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Dyslipidemia Management in Adults
With Diabetes
(Ͻ40 mg/dl), and modestly elevated trig-lycerides (4).
of alcohol or estrogen may also contribute LIPOPROTEINS BY
DYSLIPIDEMIA — The rationale for
the treatment of diabetic dyslipidemia is ACTIVITY — There is little evidence
from clinical trials to determine the effect FACTORS FOR CVD — Available
of different dietary interventions on the lipid abnormalities are associated with in- With Diabetes” (1). Type 2 diabetes is as- servational studies suggest that patients patients both with and without diabetes.
risk of cardiovascular disease (CVD).
physical activity have fewer cardiovascu- PREVALENCE OF
DIABETES — The most common pat-
tern of dyslipidemia in patients with type CLINICAL TRIALS OF LIPID
activity will lead to decreased triglycer- 2 diabetes patients is elevated triglyceride LOWERING IN DIABETIC
ides and increased HDL cholesterol levels levels and decreased HDL cholesterol lev- SUBJECTS — The recently completed
Heart Protection Study has been the larg- lesterol levels. Patients with diabetes who lesterol in those with type 2 diabetes is not significantly different from that in those scription for MNT and for increased phys- individuals who do not have diabetes.
ical activity. The proportion of saturated dl. In this trial, patients with diabetes as- fat in the meal plan should be reduced.
lesterol may be present. In particular, pa- tients with diabetes tend to have a higher compensate for the reduction in saturated duction was similar across all LDL subcat- fat. Some (but not all) studies suggest that egories examined, including patients with risk of cardiovascular events. Insufficient lower pretreatment LDL cholesterol levels have better metabolic effects than a high- carbohydrate diet, although other experts tions on the measurement of particle size fied vascular disease (3). Numerous other fication may make weight loss more diffi- cult in obese patients with diabetes.
lipid levels may be affected by factors un- related to glycemia or insulin resistance, typically reduces LDL cholesterol 15–25 gemfibrozil. In the Veterans Affairs High- mg/dl (0.40 – 0.65 mmol/l). Lifestyle in- tervention may be evaluated at regular in- t e r v a l s , w i t h c o n s i d e r a t i o n o f associated with a 24% decrease in cardio- vascular events in diabetic subjects with ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● MODIFICATION OF

The recommendations in this paper are based on the evidence reviewed in the following publication:Management of dyslipidemia in adults with diabetes (Technical Review). Diabetes Care 21:160 –178, 1998.
The initial draft of this paper was prepared by Steven M. Haffner, MD. This paper was peer-reviewed, AGENTS — Interventions to improve
modified, and approved by the Professional Practice Committee and the Executive Committee, November glycemia usually lower triglyceride levels 1997. Most recent review/revision, 2003.
Abbreviations: ADA, American Diabetes Association; CHD, coronary heart disease: CVD, cardiovascular
disease; MNT, medical nutrition therapy; NCEP, National Cholesterol Education Program.
2004 by the American Diabetes Association.
DIABETES CARE, VOLUME 27, SUPPLEMENT 1, JANUARY 2004 Dyslipidemia Management
prevention would not be able to “save” Table 1—Order of priorities for treatment of
large numbers of these diabetic patients.
diabetic dyslipidemia in adults
mmol/l), a variety of treatment strategies LIPOPROTEIN THERAPY — N o
the effect of implementing different lipid treatment goals, including the question of tection Study (3), in people with diabetes over the age of 40 years with a total cho- lesterol Ն135 mg/dl, suggest that statin for patients with complex lipid abnormal- ities. Current trials are examining these mic control in patients with diabetes and of LDL cholesterol is considered the first dyslipidemia for a number of reasons (1).
High-dose statins (in those who also have patients. If values are at low-risk levels factor for CVD in people with diabetes.
The initial therapy for hypertriglyceride- mia is lifestyle intervention with weight loss, increased physical activity, restricted intake of saturated fats, incorporation of cholesterol levels for adults with diabetes lesterol levels are Ͼ40 mg/dl (1.02 mmol/ l); and triglyceride levels are Ͻ150 mg/dl [11.3 mmol/l]), severe dietary fat restric- Decision for treatment of high LDL before elevatedtriglyceride is based on clinical trial data indicating safety as well as efficacy of the available agents. The combination of statins with nicotinic acid, feno- of elevated LDL cholesterol generally fol- fibrate, and especially gemfibrozil may carry an in- recommendations for patients with triglyceride lev- sued. Insulin therapy (alone or with insu- ference (9), with the following caveats.
lin sensitizers) may also be particularly effective in lowering triglyceride levels.
