Below you can find ADA recommendations on screening, cardiovascular risks, and treatment of dyslipidemia in the context of diabetes. As always improve lifestyle choices first. If ASCVD likelihood is still high then add medications. Statins are first-line, either of moderate or high intensity. Statin selection would depend on age, CVD status, and contributing factors.
Statin plus PCSK9 inhibitor or statin plus zetia could be used in adults with residual ASCVD risk. Statin plus fenofibrate is no longer advised unless special circumstances are present; severe hypertriglyceridemia or in men with profound metabolic syndrome. Statin plus niacin is also not recommended due to stroke concerns.
For more details, ADA standards are listed below with a slightly modified wording for easier and succinct reading:
In adults not taking statins, it is reasonable to obtain a lipid profile at the time of diabetes diagnosis, at an initial medical evaluation, and every 5 years thereafter, or more frequently if indicated.
Obtain a lipid profile at initiation of statin therapy and periodically thereafter as it may help to monitor the response to therapy and inform adherence.
Lifestyle modification focusing on weight loss (if indicated); the reduction of saturated fat, trans fat, and cholesterol intake; increase of dietary ω-3 fatty acids, viscous fiber, and plant stanols/sterols intake; and increased physical activity should be recommended to improve the lipid profile in patients with diabetes.
Intensify lifestyle therapy and optimize glycemic control for patients with elevated triglyceride ≥150 mg/dL and/or low HDL cholesterol <40 mg/dL for men, <50 mg/dL for women.
For patients with fasting triglyceride ≥500 mg/dL, evaluate for secondary causes of hypertriglyceridemia and consider medical therapy to reduce the risk of pancreatitis.
Atherosclerotic cardiovascular disease (ASCVD)
[all ages with severe risk factors] For patients of all ages with established ASCVD and diabetes, high-intensity statin therapy should be added to lifestyle therapy.
[young with extra risk factors] For patients with diabetes aged <40 years with additional ASCVD risk factors, consider using moderate-intensity or high-intensity statin and lifestyle therapy.
[middle age w/o extra risk factors] For patients with diabetes aged 40–75 years without additional ASCVD risk factors, consider using moderate-intensity statin and lifestyle therapy.
[middle age with extra risk factors] For patients with diabetes aged 40–75 years with additional ASCVD risk factors, consider using high-intensity statin and lifestyle therapy.
[older w/o extra risk factors] For patients with diabetes aged >75 years without additional ASCVD risk factors, consider using moderate-intensity statin therapy and lifestyle therapy.
[older with extra risk factors] For patients with diabetes aged >75 years with additional ASCVD risk factors, consider using moderate-intensity or high-intensity statin therapy and lifestyle therapy.
In clinical practice, providers may need to adjust intensity of statin therapy based on individual patient response to medication (e.g., side effects, tolerability, LDL cholesterol levels).
The addition of ezetimibe to moderate-intensity statin therapy has been shown to provide additional cardiovascular benefit compared with moderate-intensity statin therapy alone for patients with recent acute coronary syndrome and LDL-C ≥50 mg/dL and thus should be considered for these patients —- and also in patients with diabetes and history of ASCVD who cannot tolerate high-intensity statin therapy.
Combination therapy (statin/fibrate) has not been shown to improve atherosclerotic cardiovascular disease outcomes and is generally not recommended. However, therapy with statin and fenofibrate may be considered for men with both triglyceride level ≥204 mg/dL and HDL cholesterol level ≤34 mg/dL [profound metabolic syndrome].
Combination therapy (statin/niacin) has not been shown to provide additional cardiovascular benefit above statin therapy alone and may increase the risk of stroke and is not generally recommended.
Statin therapy is contraindicated in pregnancy.