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Hyperlipidemia Management in T2DMChanging Diabetes Mellitus to
Diabetes Lipidus
Dr.Wehad ALTourahConsultant Internist, Assistant Director
Internal Medicine Residency training ProgramFRCP(London),KBIM
Amiri Hospital
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OutlineCases
Epidemiology and cardiovascular risk
Lipid pattern & Target in T2DM
Screening
CV Risk Stratification
Treatment Options: Statins,Fibrates,Niacin,Ezetimibe,Omega-3 FA
Combination Treatment
Drug Monitoring
Statin and DM
Future Research
Conclusion
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Case 1
45 years-old gentleman
T2DM for 3 years,
No other significant history
Med.: Metformin 1gm /BID
BMI 30
Bp 120/80
Total Cholesterol 7mmol/L
LDL-C:2.6 mmol/L
HDL-C:1.0 mmol/L
TG: 2.0 mmol/L
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Case1
What will be your primary lipid target :
LDL-C?
HDL-C?
TG?
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Case 245 years- old gentleman
Current smoker,T2DM for 5 years, hypertension for 10 years
He is on lisonpril 10mg OD, metformin 1 gm BID
BMI 28
Blood pressure: 135/85 mmHg
HA1C 6.5%
Total cholesterol: 5 mmol/L
LDL-cholesterol: 2.6 mmol/L
HDL-cholesterol: 1.2 mmol/L
Triglycerides: 2.0 mmol/L
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Would You Initiate a lipid lowering agent in This
Patient?
OR
Would you advise non-pharmacological
Treatment?
Case 2
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Case 3
50 years-old lady
T2DM for 12 years, Hypertension, non-smoker
Meds: metformin 1gm BID, lisinopril 20mg/day,
simvastatin10mg/day
BMI 26.5
Bp: 135/85 mmHg
Total cholesterol: 4.7 mmol/l
LDL-cholesterol: 2.7 mmol/L
HDL-cholesterol: 1.0 mmol/L
Triglycerides: 2.4 mmol/L
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Would you Intensify This Patient’s Statin?
OR
Would you change her statin to more potent
agent?
Case 3
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Case 4
65year-old lady,
T2DM, PCI for STEMI 6 months ago
no current CV symptoms
Meds: ASA, clopidogrel, lisinopril, atorvastatin 80 mg/day
BMI 29.0
Blood pressure: 125/85 mmHg
Total cholesterol: 3.1 mmol/L
LDL-cholesterol: 0.9 mmol/L
HDL-cholesterol: 0.9 mmol/L
Triglycerides: 3.4 mmol/L
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Case 4
Would you decrease this patient’s statin dose?
ORWould you add a fibrate?
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Case 5
50 year-old lady
T2DM 5 years, Hypertension 5 years
Had pain in her arms and legs for 6 months
Meds: Lisinopril 10mg/d, atorvastatin 20mg/d, aspirin 75mg/d
LFT:N
CK:700 (40-176 IU/L)
Total cholesterol:4.0mmol/L
LDL-C:1.8mmol/L
HDL-C:0.9mmolL
TG:2.0mmol/L
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Case 5
What will be your Approach to Solve this patient’s problem?
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DM is a Huge Burden
IDF Diabetes Atlas, 6th edition
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Top 10 countries/territories for prevalence(%) of diabetes
(20-79),2013
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Dm and CVD
Dm is Strong risk Factor for CAD:DM=CHD
IDF 2013
T2DM is associated with a marked risk of CVD. Individuals with DM have an absolute risk of major coronary events similar to that on nondiabetic individuals with established coronary heart disease
Medescape.Treating Dyslipidemia: Recommendations for T2DM 27/9/13
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The risk for CVS death is ↑2-3 fold in T2DM.
