Should young, healthy people with type 1 diabetes take statins?

I encountered this question a couple months ago in a consult and intended to blog about it then, but relatively little trial data was available. I would have essentially been giving my own off-the-cuff opinion. That's very unsatisfying to me, and probably to the reader.

As background: we tend to think of type 1 diabetes as more a need for hormone replacement (insulin) than as a disease state requiring the complex management that type 2 diabetes requires. That is to say that type 1 diabetes, for all the unpleasantness it causes for people, is easier on the blood vessels as a general rule than type 2 diabetes. The ADA has a statement in its guideline that "For patients with diabetes aged <40 years with additional atherosclerotic cardiovascular disease risk factors, consider using moderate-intensity or high-intensity statin and lifestyle therapy." It's a category C recommendation, meaning it's mostly opinion and has a less-than-spectacular evidence base. It also doesn't differentiate between type 1 and type 2 diabetes. Similarly, a joint statement by the ADA and the AHA states that "Adults with T1DM who have abnormal lipids and additional risk factors for CVD (eg, hypertension, obesity, or smoking) who have not developed CVD should be treated with statins." Both statements argue against the routine use of statins in young healthy type 1 diabetics.

But a recent study from the New England Journal helps us with the question of statins in kids, and throws in ACE inhibitors for good measure. Investigators led by M. Loredana Marcovecchio and Scott T. Chiesa randomized 443 kids between 10 and 16 years with type 1 diabetes and urine albumin-to-creatinine ratios in the upper third of "normal" to some combination of ACE inhibitor, statin, and placebo. Creatinine is a consistently excreted product of muscle metabolism that serves as a nice comparator for other things the kidney excretes. So even if you drink a lot of water and dilute the amount of albumin in your urine, we can look at it compared to the similarly diluted creatinine and see if you're excreting too much.

Anyway: the investigators used a 2 x 2 trial design, meaning that there were ultimately four groups: placebo-placebo, placebo-ACEi, placebo-statin, and ACEi-statin. The statin was atorvastatin 10 mg daily, and the ACEi was quinapril 10 mg daily (after titration). They were most interested in the change in albumin excretion (that is, how much protein spilled through the kidneys into the urine). They assessed this according to that same measure, the albumin-to-creatinine ratio in the urine, from three early-morning urine samples obtained every 6 months over about two and a half years. They also looked at secondary outcomes like the new development of microalbuminuria (that is, the new appearance of protein in the urine), worsening of eye disease, changes in kidney function, blood lipid levels, and measures of cardiovascular risk. For the cardiovascular risk, they did ultrasounds of the carotids to measure the thickness of the vessels (carotid intima–media thickness) and measured levels of high-sensitivity C-reactive protein and asymmetric dimethylarginine in the blood. Both of these are generic markers of vascular risk.

After an average of 2.6 years, no benefits were found within the ACEi group, the statin group, or the ACEi+statin group compared to placebo. Unsurprisingly, the ACEi group had a much lower incidence of new microalbuminuria, but "in the context of negative findings for the primary outcome and statistical analysis plan, this lower incidence was not considered significant (hazard ratio, 0.57; 95% confidence interval, 0.35 to 0.94)." Also unsurprisingly, the use of statins resulted in lower cholesterol levels (including, unfortunately, HDL). But neither drug had significant effects on carotid intima–media thickness, C-reactive protein, kidney function, or progression of eye disease.

So we can take away from this small-ish study that, at least in a short amount of time in pretty healthy twelve-year-olds (the subjects were excluded if they had genetically bad lipid levels; the participants' average A1c was ~8.3% and their average blood pressure was 116/65 mmHg), there was no benefit to statins or ace inhibitors. This study will influence my recommendations to patients and other docs in the future. The kicker, naturally, is that many young people with type 1 diabetes have imperfect blood sugar control. What about those who can't get their diabetes controlled? It's a tougher call in that case, and this study didn't address it. 

Freedom from the vortex

Maybe you’re sick. Not throwing up or coughing up blood or having a fever, at least not most of the time, but you’re on a few medications, probably for diabetes or blood pressure issues or cholesterol, and your doctor picks on you to change your diet or be more active whenever you see her. Your medications cost a couple hundred dollars per month, and every second or third time you visit the doctor she adds another one, or replaces an old, cheap medication with a newer, more expensive one.

And maybe you weigh a few pounds (or many pounds) more than you want to. You’ve tried a few diets, mostly Atkins-type stuff, or low-fat, or calorie counting, and you’ve lost weight a few times, but each time the weight eventually came back.

Maybe you’re tired all the time. You feel bad when you get up in the morning, you are fatigued and achy all day, and you don’t sleep well at night. Your doctor thinks you might be depressed, and you’ve tried a couple medications for it, but they don’t seem to help.

And maybe you worry about money. You spend a lot of it on medications, and you go through the drive-through a few times a month even though you promise yourself that you won’t, and you end up working longer hours than you want to because you need to make sure the bills get paid.

Maybe you worry about the environment. You worry that our habits are putting your kids’ futures at risk, and you worry about it, but you aren’t sure what to do. A couple of times you’ve clicked the button to buy carbon offsets when you flew somewhere, but mostly you just try to ignore the problem.

And maybe it hasn’t occurred to you that these are all different manifestations of the same problem. You read that right. There is a very good chance that your diabetes is just another manifestation of the same set of problems as your weight and your fatigue and your money issues and even climate change.

We’re gonna talk about how. This blog is about your health, but not in the way that you’re used to talking about it with your doctor. It's not about the “blood pressure, blood sugar, cholesterol,” kind of health that makes you feel like a gadget someone is tinkering with. It’s more about the “What do I look forward to when I get out of bed in the morning?” kind of health. Or the “What can I do today to make sure I’m happier tomorrow than I was yesterday?” kind of health. Health as freedom: freedom from false choices, freedom from medications (not all of them, but some of them), freedom from the, *ahem*, Bravo Sierra that passes for medical advice from celebrities and celebrity doctors. I’m talking to you, Dr. Oz.

You’re not going to see click-baity posts on this blog about some new supplement or cellulite-destroying cream. You’re going to see posts on how you can take control of your life back. I’m not talking about a life jacket to protect you from the evil, swirling vortex of drug companies, subsidized faux-food, and carbon-spewing cars and factories. I’m talking about the freedom of learning how to swim your way out of that vortex altogether, put your feet on dry land, and walk away. All those people wrapped in spandex and padding away on a commercial gym’s treadmill under creepy fluorescent lights: do you think they’re free? They sure don’t look like it to me. You, with dry feet, having sprung once and for all from the vortex and now walking one foot in front of the other toward a happier, healthier life: that’s what freedom looks like.

I intend to be your guide along this path to medical freedom. I want to teach you a new way to think about your health; a way that allows you to make decisions that are your own and that will get you out of the vortex. You know the last time you had a bad cold, and you felt guilty for taking all the healthy days you had before that for granted, and you wondered when you would finally feel normal again? Remember how you said to yourself that you’d never take a healthy day for granted again? Once you claw your way out of the vortex, you won’t. And it will be because you MADE that next healthy day. You will have made it yourself, with your own hands and feet and decisions. If you believe me, I’ll see you at the next post.