Published Comment and Response: Do Lipid-Lowering Agents Provide a Greater Reduction in Cardiovascular Events among Patients with Diabetes?
Diabetes Mellitus (Type 2) in Adults: Screening
November 15, 2008
Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
First published as a Letter to the Editor in Annals of Internal Medicine 149(11):841, December 2, 2008.
TO THE EDITOR: The U.S. Preventive Services Task Force (USPSTF) no longer recommends routine screening for type 2 diabetes mellitus in adults with hyperlipidemia1. This recommendation seems to have been based, at least in part, on an analysis of the secondary prevention trials, which showed that lipid treatment reduced the incidence of coronary heart disease (CHD) events by about the same relative percentage among those with type 2 diabetes mellitus and those without.
Because the incidence of major CHD events is higher in adults with type 2 diabetes mellitus than in those without, one would expect that patients with diabetes would benefit more by having greater absolute reductions in CHD events than patients without diabetes despite similar reductions in relative percentage. Therefore, reductions in absolute percentage (and not relative percentage) of CHD events with lipid treatment in these groups should have been considered.
Anil K. Gollapudi, MD
W.G. "Bill" Hefner Veterans Affairs Medical Center
Salisbury, NC 28144
1. U.S. Preventive Services Task Force. Screening for type 2 diabetes mellitus in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2008;148:846-54. [PMID: 18519930]
IN RESPONSE: In making its recommendation on screening for type 2 diabetes, the USPSTF considered interventions, including lipid-lowering agents, for effects on such health outcomes as cardiovascular events. In reviewing the evidence on lipid-lowering agents, the USPSTF found that persons with diabetes do not seem to benefit to a greater extent than those without for the primary prevention of cardiovascular events, whether considering absolute or relative risk reduction. For example, in the Heart Protection Study, the absolute reduction in coronary events for participants receiving simvastatin versus placebo was similar in those with and without diabetes: 3.2% and 3.0%, respectively (calculated from data in the Heart Protection Study)1. Therefore, the evidence does not support screening for type 2 diabetes on the basis of lipid status.
However, the USPSTF encourages clinicians to perform a global cardiovascular disease risk assessment to determine a person's 10-year cardiovascular disease risk2 and to screen for type 2 diabetes if knowledge of diabetes status would change management, including the management of hypertension or the use of lipid-lowering agents and aspirin.
Ned Calonge, MD, MPH
Colorado Department of Public Health and Environment
Denver, CO 80246
Diana B. Petitti, MD, MPH
Keck School of Medicine, University of Southern California
Los Angeles, CA 90089
1. Collins R, Armitage J, Parish S, Sleigh P, Peto R. Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5963 people with diabetes: a randomised placebo-controlled trial. Lancet 2003;361:2005-16. [PMID: 12814710]
2. Health Link, Medical College of Wisconsin. Calculate Your Risk of Coronary Heart Disease. Accessed at http://hp2010.nhlbihin.net/atpiii/calculator.asp.