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Prevalence of Dyslipidemia is high in Type 2 Diabetes
Control of Lipids Patients With Diabetes, %
Patients Without Diabetes, %
P Value
LDL-C > 100 mg/dL 74.7 75.7 NS
HDL-C < 40 mg/dL (men)< 50 mg/dL (women) 63.7 40.0 < .001
Triglycerides> 150 mg/dL 61.6 25.5 < .001
N = 498 adults (projected to 13.4 million) aged > or = 18 years with diabetes representative of the US population and surveyed within the cross-sectional National Health and Nutrition Examination Survey 1999-2000. Diabetes Res Clin Pract;70:263-269.2005
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Lipid Pattern in Diabetes UKPDS
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Lipid Pattern in Diabetes UKPDS
Clinical Diabetes.Vol.24,no.1,2006
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The relationship between LDL-C,HDL-C and CVD
adapted from Gordon T. et al, American Journal of Medicine, 1977;62;707-714
UKPDS,1mmol/L ↑LDL-C was associated with 57% ↑risk MI
UKPDS,0.1mmol/L ↑HDL-C was associated with 15% ↓in CVD events
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LowHDL- C
HighTG
HighSmall dense LDL
Lipid Pattern in Diabetes
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Lipoprotein Pattern in Diabetes
Diabetes Care.16:434-444.1994
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Whom to Screen?How often?
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ADA Guidelines 2014
-In most adult patients with DM, measure fasting
LIPID PROFILE AT LEAST ANNUALLY. (LEVEL B)
-In adults with low risk lipid values(LDL-C <2.6mmol/L,
HDL-C>1.3mmol/L, and TG<1.7mmol/L),LIPID ASSESSMENT MAY BE REPEATED EVERY
2 YEARS.(Level E)
Diabetes Care,volume 37,Supp 1,January 2014
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What are the additional predictors beyond LDL and
HDL To be assessed?
1-Apo lipoprotein B:
No evidence yet for regular screening.
Very strong predictor for cardiovascular disease in DM.
Has less biologic variation, reliable measures.
Non fasting sample.
High cost.
ESC/EAS 2011
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What are the additional predictors beyond LDL and
HDL to be assessed?
2-Highly sensitive CRP
-These additional inflammatory markers are helpful in
intermediate risk patients but proven to be unhelpful
for the very high risk patients.
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Risk Stratification?Is it important?
What are the risk scoring systems?
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Total cardiovascular risk estimation
1- Framingham Risk Score.
2- Systemic Coronary Risk Estimation(SCORE).
3- Atherosclerotic cardiovascular disease risk (ASCVD).(ACC/AHA)
4- QRISK Lifetime cardiovascular risk
(Joint British Societies in 2014).
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SCORE Framingham Risk
Score
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Total cardiovascular risk estimation
Risk Level Very High Risk
High Risk Moderate Risk
Low Risk
SCORE 10yrs CVD Risk
≥ 10% ≤10% - ≥5% ≤5% - ≥1% ≤1%
CVD/PAD/Stroke
+
T2DM +
CKD +
Risk Factors(FH/Severe HTN)
++ +++
ESC/EAS Guidelines 2011
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ASCVD 10-year Risk
ACC/AHA Guidelines 2013
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Lloyd-Jones DM et al, Circulation 2006;113:791
Cumulative Incidence of CVD Adjusted for the Competing Risk of Death According to Risk Factor Burden at Age 50
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Management of Hyperlipidemia in DM?
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Management Of Hyperlipidemia in T2DM?
1-Whom should we treat?
2-What are the important targets?
3-What are the target Levels?
4-What are the treatment Strategies?
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Q1: Whom Should we Treat?
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Whom Should we Treat?ADA Guidelines 2014
1-Diabetic patients <40years,without CVD,LDL
cholesterol>2.6mmol/L(low risk) after failure of life
style modifications, or with multiple CVD risk
factors(level C).
ADA Guidelines, January 2014
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Whom Should we Treat?ADA Guidelines 2014
2- Patients without CVD,>40years,having one or more
other CVD risk factors(family history of CVD,
hypertension,smoking,albuminuria) regardless of the
LDL(level A).
3-Diabetic patients with overt CVD, regardless of the
LDL level(High risk patients),(level A).
ADA Guidelines,January 2014
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Q2:Which target is the most important?
