Dyslipidemia

Canadian Diabetes Association Clinical Practice Guidelines Expert Committee

G.B. John Mancini MD, FRCPC, FACP, FACC Robert A. Hegele MD, FRCPC, FACP Lawrence A. Leiter MD, FRCPC, FACP, FAHA

  • Key Messages
  • Recommendations
  • Figures
  • Highlights
  • Full Text
  • References

Key Messages

  • The beneficial effects of lowering low-density lipoprotein cholesterol (LDL-C) with statin therapy apply equally well to people with diabetes as to those without the disease.
  • The primary treatment goal for people with diabetes is LDL-C ≤2.0 mmol/L, which is generally achievable with statin monotherapy.
  • Achievement of the primary goal may require intensification of lifestyle changes and/or statin therapy and, on occasion, the addition of other lipid-lowering medications.

Highlights of Revisions

  • The chapter provides a more precise definition of people who should receive statin therapy as per the Vascular Protection chapter, (p. S322).
  • The total cholesterol to high density lipoprotein (TC/HDL) ratio as a target has been eliminated, as has the option to start a statin or fibrate in those with triglycerides 4.5 to 10.0 mmol/L.
  • A new recommendation to not add fibrate or niacin routinely to statin therapy for cardiovascular risk reduction has been added.

Recommendations

  1. 1.A fasting (8-hour fast) lipid profile (TC, HDL-C, TG, and calculated LDL-C) or nonfasting lipid profile (apo B, non-HDL-C calculation) should be measured at the time of diagnosis of diabetes. If lipid-lowering treatment is not initiated, (see Vascular Protection chapter. p. S100. for indications) repeat testing is recommended yearly. More frequent testing (every 3–6 months) should be performed after treatment for dyslipidemia is initiated [Grade D, Consensus].
  2. 2.For patients with indications for lipid-lowering therapy (see Vascular Protection chapter, p. S100), treatment should be initiated with a statin [Grade A, Level 1 (1,2), to achieve LDL-C ≤2.0 mmol/L [Grade C, Level 3 (3)].
  3. 3.In patients achieving goal LDL-C with statin therapy, the routine addition of fibrates or niacin for the sole purpose of further reducing CV risk should not be used [Grade A, Level 1 (4,5)].
  4. 4.For individuals not at LDL-C target despite statin therapy as described above, a combination of statin therapy with second-line agents may be used to achieve the LDL-C goal [Grade D, Consensus].
  5. 5.For those who have serum TG >10.0 mmol/L, a fibrate should be used to reduce the risk of pancreatitis (Grade D, Consensus) while also optimizing glycemic control and implementing lifestyle interventions (e.g. weight loss, optimal dietary strategies, reduction of alcohol).

Abbreviations:
apo B, apolipoprotein B; CV, cardiovascular; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; TC,  total cholesterol; TG, triglyceride.

References

  1. Collins R, Armitage J, Parish S, et al, Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5963 people with diabetes: a randomised placebo-controlled trial. Lancet 2003; 361:2005-16.
  2. Colhoun HM, Betteridge DJ, Durrington PN, et al, CARDS Investigators. Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo-controlled trial. Lancet 2004;364:685-96.
  3. Cholesterol Treatment Trialists’ (CTT) Collaborators, Kearney PM, Blackwell L, Collins R, et al. Efficacy of cholesterol-lowering therapy in 18,686 people with diabetes in 14 randomised trials of statins: a meta-analysis. Lancet 2008;371: 117-25.
  4. The ACCORD Study Group. Effects of combination lipid therapy in type 2 diabetes mellitus. N Engl J Med 2010;362:1563-74.
  5. The AIM-HIGH Investigators. The role of niacin in raising high-density lipoprotein cholesterol to reduce cardiovascular events in patients with atherosclerotic cardiovascular disease and optimally treated low-density lipoprotein cholesterol: rationale and study design. The Atherothrombosis Intervention in Metabolic syndrome with low HDL/high triglycerides: Impact on Global Health outcomes (AIM-HIGH). Am Heart J 2011;161:471-7.

 

Reproduced with permission from Canadian Journal of Diabetes © 2013 Canadian Diabetes Association. To cite this article, please refer to For citation.

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