Diabetes Standards of Care and Resources for Clinicians and Educators

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.