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LDL
HDL
TG
Others
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- LDL cholesterol was the strongest independent predictor of CHD, followed by HDL.TG level did not predict CHD events.
Clinical Diabetes.Vol.24,no. 1,2006
UKPDS
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Q3: What Are the Lipid’s Target Level?
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ADA Guidelines 2014
In individuals without overt CVD, the goal is LDL-C
<2.6mmol/L.(Level B)
Individuals with overt CVD, a lower LDL-C
goal of < 1.8mmol/L with a high dose statin.
(Level B)
If maximum tolerated statin therapy, a reduction in
LDL-C of 30-40-% from baseline is an alternative goal.(Level B)
Diabetes Care,vol.37,Supp 1,January 2014
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ADA Guidelines 2014
TG <1.7mmol/L and HDL cholesterol>1.0mmo/L in
men and > 1.3mmo/L in women.
LDL-C -targeted statin therapy remains the preferred
strategy.(Level A)
ADA Guidelines,January 2014
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Q4:What are the Treatment Options or Strategies?
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Treatment Options
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Life style modification is critical component
Weight Loss
Exercise
Diet
Life Style Intervention
>5% weight loss if BMI>25Level I
30min.moderate physical activity on most days/ wk. Level II
ESC/EAS 2011
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Life Style
Intervention
Serves up 8,000 calorie burger meal... the equivalent of FIVE DAYS worth of food
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Life Style InterventionDiet
1-High polyunsaturated fatty acids diet – saturated fat< 7% of daily calories +↓intake of cholesterol to 200mg/day(Level II).
2-↑the amount of soluble dietary fibers to 10-25g/day(level II).
→associated with 5-15% ↓in the LDL-C.
3- limits the carbohydrates to <60% in individuals with ↑TG/ ↓HDL→ short term effect /OR replace the saturated fat with carbohydrates /monosaturated fat(Level I).
National Evidence Based Guidelines for the Management of Type 2 Diabetes Mellitus. the Australian Centre for Diabetes Strategies.Part7.2004ADA.2014
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Dietary Recommendationto TC and LDL-C
ESC,EAS Guidelines2011
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Effects of Drug Therapy and Diet on Lipids
100
125
150
175
200
225
250
275
300
325 Pre-drugDrug
Drug + diet
* 84% reached NCEP LDL target (<130 mg/dL)† 63% reached NCEP LDL-C target (<100 mg/dL)Barnard RJ, et al. Exerpta Medica Brief Reports. 1997;1112-1114.
TC (mg/dL)
1° Prevention (n=40) 2° Prevention (n=53)
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Pharmacological Lipid Management
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Statins
Fibrates
NiacinEzetimibe
Combinations
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Use Statins To Treat the Risk Not Cholesterol
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Clinical Trial Evidence
Primary Prevention
Secondary Prevention
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Study Intervention Baseline LDL-
cholesterol(mg/dl)
NumberDiabetes/
Total
CVDOut
come
RRRDiabetes
(%)
RRRNon-
Diabetes(%)
Primary Prevention
CARDS
Atorvastatin 10mg
117 2838 Acute Coronary EventsStroke
36*
48*
--
Primary secondary Prevention
HPS Simvastatin 20mg
124 5963/20536 Major CHD eventAny major CVS
event
27*22*
27*24*
ALLHAT Pravastatin10mg
129 3635/10357 Major CHD event 11 8
ASCOT-LLA Atorvastatin 10mg
128 2532/10305 Major CHD eventTotal CVS events and procedures
16 23*
44*20*
Secondary Prevention
4S Simvastatin10-40mg
186 202/4444 Total mortalityMajor CHD event
43 55*
29*23*
CARE Pravastatin40mg
136 586/4159 Major CHDExpanded endpoint
13 25*
26*23*
LIPID Pravastatin 40mg
143 1077/9014 Major CHD eventAny CVS event
19 21*
23*13*
Clinical Diabetes.Vol.24.no.1,2006
Primary PreventionCARDS
Primary& Secondary Prevention HPS
Secondary Prevention4S
CTT
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Collaborative Atorvastatin Diabetes Study(CARDS)
First RCT statin trial conducted only in diabetic subjects2838 patients 40-75 yrs
T2DM1428Atorvastatin 10mg
1410 placebo
Primary endpointTime to first CV event/revascularization/stroke
FU 3.9 yrs
Lancet.364:685-696.2004
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CARDSThe trial was terminated 2 years earlier than expected
40% reduction LDL-C
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Conclusion:
Atorvastatin 10 mg daily is safe and efficacious in reducing the risk of first cardiovascular disease events, including stroke, in patients with T2DM without high LDL-cholesterol.
