Response to Sever et al.
I read with interest the article by Sever et al. in the May 2005 issue of Diabetes Care (1). I agree with the authors’ conclusion in the abstract that atorvastatin made a significant impact in reducing cardiovascular events in diabetic patients without markedly elevated cholesterol.
However, I cannot agree with the authors’ conclusion that “It now therefore seems reasonable to recommend that ALL (capitalization mine) patients with type 2 diabetes and hypertension . . . should be routinely considered for statin therapy.”
The American Diabetes Association Clinical Practice Recommendations (2), published in January 2005, stated that for lipid control, the primary goal is an LDL level <2.6 mmol/l (100 mg/dl) and a lower LDL cholesterol goal of <1.8 mmol/l (70 mg/dl) for diabetic patients with overt cardiovascular disease. In Sever et al.'s article (1), the subject's average LDL cholesterol was 3.3 mmol/l (128 mg/dl) at the baseline and decreased to a trough of an average of 2.08 mmol/l (80.4 mg/dl) at 2 years and an average of 2.15 mmol/l (83.1 mg/dl) at the end of the study.
The article's eligibility criteria included subject cholesterol:HDL cholesterol ratio ≥6 and total cholesterol ≤6.5 mmol/l (251 mg/dl) but did not break them down further into different degrees of lower cholesterol or LDL cholesterol categories. I am drawing a distinction between what the article showed (lowering of cardiovascular events by atorvastatin for a certain group of patients, excluding those with cholesterol >6.5 mmol/l [250 mg/dl], etc.) and what the authors claimed to show that “It now therefore seems reasonable to recommend that ALL (capitalization mine) patients with type 2 diabetes and hypertension (at least all those >50 years of age and/or having diabetes for ≥10 years) should be routinely considered for statin therapy.” Atorvastatin may or may not be eventually found to be useful for all levels of LDL cholesterol.
However, this article does not give an answer as to how low a level of LDL cholesterol a patient should obtain for a statin to continue or cease to be useful. For example, based on the article's information, I cannot yet say whether a 55-year-old diabetic patient without overt cardiovascular disease and LDL cholesterol of 1.8 mmol/l (70 mg/dl) will benefit from atorvastatin. That would have to await further studies and cannot be answered by the present article.
