Table 2.
Adult type 1 diabetes low-density lipoprotein-cholesterol management guidelines
| 2020 ADA SOMC | 2018 ACC/AHA guidelines | 2019 ESC/EAS guidelines | |||
|---|---|---|---|---|---|
| Age 20–39 without ASCVD | If additional ASCVD risk factors, consider moderate-intensity statin therapy. | Age 20–39 without ASCVD | If T1D duration ≥20 years, or patient with nephropathy, retinopathy, or neuropathy, reasonable to start statin therapy. | Moderate-risk: Age <35 years old with T1D duration <10 years, without other ASCVD risk factors | Statin therapy may be considered if LDL-C >2.5 mmol/L (97 mg/dL). |
| Goal LDL-C <100 mg/dL (2.6 mmol/L). | Goal LDL-C <100 mg/dL (2.6 mmol/L). | Goal LDL-C <100 mg/dL (2.6 mmol/L). | |||
| Age ≥40 without ASCVD | Moderate-intensity statin therapy. | Age ≥40 without ASCVD | Moderate-intensity statin therapy. | High-risk: Diabetes duration ≥10 years or additional ASCVD risk factor, without target organ damage (nephropathy, retinopathy, neuropathy) | If LDL-C above goal, recommend statin therapy. |
| If multiple ASCVD risk factors or age 50–70 years, reasonable to use high-intensity statin. | If multiple ASCVD risk factors or 50–75 years old, reasonable to use high-intensity statin. | If goal not achieved with maximum tolerated statin therapy, combination with ezetimibe recommended. | |||
| If 10-year ASCVD risk ≥20%, reasonable to add ezetimibe to maximally tolerated statin therapy. | If 10-year ASCVD risk ≥20%, reasonable to add ezetimibe to maximally tolerated statin therapy. | ||||
| Goal LDL-C <100 mg/dL (2.6 mmol/L). If 20-year ASCVD risk ≥20%, goal 50% LDL-C reduction. | Goal LDL-C <100 mg/dL (2.6 mmol/L). | Goal LDL-C <70 mg/dL (1.8 mmol/L), with goal reduction of ≥50% from baseline. | |||
| If 20-year ASCVD risk ≥20% or multiple ASCVD risk factors, goal 50% LDL-C reduction. | |||||
| With ASCVD | High-intensity statin therapy. | With ASCVD | High-intensity statin therapy. | Very-high-risk: Presence of either diabetes duration >20 years, target organ damage (nephropathy, retinopathy, neuropathy), three major ASCVD risk factors, or underlying ASCVD | If LDL-C above goal, recommend statin therapy. |
| If very high risk† and LDL-C ≥70 mg/dL on maximally tolerated statin therapy, consider adding ezetimibe or PCSK9 inhibitor for additional LDL-lowering. | If LDL-C ≥70 mg/dL on maximally tolerated statin therapy, reasonable to add ezetimibe. | If goal not achieved with maximum tolerated statin therapy, combination with ezetimibe recommended. | |||
| If very-high riska and LDL-C ≥70 on maximally tolerated statin therapy and ezetimibe, reasonable to add PCSK9 inhibitor. | If no underlying ASCVD and LDL-C still above goal, consider adding PCSK9 inhibitor. | ||||
| If underlying ASCVD and LDL-C still not at goal, recommend adding PCSK9 inhibitor. | |||||
| Goal LDL-C <70 mg/dL (1.8 mmol/L). | Goal LDL-C <70 mg/dL (1.8 mmol/L). | Goal LDL-C <1.4 mmol/L (55 mg/dL), with goal reduction of ≥50% from baseline. | |||
| If two ASCVD events within 2 years, consider goal LDL-C <1.0 mmol/L (40 mg/dL). | |||||
| Special considerations for Age >75 | If on statin therapy, reasonable to continue. | Special considerations for Age >75 | If on statin therapy, reasonable to continue. | Special Considerations for Age >75 | Initiation of statin therapy for primary prevention may be considered if at high-risk or very-high-risk. Start statin at low dose if significant renal impairment and/or the potential for drug interactions, and then titrate upwards to achieve LDL-C goals. |
| May be reasonable to initiate statin therapy after discussion of benefits and risks. | May be reasonable to initiate statin therapy after discussion of benefits and risks. | ||||
ACC/AHA, American College of Cardiology/American Heart Association; ADA, American Diabetes Association; ESC/EAS, European Society of Cardiology/European Atherosclerosis Society; LDL-C, low-density lipoprotein cholesterol; SOMC, Standards of Medical Care in Diabetes.
Very high-risk as defined by 2018 ACC/AHA Guidelines: history of multiple major ASCVD events, or one major atherosclerotic cardiovascular disease (ASCVD) event and multiple high-risk conditions. Major ASCVD events include history of recent acute coronary syndrome (ACS) within past 12 months, myocardial infarction (other than recent ACS), ischemic stroke, and symptomatic peripheral arterial disease. High-risk conditions include diabetes, persistent LDL _100 mg/dL (2.6 mmol/L), age _65 years, heterozygous familial hypercholesteremia, hypertension, chronic kidney disease, current smoking, congestive heart failure, and coronary bypass surgery/percutaneous coronary intervention outside of major ASCVD event(s).