Lancet.364:685-696.2004
CARDS
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Heart Protection Study(HPS)The Largest sub-analysis of statins in patients with DM
( 2912 T2DM )
Composite primary end point 33
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Effect of Statins in the 4S trial in patients with and without
Diabetes*There was 55%reduction in the incidence of CVD events(P0.002)
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CTT Meta-analysis 18686 patients with diabetes from 14 RCTs primary&
secondary CVD prevention, follow-up 4.3 years
Lancet.366.1267-1278.2005
21%reduction in the incidence of major vascular events/1mmol LDL-C reduction
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Is intensive Lipid Lowering Beneficial?
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Is intensive Lipid Lowering Beneficial?
Treating to New Targets Study (TNT)
Pravastatin or Atorvastatin Evaluation
and Infection Therapy- Thrombolysis in
Myocardial Infarction 22
(PROVE IT-TIMI22)
Incremental Decrease in Endpoints Through Aggressive Lipid Lowering(IDEAL)
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:103 patients :80mg/D,135 :10mg/D
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*LDL cholesterol levels were significantly lowered in patients receiving atorvastatin 80mg (P <0.0001).
Diabetes Care,Vol.29,no.6,January2006
*Significant differences in favour of atorvastatin 80 mg were also observed for time to CVA event (P 0.037) and any CV event (P 0.044).
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-No significant difference between the treatment groups in the rate of treatment related adverse events and persistent elevation in liver enzymes.
Diabetes Care,Vol.29,no.6,January2006
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Diabetes Care,Vol.29,no.6,January2006
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4162 patients 739 DM
ACSAtorvastatin 80mg
Pravastatin 40mg
FU18-36months
PROVE IT –TIMI 22To determine the impact of intensive lipid lowering therapy versusstandard therapy with statins on the outcome in acute coronary
syndrome(ACS) patients with diabetes.
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PROVE IT –TIMI 22
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PROVE IT-TIMI 22*Rate of events was higher in diabetic patients and the rate of acute
cardiac events was reduced with the intensive therapy
P(0.03)
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Conclusion:
In ACS patients with DM, intensive statins therapy reduces the acute cardiac events as it does in those without DM.
Despite intensive therapy, the majority of diabetics did not reach the dual goal of LDL-C< 1.8mmol/L.
PROVE IT –TIMI 22
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Statins?Which Dose?
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ADA Guidelines 2014
Maximum tolerated drug dose that will lead to the target LDL,OR 30-40%rduction in LDL-C from baseline.
(Level B)
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ACC/AHA Guideline 2013
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ACC/AHA Guidelines 2013
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Are All Statin the Same? Which Statin?
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*At doses of 10, 20, and 40 mg, atorvastatin produced reductions in LDL-C of -38%, -46%, and -51%, respectively (P>0.01).
The CURVES TrialComparison of LDL-C among
Statins
Am J Cardiol.81:582-587.1998
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Residual CV Risk
Remains?
Treatment Beyond
LDL-Cholesterol?
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Beyond LDL-Cholesterol:
Triglyceride(TG)
HDL-Cholesterol
(Guidelines for the HDL-C target levels were not established)
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What are the target levels According to the
Guidelines?ADA 2014:
TG level<150mg/dl(1.7mmol/L) and HDL-Cholesterol >40mg/dl(1.0mmol/L)in men and >50mg/dl(1.3mmol/L) in women are desirable.(Level C).
