The answer that Professor Gerald Watts from the Lipid Disorders Clinic at Royal Perth Hospital gave to this question was surprisingly philosophical.
Speaking at a session on Macrovascular Disease in Diabetes in the Young Professor Watts told delegates that the issue of early intervention with statins in diabetes had should be understood in the context that atherosclerosis was actually a paediatric condition.
A number of autopsy studies clearly showed that atherosclerosis was present in a significant proportion of young people, even before adulthood, he said.
“It starts early on and risk factors have a major impact..the most important of which is probably LDL cholesterol” he told delegates.
The hallmark of the condition was atherosclerotic plaque and for that to start you needed cholesterol.
However when thinking about diabetes we needed to think not only in terms of circulating concentrations of particles but also the fact that the arterial wall of the epithelium is actually quite abnormal, he said.
“It’s quite soggy it has increased permeability, so really an LDL cholesterol of 2 for a type 1 diabetes patient with microalbuminuria could be conceived as being an LDL cholesterol of 4…. this is a concept that not many people seem to not appreciate”.
There were expert statements and guidelines that stated type 1 diabetes should be conceived as a tier 1 high-risk condition on par with homozygous familial hypercholesterolemia.
But according to Professor the proposition that all patients should be on a statin can be true — at least in one of many possible worlds.
“There’s not just one world there are several worlds, so it is a contingent truth in whatever world you care to think about,” he said to a stunned audience.
“Before you say is this man mad, I’m just saying it is true in a particular situation…in the world of a particular patient or the world of a group of patients that you deem to be clinically requiring a statin”.
He said statins should be used in people with diabetes who:
- Are aged 40 to 80 years have no CVD and LDL is >5 and they have another risk factor such as microalbuminuria or a family history of premature CVD.
- Are aged 18-40 years with LDL >5 and other high risk factors.
- Are aged 10 to 18 with LDL >4.1; or >3.4 with other risk factors.
All these decisions have to be individualised with a fully informed patient, adopt a proactive approach and no contraindications like pregnancy, Professor Watts advised.
“At the end of the day your world is guided by your clinical nouse,” he said.
The controversial issue was unlikely to be resolved by the ongoing Adolescent type 1 Diabetes cardiovascular Intervention Trial (AdDIT).
“It’s a bold trial, it’s an essential trial I think the selection of people with persistent microalbuminuria is right on the nose,” he said.
“But at the end of the day these are just surrogate endpoints and only predict cardiovascular disease on average…it’s not a clinical endpoint.”