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CARDIOLOGY
- Publications
Practical
Guidelines For the Management of
Diabetic Dyslipidemia
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| Management
of diabetic dyslipidemia |
Priorities
for lowering lipids/lipoproteins assigned by the
American Diabetes Association |
| First
priority |
Lowering
of LDL cholesterol |
| Second
priority |
Lowering
of triglyceride levels |
| Third
priority |
Raising
levels of HDL cholesterol |
|
LDL goals recommended by the
American Diabetes Association in diabetic patients |
| Patient
Profile |
LDL
Goal |
| Pre-existing
CVD |
<
100 mg/dl |
| Absence
of CVD |
<
130 mg/dl |
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Lifestyle
Intervention
- Exercise
This is likely to provide particular benefits
for patients with type 2 diabetes, as it improves
insulin sensitivity and reduces intra-abdominal
fat, thereby reducing triglyceride and increasing
HDL levels. The American Diabetes Association
recommends aerobic exercise at 50 to 70% maximum
O2 uptake for 20 to 45 minutes, at least 3 days
per week.
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Reduction of saturated fat intake
Saturated fat should be replaced in the diet
by carbohydrate or by poly-unsaturated fat or
mono-unsaturated fat. However, mono-unsaturated
fat may result in lower triglyceride levels
and better glycemic control than carbohydrate.
- Severe
restriction of dietary fat and complete avoidance
of alcohol is recommended in case of marked
Drug
Therapy
STATINS (HMG-COA REDUCTASE INHIBITORS) e.g.
atorvastatin, simvastatin, lovastatin
- Most
effective agents for reducing LDL cholesterol
- Also
reduce triglycerides and increase HDL cholesterol
- Do
not alter glycemic control
- Recommended
as first-line agents for management of diabetic
dyslipidemia since
• lowering of LDL is first priority
• substantial evidence of statins on CHD
risk reduction is available (Table).
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Study
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Drug
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Lipid
or lipoprotein
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Percent
change
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CHD
even Reduction
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4S
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Simvastatin
20-40 mg daily
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LDL-C
Triglycerides
HDL-C
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-36%
-11%
+7%
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55%
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CARE
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Pravastatin
40 mg daily
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LDL-C
Triglycerides
HDL-C
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-28%
-14%
+5%
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25%
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LIPID
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Pravastatin
40 mg daily
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LDL-C
Triglycerides
HDL-C
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-25%
-11%
+5%
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19%
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-
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Atorvastatin
10 mg daily
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Total-C
LDL-C
Triglycerides
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-27%
-36%
-21%
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NA
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4S=Scandinavian Simvastatin Survival Study; CARE=Cholesterol
And Recurrent Events study; LIPID=Long-term Intervention
with Pravastatin in Ischaemic Disease; NA=data
not available
FIBRATES e.g. gemfibrozil, bezafibrate,
fenofibrate
- Mainly
reduce triglyceride levels
- Also
increase HDL cholesterol
- Effect
on LDL cholesterol varies with the baseline
triglyceride level.With
normal or slightly elevated triglyceride levels,
LDL cholesterol levels are lowered with fibrates,
but when baseline triglyceride levels are high,
LDL levels rise because of improved VLDL metabolism
- Increase
LDL particle size
- Do
not alter glycemic control
- Since
there is little current evidence for reduction
of CHD in diabetic patients treated with diabetes,
fibrates are not generally
used as first-line treatment for diabetic dyslipidemia.
Fibrates are used when more marked hypertriglyceridemia
is present (triglycerides > 440 mg/dl) or
as second line therapy in addition to a statin.
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| Choice
of therapy for lipid abnormalities in diabetes mellitus |
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Lipid
or lipoprotein
abnormality
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First-line
therapy
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Additional
Therapy
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| Increased
LDL cholesterol |
Statina
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Fibrate
Omega 3 fatty acids
Nicotinic acid
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| Increased
LDL cholesterol |
Statin
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Bile
acid sequestrant
Nicotinic acid
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| Increased
triglyceride |
Fibrate
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Statin
Omega 3 fatty acids
Nicotinic acid
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| Reduced
HDL cholesterol |
Statinb
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Fibrate
Nicotinic acid
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Therapeutic priority is to lower LDL cholesterol;
b Will improve ratio of LDL to HDL cholesterol.
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| Hypolipidemic
therapy: Side effects and contraindications |
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Class
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Examples
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Dosage
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Main
side effects
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Contraindications
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Statins
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Simvastatin
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5-80
mg
once daily
10-80 mg
once daily
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Gastrointestinal
disturbances,
liver enzyme elevation,
skeletal muscle
inflammation
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Hypersensitivity,
active liver disease
or unexplained
persistent elevations
of liver enzymes,
pregnancy and lactation
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Fibrates
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Gemfibrozil
Bezafibrate Fenofibrate
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1200
mg/day
400 mg daily
200 mg daily
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Gatrointestinal
disturbances, headache, itching,muscle damage,increased
risk of developing gallstones,liver
enzyme elevations
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Hypersensitivity,
hepatic or severe
renal dysfunction,
pre-existing
gall bladder disease
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Further
Reading
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Drugs 2000; 59: 1101-1111
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Am J Cardiol 1987; 59: 750-755
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Diabetes 1997; 46: 327-334
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Diabetes Care 1993; 16: 828-834
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Clinical Therapeutics 1995;17:186-202
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4th International Symposium on Multiple Risk
Factors in Cardiovascular Disease, April 23-25,
1997; Washington DC, USA.
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