The most common pattern of dyslipidemia among subjects with diabetes is characterized by elevated triglyceride and decreased HDL-cholesterol levels; mean levels of total cholesterol and low-density lipo-protein (LDL)-cholesterol often are not different in diabetic and nondiabetic subjects. With respect to LDL-cholesterol, however, diabetic individuals have a greater proportion of the particularly atherogenic small, dense LDL particles.132 Lipid management aimed at lowering LDL-cholesterol has been shown to reduce macrovascular disease and mortality in diabetic individuals with and without overt CAD and without respect to baseline cholesterol levels. According to the ADA, the primary goal of therapy is an LDL-cholesterol level lower than 100 mg/dL (<2.6 mmol/L) for all subjects with diabetes (see Table 2-9).7 The target HDL-cholesterol levels are greater than 40 mg/dL (1.03 mmol/L) in men and >50 mg/dL (1.29 mmol/L) in women. With respect to triglycerides, levels should be lower than 150 mg/dL (1.7 mmol/L).7 In the secondary CV prevention setting, the use of statins is associated with a significant reduction in total mortality and in major CVD events.133 The absolute clinical benefit achieved by lipid lowering may be greater in diabetic than in nondiabetic subjects.
With respect to primary prevention, the MRC/BHF Heart Protection Study looked at simvastatin treatment over a 5-year period, and the Collaborative Atorvastatin Diabetes Study (CARDS) used atorva-statin over a 4-year period; both demonstrated that, among diabetic individuals with no history of coronary events, statin treatment reduced major coronary events significantly.134,135 Because fibrates effectively reduce triglycerides and increase HDL-cholesterol levels, they may be especially useful in diabetes-associated dyslipidemia. In a subgroup analysis of the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study, the administration of this agent to patients with no previous CV disease and to younger (<65 years) individuals was associated with significant reductions in total CV events (19% and 20%, respectively).136 However, within the entire study population of 9795 diabetic patients, fenofi-brate did not reduce significantly the primary end point of CAD death and nonfatal MI. Therefore, the use of this drug class should be considered only in the presence of insufficient lipid control with statins. With respect to the combination of statins and eziti-mibe, outcome data in the diabetic population are lacking. Treatment of dyslipidemia in diabetic patients should not be limited to prescription of
Table 2-10. Recommended Treatment of Hypertension in Subjects with Diabetes
ACE-I, ARB, diuretics, or
P-blockers ACE-I or ARB (if neither is tolerated, non-dihydropyridine calcium channel blockers) P-Blockers and ACE-I ACE-I
statins. Regular physical activity and weight loss lead to decreased triglyceride and increased HDL-choles-terol levels. Improved glycemic control mainly lowers triglyceride levels and has only a modest effect on raising HDL. Alcohol consumption should be reduced for triglyceride levels greater than 175 mg/dL (2 mmol/L).
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All you need is a proper diet of fresh fruits and vegetables and get plenty of exercise and you'll be fine. Ever heard those words from your doctor? If that's all heshe recommends then you're missing out an important ingredient for health that he's not telling you. Fact is that you can adhere to the strictest diet, watch everything you eat and get the exercise of amarathon runner and still come down with diabetic complications. Diet, exercise and standard drug treatments simply aren't enough to help keep your diabetes under control.