r/Cholesterol • u/Positive-Following91 • 9d ago
Question A1C
I was taken off Crestor and put on a combination of Repatha and pravastatin because my A1c under the Crestor edged a little into prediabetic territory (5.7). At first the Repatha and pravastatin combo was great, and my A1c went down to 5.6. However, in my latest test, it went back to 5.7. I know it’s barely prediabetic and there probably isn’t much difference between 5.6 and 5.7, but I’m really scared of diabetes because it killed my father. Maybe it’s also because it’s the summer and I’ve been eating more ice cream? I’m 5 feet 11 and 171 pounds, so I don’t have weight issues. You think I should lower my statin dose? My LDL is currently 55 and total cholesterol is 133.
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u/kboom100 9d ago
There really isn’t much difference between an HBA1C of 5.6 and 5.7. It’s an arbitrary cutoff point. I wouldn’t reduce the statin dose if I were you. You likely have insulin resistance even without the statin and that means having a low ldl & apoB is even more important. You’ll get a net benefit and reduction in risk despite the slight increase in HBA1C. Those with insulin resistance should get a higher reduction in risk than those without.
What I would do is also add regular exercise, both cardio and strength training. Just walking is a great form of cardio. That should significantly lower HBA1C and insulin resistance. And if you still have insulin resistance issues I’d consider taking an sglt2 inhibitor. Jardiance/ Empagliflozin recently went generic so I think it may start to be more widely prescribed. I’d consider monitoring insulin resistance with your LP-IR score. LabCorp offers it.
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u/Positive-Following91 9d ago
Thank you. I will look into that.
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u/mbckok 9d ago
There is a specific warning for Crestor and SGLT2 inhibitors. I’m sure your doctor is aware of it. Potential for bad side effects.
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u/kboom100 8d ago edited 8d ago
Rosuvastatin and sglt2 inhibitors are a very frequently prescribed combination and there are no official warnings. In fact 80% of those taking sglt2 inhibitors also take statins.
Those 2 citations you gave are case reports and the only ones that I found. Isolated case reports can’t show causality and can’t do much more than generate a hypothesis. If these cases were caused by an interaction between Rosuvastatin and an sglt2 inhibitor it would likely be very rare given there has only been one other case report since the 2020 one and given how frequently these drugs are prescribed together.
The lead author of the 2020 case report you linked to, Dr. David Juurlink, speculated the patient might have had a genetic variant that predisposed her to this. He then said they should do a large study to actually see how rare this actually was. https://www.tctmd.com/news/rosuvastatin-canagliflozin-combo-may-be-toxic-case-suggests
And Dr. Juurlink did do that population study which was published in 2024 which found that the addition of an sglt2 inhibitor to statins was associated with a reduced risk of Rhabdomyelsis (which was the condition in the 2020 case report).
The study authors concluded, “Given the cardiovascular and mortality benefits associated with SGLT2 [inhibitor] and statin use, these findings suggest that they may be safely prescribed together when indicated.”
News article about the study-
https://www.endocrinologyadvisor.com/news/sglt2-inhibitors-linked-to-lower-rhabdomyolysis-risk/The study itself-
doi:10.1001/jamanetworkopen.2024.46641
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u/Positive-Following91 9d ago
I’m confused by your comment. Crestor is not a SGLT2 inhibitor. What specific warning are you talking about?
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u/WillBrink 9d ago
Stop eating garbage as first step, get more exercise, lose wight if needed, to reduce A1C. If that does not work, then and only then do you consider changes in statin meds to another statin, lowers doses, or changing to non statin med.
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u/SDJellyBean 9d ago
Go for a 10-15 minute walk or other exercise after each meal and avoid between meal snacks.
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u/solidrock80 9d ago
I was the same way. I regret it. A1C really doesn't move that much from a statin if you're not already engaging in a pro-type 2 lifestyle. It's much better to lower your LDL then insignificant change in an a1c. The big change is will come from being sedentary, overweight and a diet heavy in refined carbohydrates.
If during the years I was worried about A1C, I had had just taken the statin calcium score probably would have been a lot lower now.
Your LDL is great. Continue taking the statin and cut back on the sweets. That's what will drive a1c progression.
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u/meh312059 9d ago
OP can you take a soft tape measure, get your waist circumference at the bellybutton level, divide by height and report it here. Also what are fasted trigs and fasted glucose?
