Controversies in the Evaluation and Management of Dyslipidemia in Patients with Diabetes
Amy Sanghavi Shah, MD, MS
Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA Dan Streja, MD
David Geffen School of Medicine, UCLA, Los Angeles, CA, USA Savitha Subramanian, MD
University of Washington, Seattle, WA, USA Lisa Tannock, MD
University of Kentucky, Lexington VA Medical Center, Lexington, KY, USA
Diabetic dyslipidemia is a constellation of lipoprotein abnormalities characterized by increased triglycerides, decreased high-density lipoprotein-cholesterol levels, and an increase in small dense low-density lipoprotein (LDL). The condition is common in patients with type 2 diabetes, affecting over two-thirds of patients. Moreover, diabetes is a significant risk factor for atherosclerotic cardiovascular disease (ASCVD), and elevated LDL-cholesterol is a major predictor of ASCVD events in patients with diabetes. Thus, there is considerable interest in adequate treatment of dyslipidemia in patients with type 2 diabetes. These presenters overviewed current knowledge of management of patients with diabetes and dyslipidemia.
Type 2 diabetes has become much more common in adolescents in recent decades and is now present in a significant proportion of people.
Youth with diabetes are also at higher risk of faster progression to insulin dependence, diabetic ketoacidosis, and autoimmune conditions.
Lipids tend to be more elevated in those with type 2 diabetes vs. those with type 1 diabetes, and patients with diabetes and dyslipidemia are also at higher risk of diabetes-associated complications such as retinopathy and neuropathy.
Screening for dyslipidemia should be performed at diagnosis in those with type 2 diabetes and after the age of 10 years in those with type 1 diabetes.
Statins are the mainstay of treatment, aiming for a target LDL-cholesterol of <100 mg/dL, triglycerides <150 mg/dL, and HDL-cholesterol >35 mg/dL.
Importantly, statins have no effect on growth and development of adolescents.
The advantages of treating dyslipidemia include lowering CV risk and all-cause mortality.
On the other hand, children would be subjected to lifelong therapy and there are little effects on arterial stiffness or endothelial function, together with the potential for drug-related side effects.
Thus, clinicians should tailor management on an individualized basis, considering both the pros and cons of therapy.
In older patients with diabetes and without CV disease, current guidelines suggest that persons who are already on statins should remain on them.
Moderate-intense statin therapy should be given to individuals with clinical ASCVD.
While therapy should be discussed with the patient before initiating a statin, it should also be pointed out that intensive statin therapy appears to be associated with a reduction in the risk of major CV events even in the elderly.
However, there may be less benefit in those over the age of 75 years.
Several features should be discussed before recommending a statin.
These include the presence of comorbidities and overall prognosis, polypharmacy, and patient preferences.
Furthermore, the perceived quality of life is an increasingly important aspect, as well as level of cognitive impairment and family opinions.
Thus, the patient needs to be closely evaluated, and the risks of evidence-based therapy discussed.
The physician should also explain the perceived risk vs. benefit ratio to the patients and/or family.
Elevated triglycerides in the presence of LDL-cholesterol that is on target remains somewhat of a clinical dilemma.
There are concerns over whether this condition should be treated, and if so how should this be approached.
Data from NHANES have shown that hypertriglyceridemia is very common, and present in roughly 25% of individuals.
In large meta-analyses, elevated triglycerides have been associated with increased risk for CV disease, with a similar impact on men and women, appearing to increase the risk for mortality by about 10%.
Triglycerides are indeed an independent risk factor for ASCVD.
With mild-moderately elevated triglycerides, the goal is to prevent clinical CV events, mainly using statin therapy.
Physicians should look for both primary and secondary causes of elevates triglycerides, such as hypothyroidism, excess alcohol consumption, and weight gain.
Lifestyle changes should be recommended when appropriate, and when needed fibrates, fish oil and niacin can be considered.
Statins are not generally first-line therapy to lower triglycerides.
Several newer agents are under development and clinical trials are underway to evaluate their efficacy and safety.
Of note, icosapent ethyl recently received FDA approval for reduction of triglycerides in adults with severe hypertriglyceridemia.
Jose C. Florez, MD, PhD
Chair, ADA Scientific Sessions Meeting Planning Committee
The 79th American Diabetes Association’s Scientific Sessions were held in San Francisco, California from June 7-11, 2019. The meeting was attended by over 15,000 professional attendees from 115 countries, … [ Read all ]
Presented by: Alison B. Evert, MD; Janice MacLeod, MA, RDN, CDE; William S. Yancy, Jr., MD, MHS; W. Timothy Garvey, MD; Ka Hei Karen Lau, MS, RD, LDN, CDE; Christopher D. Gardner, PhD; Kelly M. Rawlings, MS