Association of Statin Therapy With Prevention of Vision-Threatening Diabetic Retinopathy

Abstract

Importance: Diabetic retinopathy is the leading cause of blindness in working-age adults. Studies have suggested that statins may reduce the risk of developing diabetic retinopathy.

Objective: To investigate the association between statin therapy and the development of diabetic retinopathy in patients with diabetes and dyslipidemia.

Design, setting, and participants: This population-based cohort study, conducted among 37 894 Taiwanese patients between January 1, 1998, and December 31, 2013, used the National Health Insurance Research Database to identify patients with type 2 diabetes and dyslipidemia. Outcomes were compared between those taking statins and those not taking statins. Statistical analysis was performed from May 1 to 31, 2018.

Exposure: Statin therapy with a medication possession rate of 80% or more with no other lipid-lowering medications.

Main outcomes and measures: Any stage of diabetic retinopathy and treatments for vision-threatening diabetic retinopathy.

Results: Of 1 648 305 patients with type 2 diabetes, 219 359 were eligible for analysis over the study period, including 199 760 patients taking statins and 19 599 patients not taking statins. After propensity score matching, there were 18 947 patients in the statin group (10 436 women and 8511 men; mean [SD] age, 61.5 [10.8] years) and 18 947 patients in the nonstatin group (10 430 women and 8517 men; mean [SD] age, 61.0 [11.0] years), with a mean follow-up of 7.6 years for the statin group and 7.3 years for the nonstatin group. During the study period, 2004 patients in the statin group (10.6%) and 2269 patients in the nonstatin group (12.0%) developed diabetic retinopathy. Patients in the statin group had a significantly lower rate of diabetic retinopathy (hazard ratio [HR], 0.86; 95% CI, 0.81-0.91), nonproliferative diabetic retinopathy (HR, 0.92; 95% CI, 0.86-0.99), proliferative diabetic retinopathy (HR, 0.64; 95% CI, 0.58-0.70), vitreous hemorrhage (HR, 0.62; 95% CI, 0.54-0.71), tractional retinal detachment (HR, 0.61; 95% CI, 0.47-0.79), and macular edema (HR, 0.60; 95% CI, 0.46-0.79) than the nonstatin group, as well as lower rates of interventions such as retinal laser treatment (HR, 0.71; 95% CI, 0.65-0.77), intravitreal injection (HR, 0.74; 95% CI, 0.61-0.89), and vitrectomy (HR, 0.58; 95% CI, 0.48-0.69), along with a smaller number of the interventions (retinal lasers: rate ratio, 0.61; 95% CI, 0.59-0.64; intravitreal injections: rate ratio, 0.68; 95% CI, 0.61-0.76; and vitrectomies: rate ratio, 0.54; 95% CI, 0.46-0.63). Statin therapy was also associated with lower risks of major adverse cardiovascular events (HR, 0.81; 95% CI, 0.77-0.85), new-onset diabetic neuropathy (HR, 0.85; 95% CI, 0.82-0.89), and new-onset diabetic foot ulcers (HR, 0.73; 95% CI, 0.68-0.78).

Conclusions and relevance: Statin therapy was associated with a decreased risk of diabetic retinopathy and need for treatments for vision-threatening diabetic retinopathy in Taiwanese patients with type 2 diabetes and dyslipidemia.

Figure 1.. Selection of Study Patients

^aA serum low-density lipoprotein cholesterol level of less than 100 mg/dL or a serum total cholesterol level of 160 mg/dL (to convert to millimoles per liter, multiply by 0.0259). ^bIncluding fibrates, nicotinic acid and derivatives, bile acid sequestrants, and cholesterol absorption inhibitors.

Figure 2.. Cumulative Incidence of Outcomes

A, All diabetic retinopathy in the statin and nonstatin groups (hazard ratio [HR], 0.86; 95% CI, 0.81-0.91; P < .001). B, Nonproliferative diabetic retinopathy (HR, 0.92; 95% CI, 0.86-0.99; P = .03). C, Proliferative diabetic retinopathy (HR, 0.64; 95% CI, 0.58-0.70; P < .001). D, Undergoing retinal laser treatment (HR, 0.71; 95% CI, 0.65-0.77; P < .001).

Figure 3.. Cumulative Incidence of All Diabetic Retinopathy

All diabetic retinopathy in the nonstatin group and in the statin group with a medication possession rate (MPR) of lower than 80% and in the statin group with an MPR of 80% or higher. P < .001 for trend of competing risk model.