Management of Diabetic Dyslipidemia: Beyond LDL

Friday, August 12, 2005

Breakout Session

Speaker
Judith Hsia, MD

Reported by Joelle Escoffery, PhD

Diabetes is considered a cardiovascular risk equivalent. Appropriate management of diabetic dyslipidemia is an important strategy to reduce the risk of macrovascular complications. Clinical outcomes research supports the use of statins for both primary prevention and secondary prevention. The Collaborative Atorvastatin Diabetes Study (CARDS) demonstrated a significant effect on the primary prevention of cardiovascular disease, and the Treating to New Targets (TNT) study demonstrated the efficacy of high dose statin therapy for the secondary prevention of cardiovascular disease among people without diabetes. Whether or not the findings from this study should be generalized to patients with diabetes (a cardiovascular risk equivalent) has not been fully answered. The available research also suggests that there is no cutoff point for LDL cholesterol. Stated differently, there does not appear to be any level of LDL cholesterol that is too low. For patients who have difficulty tolerating statin therapy, a number of alternative approaches are available. One strategy is to try a different member of the drug class to determine if it might be better tolerated. An alternative approach is to give a lower dose of a longer acting statin every other day to determine if tolerability is improved at a lower dose.

To address persistently low HDL levels, both niacin and fibrate treatment have been shown to be effective for increasing HDL and improving outcomes. For triglyceride elevations, the underlying cause of elevated triglycerides should be considered (eg, alcohol use, overweight, high carbohydrate diet, certain medical conditions and therapies, or certain types of genetic dyslipidemia). If pharmacologic therapy is needed in addition to behavior change, both fenofibrate and gemfibrozil have been shown to reduce triglycerides by 30% to 40%.

Although there is very little outcomes data regarding the use of combination therapy, the rigorous targets and polypharmacy required to treat not only dyslipidemia but also blood pressure abnormalities make this approach attractive. Although combination therapy is generally considered to be safe, one point to consider when initiating combination therapy is the risk of muscle problems, including myalgia (eg, muscle symptoms without elevated creatine kinase [CK]), myopathy (eg, muscle symptoms with elevated CK), and rhabdomyolysis (eg, muscle symptoms with markedly increased CK on the order of 10 times greater than normal). A baseline CK measurement is recommended, but monitoring CK is unlikely to provide useful information due to normal fluctuations. Additionally, a baseline measure of muscle symptoms using a standardized self-report measure may also be a beneficial clinical tool.