Background: Lipids are implicated in the pathogenesis of accelerated atherosclerosis and in microvascular damage in diabetes. Many trials demonstrate vascular benefit of lipid lowering and of some glucose and BP drugs and insulin pumps. Statin intolerance can limit statin use. Vascular memory exists for vascular risk factors and some drugs.
Aims: To summarise (a) results of trials and observational studies of clinically available drugs that can improve clinical outcomes in people with diabetes; (b) current treatment guidelines; (c) a clinical approach to statin intolerance.
Methods: Review of (i) trials of statins, ezetimibe, fenofibrate and PCSK9 inhibitors in diabetes, and (ii) BP and glucose control trials with cardiovascular end-points; (iii) current guidelines for cardiovascular risk assessment and management including (iv) statin intolerance.
Results: A general assessment of cardiovascular risk is favoured by many guidelines and is used to guide drug use and the intensity of (if appropriate) statin therapy. Various cardiovascular risk calculators exist to assess vascular risk in diabetic patients without clear-cut evidence for pharmacologic lipid control. Statins, ezetimibe and PCSK9 inhibitors, which predominantly lower LDL-C, have macrovascular disease benefit. Guidelines for statin intolerance are available. Fenofibrate has proven benefit against microvascular complications and for some cardiovascular complications in adults with Type 2 diabetes. Updated lipid guidelines by ADS will soon be released. There are guidelines to diagnose and manage statin intolerance. Glucose control SGLT2 inhibitors also have trial-proven cardiovascular benefit in diabetes. In Type 1 diabetes large observational studies support vasoprotection with insulin delivery by pumps rather than multiple daily injections. Metabolic memory has been shown for vascular risk factors and related drugs, including fenofibrate and metformin.
Conclusions: Many clinical trials show vascular benefit of an increasing range of existent lipid (and non-lipid) drugs and devices in people with diabetes. Updated guidelines exist, including for statin intolerance.