HDL-C raising strategies may be considered in high-risk individuals with HDL-C < 40mg/dl(<50mg/dl in women).
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What are the available agents?
Fibrates
Niacin
Omega 3
Ezetimibe
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What is the evidence from the trials?
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Fibrates
FIELD
VA-HIT
ACCORD
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Fenofibrate Intervention and Event Lowering in DM study
(FIELD)-FIELD is primary prevention , double-blind, placebo-controlled trial in 63 centres in 3 countries.
-Examining the effects of long-term fibrate therapy on coronary heart disease (CHD) event rates inpatients with T2DM regardless of the lipid profile.
Lancet,366:1849.2005
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FIELD
Primary end point:
CAD death, non-fatal MI
Significant reduction in all CV death& secodary end point (P0.035).Effect is more in mixed lipidemia.
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- Hypertriglyceridemia
dietary and life style changes.
-Severe hypertriglyceridemia is absent
therapy targeting HDL-C or TG lacks the strong evidence base of statin therapy.
- Severe hypertriglyceridemia <1000mg/dl(11mmol/L)
immediate pharmacological therapy may be warranted with fibtares, niacin or fish oil.
ADA Guidelines 2014
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Is Combination therapy Beneficial?
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The Action to Control Cardiovascular Risk in
Diabetes-Lipid trial(ACCORD)
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ACCORD
-Investigated whether combination therapy with a statin plus a fibrate, as compared with statin monotherapy, would reduce the risk of cardiovascular disease in patients with T2DM at high risk for CVD.
NEJM. Vol. 362. no.17.April 29,2010
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2765received fenofibrate &simvastatin
2753 receivedSimvastatin&
placebo FU 4.7 years
primary outcome was the first occurrence of a major cardiovascular event
ACCORD
5518 patients T 2 DM
Secondaryoutcomes included the
combination of theprimary outcome plus revascularization or
hospitalizationfor congestive heart
failure
NEJM.vol.362no.17.April 29.2010
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ACCORD: Results
NEJM.vol.362.no.17.April 29.2010
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ACCORD: Results
NEJM.vol.362.no.17.April 29.2010
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“The combination of fenofibrate and simvatatin did not reduce the rate of fatal cardiovascular events, non-fatal MI or non-fatal stroke, as compared with simvatatin alone.”
NEJM, April 29,2010.vol.362no.17
ACCORD
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ADA Guidelines 2014
Combination therapy with statin and fibrates maybe efficacious for treatment for all three lipid fractions, but this combination is associated with an increased risk of abnormal transaminase levels, myositis or rhabdomyolysis and does not provide additional CVS benefit. Hence, combination therapy can not be broadly recommended.(Level A)
*Gemfibrozil is not preferably combined with statins
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ACC/AHA 2013 Guidelines
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Niacin:
-Niacin is the most effective drug for raising HDL-C.
-Niacin Trials:
ARBITER 6-HALTSNIA-Plaque,AIM-HIGH,
-HPS2-THRIVE showed disappointing results.
Diabetes&Vascular Disease Research.10(2) 99-114.2012
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-NO COMPLETED RCT with clinical endpoints are available yet to guide practice on addition of niacin to statin therapy.
-Until the results of the ongoing trials are reported,
a consensus suggested to add niacin to statin in very high risk group.
Medescape .15.3.2011
Niacin:
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ADA Guidelines 2014
If the HDL-C<1mmol/L and the LDL-C between 2.6mmol/L and 3.3mmol/L , a fibrate or niacin might be used especially if a patient is intolerant to statins.
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Ezetimibe
The Improved Reduction of Outcomes: Vytorin Efficacy International Trial:
IMPROVE-IT Trial:
-The trial is investigating the effect of simvastatin 40mg/d with or without ezetimibe 10mg/d in patients with ACS.
Outcome:
-Effect of treatment on CVD death, non-fatal stroke and mom-fatal MI
-The results will be released in September 2014
Diabetes&Vascular Disease Research.10(2) 99-114.2012
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Omega- 3 Fatty Acids
- Omega-3 PUFAs can be used to ↓ TG levels.
