Reducing cardiovascular risk in patients with type 2 diabetes: management of dyslipidemia

Cardiovascular disease (CVD) remains the leading cause of death in patients with diabetes mellitus, accounting for 50% of all deaths. Dyslipidemia is an important modifiable risk factor in diabetic patients and represents a key area for intervention in these patients. Diabetic patients have a lipid profile characterized by low high-density lipoprotein cholesterol (HDL-C) levels and an increase in triglyceride levels. Diabetics have increased numbers of low-density lipoprotein cholesterol (LDL-C) particles but with a shift to smaller, denser LDL-C particles. The net effect is that patients with type 2 diabetes do not have substantially higher LDL-C concentrations than patients without diabetes. Lifestyle modification with reductions in saturated fat, trans fat, and cholesterol intake, weight loss (if indicated), and increased physical activity are initially recommended to improve the lipid profile. In addition, enhanced glycemic control can improve plasma lipid levels, especially in patients with very high triglycerides. Statin therapy should be added to lifestyle therapy, regardless of baseline lipid levels for diabetic patients without overt CVD and for diabetics >40 years who have 1 or more other cardiovascular risk factors. For lower-risk patients without overt CVD <40 years of age, statin therapy should be considered in addition to lifestyle therapy if the LDL-C remains above 100 mg/dL or in those with multiple risk factors. In individuals without overt CVD, the primary LDL-C goal is <100 mg/dL. In individuals with overt CVD, a lower LDL-C goal <70 mg/dL, using a high dose of a statin is an option. If drug-treated patients do not reach their LDL-C targets on maximal tolerated statin therapy, a reduction in LDL-C of 30% to 40% from baseline is an acceptable alternative goal. Triglyceride levels <150 mg/dL and HDL-C >40 mg/dL in men and >50 mg/dL in women are desirable. If triglyceride and HDL-C targets are not achieved using statins, the use of a statin and other lipid-lowering therapy may be considered, but combination therapy has not been shown to reduce the risk of adverse cardiovascular events to an extent greater than that of a statin alone. (Formulary. 2010;45:124-134.)