DYSLIPIDEMIA IN ADULTS WITH DIABETES*

1
DYSLIPIDEMIA IN ADULTS WITH DIABETES

• 2003 Clinical Practice Guidelines
• for the Prevention and Management
• of Diabetes in Canada

Updated in 2006. Leiter LA, et al for the CDA
CPG Expert Committee. Can J Diabetes.
200630230-240.
2
DYSLIPIDEMIA

• Diabetes is associated with high risk for
  vascular disease, and aggressive lipid management
  is generally necessary. Attention to the full
  lipid profile is required, as hypertriglyceridemia
  and low HDL-cholesterol are particularly common.
• All patients should be assessed for their risk of
  a vascular event. Most patients with diabetes are
  at high risk. Younger patients with a shorter
  duration of diabetes and without other risk
  factors and without complications of diabetes
  would be considered at lower risk.

CDA CPG Expert Committee. Can J Diabetes.
200630230-240.
3
DYSLIPIDEMIA

• Achieving an LDL-C of lt2.0 mmol/L is the primary
  goal of therapy.
• Once the LDL-C goal has been attained,
  consideration to achieving the secondary target
  of an TC/HDL-C ratio of lt4.0.
• The vast majority of patients with be able to
  attain the LDL-C goal on statin therapy.
• Although not formal goals of therapy, optimal TG
  is lt1.5 mmol/L and apo B is 0.9 g/L
• Lifestyle modification should be seen as an
  important adjunct to, not substitution for,
  pharmacologic therapy.

CDA CPG Expert Committee. Can J Diabetes.
200630230-240
4
DYSLIPIDEMIA

• Effective risk reduction requires a multifaceted
  approach targeting all risk factors
• - Obesity
• - Hypertension
• - Hyperglycemia
• - Dsylipidemia
• - Microalbuminuria
• - Smoking
• - Sedentary lifestyle
• - Diet

CDA CPG Expert Committee. Can J Diabetes.
200630230-240
5
FIRST-LINE Rx FOR DYSLIPIDEMIA

• Statins are the drugs of choice to lower LDL-C.
• At higher doses, statins have modest TG-lowering
  effects and HDL-C-raising effects
• - atorvastatin (Lipitor)
• - fluvastatin (Lescol)
• - lovastatin (Mevachor and generic)
• - pravastatin (Pravachol and generic)
• - rosuvastatin (Crestor)
• - simvastatin (Zocor and generic)

CDA CPG Expert Committee. Can J Diabetes.
200630230-240
6
LIPID TARGETS
LIPID TARGETS FOR ADULTS WITH DM AT HIGH RISK FOR
CVD
INDEX TARGET VALUE
Primary target LDL-C lt2.0 mmol/L
Secondary target TC/HDL-C ratio lt4.0
Clinical judgment should be used to decide
whether additional LDL-C lowering is required for
patients with an on-treatment LDL-C of 2.0 to 2.5
mmol/L.
CDA CPG Expert Committee. Can J Diabetes.
200630230-240
7
OTHER DRUGS FOR DYSLIPIDEMIA
Drug class Principal effects Considerations
Bile acid sequestrants Lower LDL-C GI intolerability May raise TG
Cholesterol absorption inhibitor Lower LDL-C Less effective than statins as monotherapy
Fibrates Lower TG Variable effect on LDL-C Highly variable effect on HDL-C May increase creatinine homocysteine Do not use gemfibrozil with statins
Nicotinic acid Raise HDL-C Lower TG Lower LDL-C Can cause worsening of glycemic control Extended-release has similar efficacy better tolerability than immediate-release Do not use long-acting niacin
CDA CPG Expert Committee. Can J Diabetes.
200630230-240
8
DYSLIPIDEMIA RECOMMENDATIONS

• People with type 1 or type 2 diabetes should be
  encouraged to adopt a healthy lifestyle to lower
  their risk of CVD. This entails adopting healthy
  eating habits, achieving and maintaining a
  healthy weight, engaging in regular physical
  activity and smoking cessation Grade D,
  Consensus.

