Eddy Edson
Well-Known Member
- Relationship to Diabetes
- In remission from Type 2
Just to highlight the NICE guidance: https://www.nice.org.uk/guidance/cg...the-primary-and-secondary-prevention-of-cvd-2
An important part of the recommendations is for the HCP to discuss risks and benefits with the patient and if that isn't happening, you should jump up & down. It's not good enough for a doc just to toss you a prescription.
They're supposed to use a tool to formalise the risk assessment (and of course discuss it with you). The tool is: https://qrisk.org/2017/index.php
This isn't supposed to take the place of clinical judgement, but does need to be considered.
Lifestyle modifications are of primary importance, but, with a whole bunch of caveats, exceptions etc etc, for a T2D, if the risk assessment says you have a 10 year risk of some major CV event of 10%+, then the recommendation is to take a statin and keep monitoring your cholesterol levels. If your non-HDL cholesterol doesn't reduce by at least 40%, then up the statin dose.
Exceptions: If you already have CVD of some kind, then skip the risk assessment. Do things differently if you have T1D, CKD, familial high-cholesterol.
Once you get to ~50 years of age, for a T2D the risk tool will probably spit out a 10%+ risk estimate no matter what else. Hence the common practice of putting middle-aged T2D's on statins without much further discussion (which IMO shouldn't happen - the lack of discussion, I mean).
A complication to this picture is that NICE itself doesn't really believe some of these details. Its surveillance committee made recommendations back in January 2018 which for whatever reason still haven't been implemented. https://www.nice.org.uk/guidance/cg...73/chapter/Surveillance-decision?tab=evidence
Some of these new recs:
- Use this updated risk assessment tool instead: https://qrisk.org/three/index.php The major change seems to be that it's supposed to handle T1D and CKD better. So it's no longer correct to say absolutely that this assessment isn't appropriate for T1's.
- The 40% non-HDL reduction target should probably be replaced by absolute LDL targets, the lower the better. (Parenthetically, there's a huge weight of evidence supporting findings that at the population level, a reduction of 1.0 mmol/L in LDL levels reduces CVD major event risk by 20% on average. So if I have a 15% 10 year risk to start with, and by taking statins I reduce my LDL by 2.0 mmol/L, then notionally my 10 year risk reduces to 9%. That seems pretty significant to me.)
- New classes of drugs for those who are statin-intolerant.
- Now that rosuvastatin is off-patent in the UK, maybe it should become the first-choice statin.
(Personally, and FWIW, I think the more detailed US guidelines are better and supported by a more up-to-date evidence review. Essentially: for most people, if you have a risk of 10%+, get LDL as low as possible, including with maximally-tolerated statin dosage; taking into account a whole bunch of detailed factors when assessing risk. Whatever.)
If you have questions, objections, concerns about any of the guidelines, read the studies if you're into that kind of thing & anyway your doc should be capable of talking about them with you. If not, find a different doc. On the Internet you'll mainly find a useless echo-chamber.
EDIT: For interest, this is the main US risk calculator: http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/
It's kind of klunky and you can't put in a total cholesterol lower than 3 point something, or LDL less than 1.8, which is annoying. But it does have a neat feature where you can put in before and after values for the various fields, which the model uses to refine your current risk assessment.
Both this and the UK tool tell me my risk at DX was about 50% - heavy smoker, pretty high BP, cholesterol a bit high, too frikkn old. But the US one tells me that Eddy 2.0 after all my changes has a risk of just 5.2%, which is better than the 11.8% I get from the UK one, so I like it a lot more!
Actually, I'm disqualified - I have peripheral artery disease, which is a CVD, so the tools aren't supposed to be for me, or anybody else with significant plaque in their arteries - we go straight to statins regardless. But even so ...
An important part of the recommendations is for the HCP to discuss risks and benefits with the patient and if that isn't happening, you should jump up & down. It's not good enough for a doc just to toss you a prescription.
They're supposed to use a tool to formalise the risk assessment (and of course discuss it with you). The tool is: https://qrisk.org/2017/index.php
This isn't supposed to take the place of clinical judgement, but does need to be considered.
Lifestyle modifications are of primary importance, but, with a whole bunch of caveats, exceptions etc etc, for a T2D, if the risk assessment says you have a 10 year risk of some major CV event of 10%+, then the recommendation is to take a statin and keep monitoring your cholesterol levels. If your non-HDL cholesterol doesn't reduce by at least 40%, then up the statin dose.
Exceptions: If you already have CVD of some kind, then skip the risk assessment. Do things differently if you have T1D, CKD, familial high-cholesterol.
Once you get to ~50 years of age, for a T2D the risk tool will probably spit out a 10%+ risk estimate no matter what else. Hence the common practice of putting middle-aged T2D's on statins without much further discussion (which IMO shouldn't happen - the lack of discussion, I mean).
A complication to this picture is that NICE itself doesn't really believe some of these details. Its surveillance committee made recommendations back in January 2018 which for whatever reason still haven't been implemented. https://www.nice.org.uk/guidance/cg...73/chapter/Surveillance-decision?tab=evidence
Some of these new recs:
- Use this updated risk assessment tool instead: https://qrisk.org/three/index.php The major change seems to be that it's supposed to handle T1D and CKD better. So it's no longer correct to say absolutely that this assessment isn't appropriate for T1's.
- The 40% non-HDL reduction target should probably be replaced by absolute LDL targets, the lower the better. (Parenthetically, there's a huge weight of evidence supporting findings that at the population level, a reduction of 1.0 mmol/L in LDL levels reduces CVD major event risk by 20% on average. So if I have a 15% 10 year risk to start with, and by taking statins I reduce my LDL by 2.0 mmol/L, then notionally my 10 year risk reduces to 9%. That seems pretty significant to me.)
- New classes of drugs for those who are statin-intolerant.
- Now that rosuvastatin is off-patent in the UK, maybe it should become the first-choice statin.
(Personally, and FWIW, I think the more detailed US guidelines are better and supported by a more up-to-date evidence review. Essentially: for most people, if you have a risk of 10%+, get LDL as low as possible, including with maximally-tolerated statin dosage; taking into account a whole bunch of detailed factors when assessing risk. Whatever.)
If you have questions, objections, concerns about any of the guidelines, read the studies if you're into that kind of thing & anyway your doc should be capable of talking about them with you. If not, find a different doc. On the Internet you'll mainly find a useless echo-chamber.
EDIT: For interest, this is the main US risk calculator: http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/
It's kind of klunky and you can't put in a total cholesterol lower than 3 point something, or LDL less than 1.8, which is annoying. But it does have a neat feature where you can put in before and after values for the various fields, which the model uses to refine your current risk assessment.
Both this and the UK tool tell me my risk at DX was about 50% - heavy smoker, pretty high BP, cholesterol a bit high, too frikkn old. But the US one tells me that Eddy 2.0 after all my changes has a risk of just 5.2%, which is better than the 11.8% I get from the UK one, so I like it a lot more!
Actually, I'm disqualified - I have peripheral artery disease, which is a CVD, so the tools aren't supposed to be for me, or anybody else with significant plaque in their arteries - we go straight to statins regardless. But even so ...
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