We appreciate Dr. Tseng’s letter (1), as it identifies an error in our 2006 stated HDL cholesterol goals (2), when expressed in SI units, and allows us to comment further on our recommendation regarding the use of statins in those with type 2 diabetes.
Tseng is correct that the 2006 goals for HDL (2) should read 40 mg/dl (1.03 mmol/l) for men and 50 mg/dl (1.29 mmol/l) for women. We will make this change for the 2007 position statement.
Tseng also raises the issue that he does not feel that the evidence supplied supports our recommendation that “For those over the age of 40 years, statin therapy to achieve an LDL reduction of 30–40% regardless of baseline LDL is recommended.” We are in disagreement on this point. While he is correct that in the Heart Protection Study (3), the cut point for LDL level was 3.0 mmol/l (116 mg/dl), they found that “lowering the LDL cholesterol from <3.0 mmol/l to <2.0 mmol/l (i.e., <116–<77 mg/dl) in people with diabetes reduces macrovascular disease” and concluded that “statin therapy should now be considered routinely for all diabetic patients at sufficiently high risk of such major vascular event, irrespective of their initial cholesterol concentrations.” Similarly, while the cut point in the Coronary Artery Diabetes Study (4) was 3.1 mmol/l (120 mg/dl), the median LDL cholesterol on statin treatment was 2.0 mmol/l (77 mg/dl), and 25% had a concentration <1.7 mmol/l (66 mg/dl). The Coronary Artery Diabetes Study investigators also concluded that “no justification is available for having a particular threshold level of LDL cholesterol as the sole arbiter of which patients with type 2 diabetes should receive statins.” Based on the above, we continue to feel our recommendation is appropriate and evidence based. Of note, we do review and revise the American Diabetes Association Clinical Practice Recommendations each year based on current evidence.