CDA CPG Expert Committee. Can J Diabetes.
200630230-240
9
DYSLIPIDEMIA RECOMMENDATIONS

• A fasting lipid profile (TC, HDL-C, TG and
  calculated LDL-C) should be conducted at the time
  of diagnosis of diabetes and then every 1 to 3
  years as clinically indicated. More frequent
  testing should be done if treatment for
  dyslipidemia is initiated Grade D, Consensus.

CDA CPG Expert Committee. Can J Diabetes.
200630230-240
10
DYSLIPIDEMIA RECOMMENDATIONS

• Most adults with type 1 or type 2 diabetes should
  be considered at high risk for vascular disease
  Grade A, Level 1, Level 2. The exceptions are
  younger adults with shorter duration of disease
  and without complications of diabetes (including
  established CVD) and without other CVD risk
  factors Grade A, Level 1. A computerized risk
  engine (e.g. UKPDS risk engine, Cardiovascular
  Life Expectancy Model) can be used to estimate
  vascular risk Grade D, Consensus.

CDA CPG Expert Committee. Can J Diabetes.
200630230-240
11
DYSLIPIDEMIA RECOMMENDATIONS

• Adults at high risk of a vascular event should be
  treated with a statin to achieve an LDL-C lt2.0
  mmol/L Grade A, Level 1, Level 2. Clinical
  judgment should be used to determine whether
  additional LDL-C lowering is required for adults
  with an on-treatment LDL-C of 2.0 to 2.5 mmol/L
  Grade D, Consensus.

CDA CPG Expert Committee. Can J Diabetes.
200630230-240
12
DYSLIPIDEMIA RECOMMENDATIONS

• In adults, the primary target of therapy is LDL-C
  Grade A, Level 1, Level 2 the secondary target
  is TC/HDL-C ratio Grade D, Consensus.

CDA CPG Expert Committee. Can J Diabetes.
200630230-240
13
DYSLIPIDEMIA RECOMMENDATIONS

• In adults, if the TC/HDL-C ratio is gt4.0,
  consider strategies to achieve a TC/HDL-C ratio
  of lt4.0 Grade D, Consensus, such as improved
  glycemic control, intensification of lifestyle
  (weight loss, physical activity, smoking
  cessation) and, if necessary, pharmacologic
  interventions Grade D, Consensus.

CDA CPG Expert Committee. Can J Diabetes.
200630230-240
14
DYSLIPIDEMIA RECOMMENDATIONS

• In adults with serum TG gt10.0 mmol/L despite best
  efforts at optimal glycemic control and other
  lifestyle interventions (e.g. weight loss,
  restriction of refined carbohydrates and
  alcohol), a fibrate should be prescribed to
  reduce the risk of pancreatitis Grade D,
  Consensus. For those with moderate hyper-TG (4.5
  to 10.0 mmol/L), either a statin or fibrate can
  be attempted as first-line therapy, with the
  addition of a second lipid-lowering agent of a
  different class if target lipid levels are not
  achieved after 4 to 6 months on monotherapy
  Grade D, Consensus.

CDA CPG Expert Committee. Can J Diabetes.
200630230-240
15
DYSLIPIDEMIA RECOMMENDATIONS

• For adult patients not at target(s), despite
  optimally dosed first-line therapy as described
  above, combination therapy can be considered.
  Although there are as yet no completed trials
  demonstrating clinical outcomes in adults
  receiving combination therapy, pharmacologic
  treatment options include (listed in alphabetical
  order)
• - Statin plus ezetimibe Grade B, Level 2
• - Statin plus fibrate Grade B, Level 2, Level 3
• - Statin plus niacin Grade B, Level 2

CDA CPG Expert Committee. Can J Diabetes.
200630230-240
16
DYSLIPIDEMIA RECOMMENDATIONS

• In adults, plasma apo B can be measured, at the
  physicians discretion, in addition to LDL-C and
  TC/HDL-C ratio, to monitor adequacy of
  lipid-lowering therapy in the high-risk patient
  Grade D, Consensus. Target apo B should be 0.9
  g/L Grade D, Consensus.

CDA CPG Expert Committee. Can J Diabetes.
200630230-240