In Depth

The convoluted nature of statin treatment and its link with diabetes

The relationship between statins and diabetes is confusing, whether you’re a patient, GP or impartial bystander. It’s complexity as a treatment is vast, and many studies link statin use to the onset of diabetes.

Statins are drugs designed to reduce cholesterol. Specifically, they reduce LDL (low density lipoprotein) cholesterol, which has been traditionally linked with a higher risk of heart disease.

Having high levels of cholesterol is commonly linked to the development of type 2 diabetes, particularly when strong doses are used, but statins are marketed as being able to lower the risk of a cardiovascular (CVD) event, despite evidence being unclear as to how widely they should be prescribed.

As statins only cause minor increases in blood glucose levels, they are often used in diabetes care as diabetic patients face a heightened likelihood of heart attack and stroke.

So, while statins reportedly increase the risk of type 2 diabetes, they are used as part of diabetes care to reduce CVD risks.

A number of studies have linked statin treatment to the onset of type 2 diabetes

A number of studies have linked statin treatment to the onset of type 2 diabetes

Firstly, let’s examine how statins can reportedly cause diabetes.

In May, cholesterol-lowering statin drugs were found to increase the risk of developing diabetes by 87 per cent in a University of Texas Southwestern study. Meanwhile, a separate 2015 study, published in Diabetologia, reported men who were prescribed statins to lower their cholesterol were 46 per cent more likely to develop type 2 diabetes.

Canadian Diabetes Association Scholar Jonathan Schertzer and colleagues sought to investigate this link in a 2014 study. Schertzer’s team found that statins “activated a very specific immune response, which stopped insulin from doing its job properly”. This then led to increased blood glucose levels, which can cause type 2 diabetes.

They also reported that a drug called glyburide was able to suppress this immune response when used alongside statins, potentially signalling the development of a new treatment that could prevent diabetes from developing. However, as glyburide stimulates insulin production, using a type 2 diabetes drug to prevent type 2 diabetes seems a perculiar treatment.

This aspect of statins research is being examined, at least. However, there is no timeframe for such a treatment making its way to market, and presently, the risk of onset diabetes from statins is still possible.

Moreover, Colin R Dormuth et al concluded that use of statins with higher potency increases the risk of new onset diabetes compared to lower potency stains. Subsequently, the researchers advised for this risk to be considered by clinicians when prescribing statins.

However, the decision by NICE (National Institute for Health and Care Excellence) is that the potential benefit of reducing CVD risk in patients is of greater significance than the diabetes risk.

However, the decision by NICE (National Institute for Health and Care Excellence) is that the potential benefit of reducing CVD risk in patients is of greater significance than the diabetes risk.

So we come to the next questio, do statins actually reduce one’s risk of cardiovascular disease?

The research points to yes being the answer. “Statins can help lower your (CVD) risk,” according to the British Heart Foundation, while NICE guidelines report up to 8,000 lives could be saved every three years by offering statins to anyone with a 10 per cent risk of developing (CVD) within 10 years.

For every 100 people treated with statins for three years, statin treatment will help one of these patients to avoid a serious cardiovascular event such as a heart attack, stroke or death from heart disease.

However, in addition to the risk of type 2 diabetes, there are a number of side effects that can be caused by statins. These can vary in severity from person to person, but include headaches, rashes, muscle disorder and memory problems.

This is why there is a debate as to whether the prevention of heart disease in 1% of people is worth the increased risks of diabetes and other side effects. Some would say yes, others would argue no.

While NICE believe that statins are overall beneficial, and have recently called for increased prescribing of statin therapy in cholesterol, the Royal College of General Practioners (RCGP) and the General Practitioners Committee (GPC) are among those who disagreen, and have spoken out against NICE plans.

A 2014 study showed that nearly 99% of people will not benefit from statins

A 2014 study showed that nearly 99% of people will not benefit from statins

So, should people with diabetes be on statins?

According to the 2014 NICE guidelines, statins should be recommended by healthcare professionals for patients with type 2 diabetes and people with a 10 per cent or greater risk of developing cardiovascular problems.

Type 1 diabetics, meanwhile, may be considered for statins if they have had the condition for over 10 years, if they are over 40 years old, have kidney disease or additional cardiovascular risk factors.

However, a statin is only one part of treatment.

Simply taking a statin is not sufficient to single-handedly reduce one’s CVD risk. If you have been offered a statin to reduce your cholesterol, you will only reduce your CVD risk if it is taken alongside good exercise, regular exercise and controlled blood pressure, while avoiding smoking and excessive alcohol.

While there is certainly a case for statins for people with diabetes that are at an increased risk of heart disease, the research is less clear in terms of benefits for people at a lower risk of heart disease. This is one reason why the latest NICE guidelines on cholesterol management have been viewed as so controversial, and they indicate that most people with diabetes will be eligible for and offered statin treatment.

Simply taking a statin is not sufficient to single-handedly reduce one’s CVD risk. If you have been offered a statin to reduce your cholesterol, you will only reduce your CVD risk if it is taken alongside good exercise, regular exercise and controlled blood pressure, while avoiding smoking and excessive alcohol.

If you have been on statins, and suffered any of the aforementioned side effects, a new cholesterol drug which could be more effective than statins may be worth keeping an eye on.

The new drugs, known as evulocumab and alirocumab, reduce LDL cholesterol by up to 60 per cent, according to a study led by a senior physician in the Division of Cardiovascular Medicine at Brigham and Women’s hospital, Boston.

The treatments show a proven track record for very strong reduction of cholesterol, but the question will be whether this reduction corresponds to any reduction in risk of heart disease. However, they are yet to be approved by the U.S. Food and Drug Administration (FDA) and it may be many years before they are released in the UK.

For the time being, statins are here to stay as the main medication for treating and preventing heart disease, alongside the even more important lifestyle changes such as maintaining a healthy diet and exercising. The debate about how widely statins should be prescribed will inevitably continue to rage on.

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