Jennifer Goldman, RPh, PharmD: How Advances in Lipid Management Fit Into Diabetes Care

Since the turn of the century, diabetes management has seen, and is still in the midst of, dramatic change; with much of this coming as a result of advancement in pathophysiology, but also pharmacotherapy related to management of dysglycemia and other risk factors contributing to early mortality. Furthering the benefit of patients with diabetes has been the similar level of magnitude seen in regard to advances in lipid management.

After decades with relatively limited advances, the community has witnessed an onslaught of advances that include PCSK9 inhibitors and ATP-citrate lyase inhibitors. ON the horizon, the community waits with bated breath for phase 3 results of agents targeting lipoprotein(a) and severe hypertriglyceridemia.

With atherosclerotic cardiovascular disease risk chief among the drivers of premature mortality among people with diabetes, optimal knowledge and application of novel pharmacotherapies serves to provide significant benefit on a population level as the rate of diabetes continues to climb. However, as existing healthcare structures deal with a growing prevalence of metabolic illness across the US, the diabetes care team has been given a Herculean task of keeping pace with all these updates.

In a recent interview, we sat down with Jennifer Goldman, RPh, PharmD, clinical pharmacist and director of the Cardiometabolic Program at Well Life as well as a professor of Pharmacy Practice at the Massachusetts College of Pharmacy and Health Sciences, to discuss advancements in lipid management, the role of the endocrinology in cardiovascular risk management, how the role of statins and other traditional therapies has evolved in recent years, and the role of educating clinicians on emerging risk factors.

HCPLive: With such an elevated prevalence of dyslipidemia, where does the role of lipid management lie within the diabetes care team or should this remain under the purview of cardiology specifically?

Goldman: You’ve made a really good point. Many people are responsible for taking care of patients, but who does it fall to? I think we need to be a team—a collaborative team—that includes endocrinologists. Here at the ADA meeting, we consider the ADA standards of care, specific recommendations for the treatment of type 2 diabetes and type 1 diabetes, and goals of therapy.

We all need to take responsibility. If someone is being seen by an endocrinologist and they are not reaching their goals according to the standards of care, someone needs to intervene. Whatever the drug therapy is, if a patient has had an ASCVD event and their goal is less than 55 mg/dL, we need to decide what to do about it. Someone has to take responsibility for adding the appropriate drug therapy.

HCPLive: What recent advances in lipid therapy do you believe are most pertinent for endocrinology?

Goldman: I think we need to pay attention to outcome data and not settle for “good enough.” One of the things I like to challenge providers about is, what would you do if it was you or your family? We need to look at our patients the same way. We know we can prevent cardiovascular death and stroke, and we have the tools to do that now, so we can’t settle for “good enough” anymore. We have to look at those outcomes and treat people the way we want our family to be treated. Whatever drug therapy has that outcome data is what we should be using.

HCPLive: How important is it to emphasize the role of statin therapy and other basic lipid management principles in patients with diabetes?

Goldman: When we think about people with diabetes, they don’t die from diabetes—they die from cardiovascular disease. Statins are certainly important because we have primary and secondary prevention data with them. When we look at all the new therapies and the “new shiny things” with outcome data, it’s on a background of maximally tolerated statins.

This means it’s in addition to statins, which could be no statin if someone can’t tolerate it.

According to the ADA standards of care, the recommendation is moderate to intensive statin therapy. If you don’t reach your ADA goal—less than 70 mg/dL or less than 55 mg/dL—then we will look at the new therapies to reach those goals.

HCPLive: How does the emerging role of Lp(a) influence risk stratification of patients with diabetes?

Goldman: We know that people with diabetes are at the highest risk of dying from cardiovascular disease. By monitoring this risk, we can better understand and manage it. So, what does that conversation look like with a patient? It might change things significantly. For instance, if you discuss how their condition increases their risk and consider other factors such as family history, obesity, or other risk factors, having that information available might help motivate them.

But who’s responsible for this? I believe we need a collaborative team, whether it’s the endocrinologist, the cardiologist, or the primary care provider. We should all be working together to ensure this gets done.

Editor’s Note: This transcript has been edited grammar and clarity using artificial intelligence.

Relevant disclosure for Goldman include Novo Nordisk, Abbot Diabetes, Amgen, Lilly, Sanofi, Xeris Biopharma Holdings, and CeQur Corporation.

References:

Chait A, Eckel RH, Vrablik M, Zambon A. Lipid-lowering in diabetes: An update. Atherosclerosis. 2024;394:117313. doi:10.1016/j.atherosclerosis.2023.117313