipid guidelines from the ACC/AHA came out last fall after we had already completed our review for the 2014 standards of care. Those are two of the debates that we are going to be having here at this meeting. One of the purposes is to air the data and air the differences of the interpretation of the data so that our professional practice committee and our executive committee can weigh those factors and incorporate them into our clinical practice recommendations for 2015. It will help to inform our next set of clinical recommendations. Therefore, we view these debates as a critical piece for the attendees; for them to apply in their interpretation of the data in their clinical practice.
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