Statins' Diabetogenic Impact Influenced by Underlying Risks

The risk that patients will develop new-onset diabetes on statin treatment appears to be proportional to a patient’s pretreatment risk for diabetes, as well as the statin dose they receive and other drugs they may also be on.

But despite growing evidence that statin treatment seems capable of causing diabetes in a small fraction of patients who get these drugs, study results also consistently show that the reduction in cardiovascular events that statins produce in secondary prevention outweigh the small risk for incident diabetes they pose. That’s the bottom line that has come through over and over again.

Especially for secondary prevention, the diabetes risk from statins is more of a nuisance than anything else. I think you can ignore the risk; avoiding statin treatment just because of the diabetes risk is wrong. If you stop using statins, what else can you use in a high-risk patient who needs a 30%-50% reduction in low-density lipoprotein cholesterol? That level of reduction is very hard to achieve without a statin. I’m not happy about the risk, but currently there are no good alternatives.

Ideally, we should develop new strategies that could reduce the risk, such as possibly earlier treatment with a bile-acid sequestrant or niacin. Another important goal is to try to figure out how statins trigger diabetes. It would be spectacular if the mechanism was identified and someone came up with a statin that did not cause diabetes.

Regarding other drug classes that also seem capable of triggering diabetes, judgment must also be used and alternative drug classes considered. The diabetes-causing potential of beta-blockers and thiazide diuretics can in some cases be avoided by using alternative drugs. But, as with statins, if a patient has depression and needs treatment with an antidepressant, I think it would be a huge mistake to not use that treatment out of concern that it might provoke diabetes.

Dr. P. Barton Duell is an endocrinologist and director of the lipid disorders clinic at the Oregon Health & Science University in Portland. He said that he had been a speaker on behalf of Merck, a consultant to Pfizer, Genzyme, Merck, Aegerion, and Amarin, and that he has received research grants from Genzyme, Pfizer, Bristol Meyers Squibb, and Cerenis. He made these comments as a discussant at the meeting and in an interview.