Do Diabetics Really Need Lipitor?

You'd practically think doctors had discovered vitamin L.

Almost every doctor who treats diabetics in the USA will recommend treatment with the cholesterol-lowering drug atorvastatin, also known as Lipitor, the moment an LDL test comes back with a reading higher than 120 mg/dl.

This is wrong on many levels.

Even if there were no side effects of Lipitor, if it never caused potentially fatal rhabdomyolysis, an extreme form of muscle pain and soreness from taking Lipitor, if no one ever noticed a relationship between constant throat clearing and Lipitor, if there were no connection between Lipitor and forgetfulness, automatically prescribing this statin drug to just about everyone who has diabetes would be bad medicine.

First of all, the test your doctor gives you usually doesn't measure LDL. It's a "guestimate" of "bad" cholesterol from your total cholesterol, HDL, and trigylceride levels--and LDL and HDL are not the only kinds of cholesterol. A direct measurement of low-density lipoprotein is probably more expensive than every other test your doctor will order for your diabetic checkup.

And if you've been careful to get your sugars under control, lowering your triglycerides, guess what? Your LDL number will be higher! This is the case whether or not the actual concentration of this form of cholesterol has gone up.

Secondly, there's more than one kind of LDL. Apo-A is not associated with cardiovascular risk. Apo-B is associated with cardiovascular risk. If your LDL is really apo-A, Lipitor is not going to protect you against having a heart attack.

But suppose your doctor argues that, yes, you're right, the tests the doctor ordered don't really measure any kind of cardiovascular risk factor, but "we" know that Lipitor and other statins are anti-inflammatory and its stopping inflammation that really does you good. After all there was the famous TNT study.

What was the TNT study? Does your doctor think it was dynamite?

The Treating to New Targets study was a South African clinical trial that found that diabetics given a high dose of Lipitor were 25 per cent less likely to have a fatal heart attack, non-fatal heart attack, fatal stroke, or non-fatal stroke, than diabetics given a lower dose Lipitor.

So the scientists weren't studying 1,501 diabetics, some of whom weren't already on Lipitor. Everybody in the study was on Lipitor. Some just got more.

And that 25 per cent figure is misleading.

The study found that 13 per cent of diabetics on high-dose Lipitor had a heart attack or stroke over the 5 years of the trial, while 17 per cent of diabetic on low-dose Lipitor had heart attack or stroke during the same period. Lipitor is hardly a magic bullet.

And doesn't that 17 per cent figure sound awfully high? Well, there's a reason for that, too.

The TNT study found that additional Lipitor had additional benefit only for South African diabetics who had already developed coronary heart disease before the age of 56.

Now, if you happen to be a South African male diabetic under the age of 56 who has already had a heart attack or stroke and you are already taking Lipitor, maybe you should take more. But what if you are a diabetic, but you haven't had a heart attack or a stroke, and you're not taking a statin drug?

A much larger study in Israel has an answer.

In five years of follow-up of 2,482 diabetics aged 45 to 74, Israeli researchers found that 5 per cent of the diabetics died. Cholesterol, however, was not the predictor of death. Blood pressure was. Israeli doctors found that getting blood pressure under control while diabetes could still be treated with diet was ideal. About 5 per cent of diabetics who had high blood pressure died over the five-year period. About 4 per cent of diabetics who managed to control their blood pressure suffered the same fate.

So what's the bottom line?

Ask your doctor about Lipitor if you are concerned about preventing a second, fatal heart attack or stroke.

Get your blood pressure under control if you are concerned about preventing a first, fatal heart attack or stroke.

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Citations:

(no authors listed) High-dose atorvastatin therapy achieves 25% reduction in CV events in TNT substudy of diabetic patients. 1: Cardiovasc J S Afr. 2006 Jul-Aug;17(4):206-7.

Tenenbaum A, Fisman EZ, Boyko V, Goldbourt U, Graff E, Shemesh J, Shotan A, Reicher-Reiss H, Behar S, Motro M. Hypertension in diet versus pharmacologically treated diabetics: mortality over a 5-year follow-up. Hypertension. 1999 Apr;33(4):1002-7.