Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 58-year-old man is evaluated during a routine appointment. He is asymptomatic. He was diagnosed with type 2 diabetes mellitus 4 years ago and has hypertension, dyslipidemia, and obesity. His medications are enteric-coated low-dose aspirin, lisinopril, fluvastatin (20 mg/d), and metformin.

His calculated 10-year risk of atherosclerotic cardiovascular disease (ASCVD) using the Pooled Cohort Equations is 10%.

On physical examination, blood pressure is 126/78 mm Hg and pulse rate is 72/min. The remainder of the examination is normal.

Laboratory studies show total cholesterol 186 mg/dL (4.82 mmol/L), LDL cholesterol 123 mg/dL (3.19 mmol/L), HDL cholesterol 44 mg/dL (1.14 mmol/L), and triglycerides 109 mg/dL (1.23 mmol/L).

Which of the following is the most appropriate statin management?

A. Increase fluvastatin to 40 mg/d
B. Switch to atorvastatin, 40 mg/d
C. Switch to lovastatin, 20 mg/d
D. Switch to pravastatin, 20 mg/d
E. Switch to simvastatin, 10 mg/d

MKSAP Answer and Critique

The correct answer is B. Switch to atorvastatin, 40 mg/d.

The most appropriate management in this patient with a coronary heart disease (CHD) risk equivalent is to switch to atorvastatin, 40 mg/d. Current guidelines recommend that statin therapy be initiated in patients at high risk for CHD. The intensity of the statin therapy should be tailored to the CHD risk. Candidates for high-intensity statin therapy include:

•Patients with known atherosclerotic disease (clinical CHD, cerebrovascular disease, or peripheral arterial disease)

•Patients with an LDL cholesterol level 190 mg/dL (4.92 mmol/L) or greater

•Patients with diabetes mellitus, an LDL cholesterol level below 190 mg/dL (4.92 mmol/L), and calculated 10-year CHD risk of 7.5% or higher

•Some patients without diabetes with an LDL cholesterol level below 190 mg/dL (4.92 mmol/L) and calculated 10-year CHD risk of 7.5% or higher

Moderate-intensity statin therapy can be considered for:

•Patients with diabetes who are not receiving high-intensity therapy

•Most patients without diabetes with an LDL cholesterol level below 190 mg/dL (4.92 mmol/L) and calculated 10-year CHD risk of 7.5% or higher

•Some patients without diabetes with an LDL cholesterol level below 190 mg/dL (4.92 mmol/L) and calculated 10-year CHD risk of 5% or higher but lower than 7.5%

This patient has diabetes, an LDL cholesterol level less than 190 mg/dL (4.92 mmol/L), and a calculated 10-year CHD of 10%, and, therefore, should be considered for high-intensity statin therapy. Drugs and doses that constitute high-intensity statin therapy include atorvastatin, 40 to 80 mg/d; rosuvastatin, 20 to 40 mg/d; and simvastatin, 80 mg/d. (The FDA has issued a warning regarding the incidence of muscle injury with products that contain 80 mg of simvastatin and recommends that patients be switched to a different statin rather than increasing the dosage of simvastatin to 80 mg/d.)

Fluvastatin, 40 mg/d; lovastatin, 20 mg/d; pravastatin, 10 mg/d; and simvastatin, 10 mg/d, are all classified as low-intensity dosing and are inadequate to reduce this patient’s CHD risk.

Key Point

• Patients with diabetes mellitus should receive moderate- or high-intensity statin therapy to reduce their risk of coronary heart disease.

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