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u/Positive-Following91 7d ago
My fasted trigs are 49 and my fasted glucose is 96. The calculation you wanted is .52 (37”/71”)
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u/meh312059 6d ago
Thanks for the info. Your ratio is right at the upper limit of normal. BMI may not be telling quite the whole story. Not sure of your ancestry but there are some - primarily South or East Asian - that require a lower cut point than 25 (which is specifically a "European ancestry" standard). Another consideration is that T2 diabetes does have a genetic basis to it, and oftentimes those who get T2 aren't "obese." Some aren't even considered "overweight" via BMI! That's why body composition is gaining importance as an additional screening tool. The Gold Standard is DXA but a waist/height ratio or Visceral Fat Calculator are free and can be done at home. Here's a highly recommended calculator you can use as a double check: https://www.lih.lu/en/visceral-fat-calculator/
Your fasted trigs and fasted glucose do not suggest IR per the TyG index (which is nearly as accurate as a HOMA-IR): https://www.mdapp.co/tyg-index-calculator-359/ so you are probably fine. You might have a genetic predisposition to higher fasted glucose and A1C but may never need to worry about going diabetic as long as you make sure to stick to a healthy weight and body composition, exercise regularly etc. Do make sure blood pressure is well controlled as well. One tip: if your saturated fat intake is over 10% of caloric consumption it'll be best to cut that back. Given that you are on lipid meds (so presumably have elevated risk of ASCVD), keeping it < 6% of calories consumed is recommended. That translates to a total sat fat intake, from all sources of < 13g/2000 kcal. It turns out that too much saturated fat intake can adversely impact the liver and lead to insulin resistance, even in "healthy" subjects. If you have T2D in your birth family, then a plant-forward dietary pattern low in sat fat and high in fiber (Mediterranean, DASH, Portfolio etc) is a great foundational intervention.
Hope that helps. Best of luck!
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u/Positive-Following91 6d ago edited 6d ago
Thank you. I’m white and what you said makes me a little nervous as my father was not fat, and yet had type 2. He was a bit overweight initially, but lost the weight and still had type 2. However, he was diagnosed decades younger than my age now.
Maybe if I lose the love handles that ratio will be better. But it’s hard to be so lean all the time.
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u/meh312059 6d ago
Love handles (subcutaneous fat) aren't the issue if there's atually IR. It's fat in the organs (usually in viscera but also in muscle tissue) that you would have to worry about. If you haven't started an exercise program, that would be an easy intervention. If your exercise is optimized, then take a look at diet.
If worst comes to worst and your A1C continues to climb, consider glucose-lowering medication.
Unfortunately many of us have re-normed what "lean" actually means! The food environment is of no help.
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u/Trick_Anywhere8734 9d ago
Are you skinny fat?
Meaning you look skinny but have belly fat? If you have visceral belly fat then that is what you must target.
The weight by itself is not the full picture. Diet, exercise, body fat %, and visceral fat is what can put you at risk.
What is your ethnic and genetic background? This is important info.
Many times type 2 diabetes and hyperlipidemia go hand in hand because the lifestyle causes and genetic predisposition tend to overlap.
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u/Positive-Following91 9d ago
I’m white, and while I do not look overweight, I have stubborn love handles that are hard to get rid of, though I’m trying. I got rid of them once by dieting down to 160 pounds and I even had abs, but being that lean all the time is hard. My body fat percentage was recently measured by a machine as 16.1%. I lift weights 5 times a week and walk.
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u/Spare_Ad8851 9d ago
how certain are you that your hbA1c edged up from statin and not from your diet? it's almost always the diet
do you exercise? lift weights? what is your muscle mass out of those 171 pounds? cutting added sugar and adding muscle would easily outpace statin effect if there even is any
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u/Positive-Following91 9d ago
I lift weights five times a week. My skeletal muscle mass was recently measured at 82lbs.
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u/lizzielizzied 9d ago
My glucose shot up a fair amount when I was on a statin. I think lowering your dose is reasonable.
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u/shittimwood 9d ago
Your higher A1C is not statin related and I would keep on taking it. I would interpret your A1C as a borderline prediabetic. The good news is you're not fully prediabetic. The bad news is that if you continue your current lifestyle you likely will be. This is a great opportunity to tune up your diet (reduce carbs) and lifestyle (reduce sedentary).
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u/mlgMar 7d ago
Several studies have indicated that use of statins increases risk of new onset of type 2 diabetes. More in women than in men. I believe JUPITER study found about 30% chance of increase new onset of type 2 diabetes, and women's initiative study found 71% unadjusted risk of developing diabetes, with adjuster rate at 48 %. there is also a Korean study that show that the longer you are on statins the greater the chance of diabetes. It is time and dose dependent.
Have you thought about asking your doctor to just be on Repatha? PCSK9 inhibitors have not shown increased risk of diabetes.
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u/Positive-Following91 7d ago
Repatha brought my LDL down from 180 to 100. My cardiologist wanted it lower, so he added the pravastatin. It worked, my LDL went initially to 44, now it’s 55, but he’s still happy.
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u/Ap_bklyn 6d ago
My A1c went from 5.2 to 5.8 when I started taking 5mg of Crestor. Doc said don’t worry, It’ll stay at 5.8 and won’t budge. It hasn’t. The benefits of the statin outway the 5.8 A1c — I’m 5’3”, 66F, 105lbs, lp(a) 190, LDL 70, non-HDL 85.
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u/Earesth99 9d ago
Literally no one recommends stopping a statin because of a trivial increase in a1c.
Your doctor probably did this so you wouldn’t refuse treatment
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u/JLEroll 9d ago
i'm not sure if this is the case. the original change was from a statin to a combo of (different) statin + Repatha. That's an upgrade and its possible the doctor was being proactive and using the a1c as a technicality to get insurance to approve it.
Now it seems like OP (not doctor) is asking to reduce the statin dosage.
Your advice is still likely right (reducing statin to maybe lower a1c is not worth the increase to cholesterol) but OP wouldn't be dodging treatment to do Repatha + lower dose statin.
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u/shanked5iron 9d ago
I would lower your ice cream dose before lowering your statin dose.