Diabetes Standards of Care and Resources for Clinicians and Educators

Recommendations for Lipid Management and ASCVD Risk Reduction

Measurement

• Order a fasting lipid panel (LDL, HDL, total cholesterol, and triglycerides)
  • at diagnosis of diabetes, or initial diabetes visit;
  • at least every 5 years if age <40 years, annually after 40; and
  • at initiation of statin therapy and after dosing changes.

Treatment

• Provide patient-centered education and ongoing support for lifestyle interventions for all patients to reduce ASCVD¹ risk: individualized nutrition therapy, physical activity and weight loss guidance, as well as smoking cessation counseling.
• Prescribe high intensity statin therapy for patients with ASCVD (Secondary Prevention).
• Prescribe moderate or high intensity statin therapy for all patients aged 40-75 years without ASCVD (Primary Prevention).
  • Evaluate 10-year ASCVD risk using the ASCVD Risk Estimator Plus Exit Disclaimer: You Are Leaving www.ihs.gov  and/or assess ASCVD risk factors independent of diabetes² for use in determining statin therapy intensity.
  • Prescribe high intensity statin in patients aged 40-75 years with 10-year ASCVD risk >20%.
• Utilize a shared decision making model when considering moderate or high intensity statin therapy for patients aged <40 years without ASCVD but with one or more additional ASCVD risk factors independent of diabetes².
• Discuss risk-benefit of statin therapy with patients aged >75 years without ASCVD; initiate or continue statin based on shared-decision-making.
• Consider bempedoic acid for patients with statin intolerance.

See Diabetes Treatment Algorithm: Lipid and Aspirin Therapy in Type 2 Diabetes for detailed guidance on statin therapy based on age and ASCVD risk. Statin dosing information is provided.

References

1. ASCVD (Atherosclerotic Cardiovascular Disease) is atherosclerosis affecting the vasculature that results in diseases of any of the following: heart (e.g. myocardial infarction, angina), the brain (e.g., stroke, transient ischemic attack), and the lower extremities (e.g. peripheral artery disease, limb ischemia).
2. Risk Factors independent of diabetes include: LDL cholesterol ≥100 mg/dL, smoking, hypertension, chronic kidney disease, albuminuria, or family history of premature ASCVD.

• Additional Recommendations for Lipid Management and ASCVD Risk Reduction

  Secondary Prevention of ASCVD

  • Consider the addition of the following medications for patients with ASCVD and very high risk with an LDL cholesterol ≥55 mg/dL on a maximally tolerated statin.
    • Ezetimibe 10 mg daily
    • PCSK9 inhibitor
      • Evolocumab (Repatha) 140 mg SC every two weeks or 420 mg SC monthly
      • Alirocumab (Praluent) 75-150 mg SC every two weeks or 300 mg SC monthly
  • Consider addition of icosapent ethyl (Vascepa) 2 g twice a day to maximally tolerated statin therapy in patients with ASCVD and/or other ASCVD risk factors when triglyceride level is 135-499 mg/dL.
  • Consider adjunctive agents to decrease LDL cholesterol in patients with ASCVD or heterozygous familial hypercholesterolemia who are not at LDL cholesterol targets with low fat diet and maximally tolerated statin.
    • Bempedoic acid (Nexletol) 180 mg po daily
    • Bempedoic acid and ezetimibe (Nexlizet) 180-10 mg po daily
    • Inclisiran (Leqvio) 284 mg SC every 6 months

  Note: Addition of fibrates and/or niacin to maximally tolerated statin treatment have not been shown to reduce ASCVD events and are not recommended.

  Primary Prevention of ASCVD

  • Prescribe high intensity statin in patients aged 40-75 years with 10-year ASCVD risk >20%.
    • Consider adding ezetimibe 10 mg daily to maximally tolerated statin to reduce LDL cholesterol by 50% or more from baseline.

  Other Lipid Treatment Considerations

  • Elevated Triglycerides (>150 mg/dL):
    • Ensure optimal blood glucose control; identify and address any secondary causes (e.g., high fat and/or high carbohydrate diet, hypothyroidism, excessive alcohol use, and medications).
    • Consider initiating or increasing statin therapy in patients with triglyceride level >150 mg/dL to ≤500 mg/dL.
    • Consider additional lipid lowering medications to reduce risk of pancreatitis if triglycerides ≥500 mg/dL (especially ≥1,000 mg/dL).
      • Fenofibrate 120-160 mg daily
      • Omega 3 fatty acid 2 g bid
      • Icosapent ethyl (Vascepa) 2 g bid
  • Low HDL cholesterol (<40 mg/dL in men; <50 mg/dL in women):
    • Ensure optimal blood glucose control and address other factors that lower HDL cholesterol such as smoking or high carbohydrate diet.
    • Consider a lifestyle program for weight reduction and increase physical activity.

Featured Lipid Management Resources

Organization	Resource
	Diabetes Treatment Algorithm: Lipid and Aspirin Therapy in Type 2 Diabetes
	National Pharmacy and Therapeutics Committee Formulary Brief: Hyperlipidemia [PDF – 200 KB]
	Million Hearts: Cholesterol Management Exit Disclaimer: You Are Leaving www.ihs.gov
	ASCVD Risk Estimator Plus Exit Disclaimer: You Are Leaving www.ihs.gov
	American Diabetes Association. 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2026 Exit Disclaimer: You Are Leaving www.ihs.gov  Diabetes Care 2026, Vol.49, S216-S245 https://doi.org/10.2337/dc26-S010
	2018 AHA/ACC Guideline on the Management of Blood Cholesterol Exit Disclaimer: You Are Leaving www.ihs.gov  Circulation Nov 2018; doi:10.1161/CIR.0000000000000625
	Calculator: Estimated Risk of Developing CHD in 10 Years Exit Disclaimer: You Are Leaving www.ihs.gov

Lipid Management Patient Education Resources

Organization	Resource
	Education Materials and Resources (Online Catalog): Fats and Heart Health Blood Pressure and Diabetes Keeping Your Heart Healthy
	Million Hearts: Statins Infographic Exit Disclaimer: You Are Leaving www.ihs.gov
	Cholesterol Exit Disclaimer: You Are Leaving www.ihs.gov
	Prevention and Treatment of High Cholesterol (Hyperlipidemia) Exit Disclaimer: You Are Leaving www.ihs.gov

Session Title	Session Material	CME/CE Information