Cardiovascular risk reduction in diabetes Lipids (NICE CG181) Primary Prevention T1DM Offer Atorvastatin 20mg if >40 years old Diabetes duration >10 years Established nephropathy Other CVS risk factors The aim is to reduce CVS risk and so an 18 year old with diabetes duration of >10 years is probably still at low risk and so a statin is unlikely to be necessary. Also important to consider in women of child bearing age T2DM Offer atorvastatin 20mg if QRISK2 score estimates >10% risk of developing CVD in 10 years. Secondary prevention T1DM and T2DM Offer Atorvastatin 80mg Measure baseline LFTs before commencing statin and again at 3 months and 12 months, do not measure CK in asymptomatic patients. Do not omit statin if ALT raised but less than x3uln
Intolerance of statins is a common issue and modifying lipid profile is important in these high risk individuals Enquire about muscle pain before starting a statin, if present check CK and if >x5 ULN do not start and re-measure after 7 days. If CK still >x5 ULN then do not start statin. If < x5uln start at a lower dose (ie atorvastatin 10mg ). If patient develops symptoms measure CK and LFTs stop statin if CK >5 ULN or ALT > x3 ULN, if raised but less than these values could consider a lower intensity statin If intolerant, ie symptoms but no measurable change in ALT or CK Explain importance of statin Try again at a lower dose eg rosuvastatin 5 mg once a week and titrate gradually on a weekly base Try a lower intensity statin Ensure not taking with grapefruit juice Treat with maximum tolerated dose Titrate dose aiming for a target 40% reduction in non-hdl cholesterol Other agents Ezetimibe If on maximum dose Atorvasatin 80mg or unable to tolerate a higher dose and target not achieved; consider adding ezetimibe Fenofibrate Can be used if fasting triglycerides consistently > 7.5mmol/L despite adequate glycaemic control, minimal alcohol intake and after addressing diet PCSK9 inhibitors The PCSK9 inhibitors evolocumab and alirocumab are recommended in patients with non-familial hypercholesterolemia or mixed dyslipidaemia in patients with CVD and LDL cholesterol > 4mmol/l in those at high risk 1 of further CVD or LDL cholesterol >3.5 mmol/l in those at very high risk 2 of CVD.
1 High risk of CVD is defined as a history of any of the following: acute coronary syndrome (such as myocardial infarction or unstable angina needing hospitalisation); coronary or other arterial revascularisation procedures; chronic heart disease; ischaemic stroke; peripheral arterial disease. 2 very high risk of CVD is defined as recurrent cardiovascular events or cardiovascular events in more than 1 vascular bed (that is, polyvascular disease)
Anti-platelet therapy Primary prevention of CVD (NG 17 and NG28) Do NOT offer aspirin for primary prevention of CVD in T1DM or T2DM Secondary prevention of MI (NICE CG172 and TA210) Offer aspirin to all people after an MI and continue indefinitely Consider clopidogrel in patients with hypersensitivity to aspirin following MI Dual anti-platelet therapy following acute coronary syndromes Often dependant on procedures/type of MI etc Offer clopidogrel in combination with aspirin for up to 12 months following NSTEMI or a STEMI and insertion of a bare-metal or drug-eluting stent or following a CABG Tiacagrelor may also be offered in addition to low dose aspirin following MI for 12 months Secondary prevention of ischaemic stroke or in peripheral arterial disease or multivascular disease (often seen in patients with diabetes) Clopidogrel is recommended Dual anti-platelet following TIA or ischaemic stroke Modified release dipyridamole in combination with aspirin following TIA
Blood Pressure Target 140/80mmHg or <130/80 mmhg if evidence of complications Retinopathy Microalbuminuria or established nephropathy Neuropathy Cardiovascular disease 1 st agent ACE inhibitor (titrate to full dose if nephropathy or microalbuminuria) ARB is an alternative if ACEi not tolerated (do not combine these agents). Avoid if pregnancy desired If Afro-carribean and no renal disease calcuim channel blocker 2 nd agent add Ca channel blocker (or ACEi) 3 rd agent diuretic usually thiazide (frusemide if egfr <30ml/min) 4 th agent alpha blocker 5 th agent Beta blocker NB If IHD β-blocker can be used earlier If CCF or oedema diuretics can be started earlier