ated after lifestyle intervention has been both triglyceride and LDL cholesterol. Fe- mic control (or at least after the achieve- Ͼ100 mg/dl, pharmacological therapy be possible), the physician should con- with statin therapy, and may be useful inshould be initiated at the same time that sider adding a fibric acid and/or niacin.
therapy is dependent on the clinician’s diabetes, it is difficult to raise HDL cho- therapy are 1) an LDL cholesterol level of Ն130 mg/dl (3.35 mmol/l) and 2) a goal mmol/l), strong consideration should be intervention. Nicotinic acid, whichof Ͻ100 mg/dl (2.60 mmol/l) for LDL given to pharmacological treatment of tri- glyceridemia to minimize the risk of pan- with diabetes, and fibrates can effectively statins are moderately effective in reduc- doses of nicotinic acid (Յ2 g nicotinic ac- ing triglyceride levels in markedly hyper- a large proportion of diabetic patients die Ն300 mg/dl [3.40 mmol/l]). Gemfibrozil deterioration may be easily remediable by before they reach the hospital, a preven- should not be initiated alone in diabetic adjustment of hypoglycemic medications.
smoking cessation, increased physical ac- CVD. It seems reasonable that if patients lipid profile in patients with diabetes.
tivity) may increase HDL cholesterol.
with type 1 diabetes have LDL cholesterol ● Patients who do not achieve lipid goals apy may be initiated. Several options are atins with nicotinic acid, fenofibrate, and sively treated. Improved glycemic control especially gemfibrozil has been associated with increased risk of myositis, although the risk of clinical myositis (as opposed to type 2 diabetes for reduction of CVD (e.g., ● Lowering LDL cholesterol with a statin elevated creatinine phosphokinase levels) is associated with a reduction in cardio- ● In people with diabetes over the age of bination of gemfibrozil and a statin or in CONCLUSIONS
patients with renal disease. Combinations of statins with nicotinic acid and fibrates the risk of CVD in patients with diabetes.
are extremely effective in modifying dia- Primary therapy should be directed first at ● In children and adolescents with diabe- lowering LDL levels. The goal is to reduce LIPID-LOWERING AGENTS
ioral interventions is also an LDL choles- initial pharmacological therapy should be ● Lower triglycerides to Ͻ150 mg/dl (1.7 to use statins. A cholesterol absorption in- hibitor, a resin, niacin, or fenofibrate may doses of statins may be moderately effec- goal or in the case of statin intolerance.
● Lowering triglycerides and increasing combination therapy. With the use of sta- a fibric acid, such as fenofibrate, or niacin lar events in patients with clinical CVD, very high-dose statin therapy (e.g., simva- ● Combination therapy using statins and statin 80 mg or atorvastatin 40 or 80 mg) lifestyle intervention. Additional triglyc- eride lowering can be achieved with fibric restricted to patients with both high LDL References
1. Haffner SM: Management of dyslipidemia goals have been achieved, laboratory fol- RECOMMENDATIONS
low-up every 6 –12 months is suggested.
view). Diabetes Care 21:160 –178, 1998 2. Turner RC, Millns H, Neil HA, Stratton CONSIDERATIONS IN THE
● In adult patients, test for lipid disorders RR: Risk factors for coronary artery dis- TREATMENT OF ADULTS
mellitus (UKPDS 23). BMJ 316:823– 828, mal levels of lipoproteins, unless they are may get a lipid profile very similar to that ised placebo-controlled trial. Lancet 361: tion of lipoproteins may be abnormal, but 4. Rubins HB, Robins SJ, Collins D, Fye CL, the effects of these compositional abnor- ● Lifestyle modification focusing on the malities in relation to CVD are unknown.
There is relatively little observational data no clinical trials relating lipoproteins to DIABETES CARE, VOLUME 27, SUPPLEMENT 1, JANUARY 2004 Dyslipidemia Management
on Detection, Evaluation and Treatment of tervention Trial Study Group. N Engl 5. American Diabetes Association: Nutrition 9. American Diabetes Association: Detection disease: a statement for healthcare profes- and management of lipid disorders in dia- betes (Position Statement). Diabetes Care betes (Consensus Statement). Diabetes Care 6. American Diabetes Association: Physical 8. NCEP Expert Panel on Detection, Evalua- Pyo¨ra¨la¨ K, Laakso M: Mortality from cor- Statement). Diabetes Care 27:S58 –S62, onary heart disease in subjects with type 2 terol in Adults: Executive Summary of the diabetes and in nondiabetic subjects with and without prior myocardial infarction.


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