Trials:
ORIGIN
GISSI-P
JELIS
-There were differences in the outcomes seen in the various PUFA studies.
-Further studies are needed to confirm the benefit of omega -3 FA in patients with DM and dyslipidemia.Pharmacotherapy.24(12):1692-1713.2004
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How would you monitor Lipid Lowering Therapy?
How Would You Treat Intolerability to Lipid
Lowering Agents?
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ESC/EAS Guidelines 2011
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OutcomeStatin(%)
Placebo (%) RD P value
Myalgias 15.4 18.7 2.7 0.37
CK elevations 0.9 0.4 0.2 0.64
Rhabdomyolysis 0.2 0.1 0.4 0.13
LFT elevation 1.4 1.1 4.2 <0.01
AE discontinuation 5.6 6.1 -0.5 0.80
Statins are safe but nothing is without risk: Review of 35 statin therapy trials
FDA-approved statin* monotherapy vs placebo (N = 74,102)
*Atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin.AE:adverse events.
Circulation;114:2788-97.2006
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ESC/EAS Guidelines 2011
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Statin DiabetogenicityRemaining Question
-JUPITER Trial: 26% higher incidence of DM in the rosuvastatin group.
-A meta-analysis of 13 RC statin trials with 91140 participants showed that treatment of 255 patients with statins for 4 years resulted in one additional case of DM while preventing 5.4 vascular events among 255 patients.
-Future studies should continue to assess the effects of end organ dysfunction related to long-term hyperglycemia from statin therapy.Am J Cardiovasc Drugs.14:79-87(2014)
Curr Opin Cardio.28:554-560.2013/ Lancet.375:75-742.2010.
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Future Research
New LDL-C lowering drugs Phase III trials:
1-Microsomal transfer protein inhibitors(MTP).
2-Thyroid hormone mimetics with liver selectivity.
3-Oligonucleotides suppressing Apo B.
ESC/EAS Guidelines 2011
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CASES
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Case 1What will be your primary lipid target :LDL-C? HDL-C? TG?
45 years-old gentleman
T2DM for 3 years,
No other significant history
Med.: Metformin 1gm /BID
BMI30
Bp 120/80
Total Cholesterol 7mmol/L
LDL-C:2.6 mmol/L
HDL-C: 1 mmol/L
TG: 2 mmol/L
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Case 1
UKDP: LDL cholesterol was the strongest independent predictor of CHD, followed by HDL.TG level did not predict CHD events.
-LDL-C remains the primary goal in the treatment of dyslipidemia according to ADA,ACC,ESC and NCEP.
-Targeting HDL-C may be useful in high risk patients but still the evidence is lacking.
Diabetes&Vascular Disease Research.10(2).99-114.2012
British Journal of Diabetes and Vascular Disease.Vol.5.issue2.56-62.2005
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Case 2: Would You Initiate a lipid lowering agent in This Patient? OR Would you advise non-pharmacological Treatment 45 years- old gentleman
Current smoker, 10 year history of hypertension
He is on lisonpril 10mg OD
BMI 28
Blood pressure: 135/85 mmHg
HA1C 6.5%
Total cholesterol: 5 mmol/L
LDL-cholesterol: 2.6 mmol/L
HDL-cholesterol: 1.2 mmol/L
Triglycerides: 2.0 mmol/L
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Whom Should we Treat?ADA Guidelines 2014
1-Diabetic patients <40years,without CVD,LDL
cholesterol>2.6mmol/L(low risk) after failure of life
style modifications, or with multiple CVD risk
factors(level C).
ADA Guidelines, January 2014
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Whom Should we Treat?ADA Guidelines 2014
2- Patients without CVD,>40years,having one or more
other CVD risk factors(family history of CVD,
hypertension,smoking,albuminuria) regardless of the
LDL(level A).
3-Diabetic patients with overt CVD, regardless of the
LDL level(High risk patients),(level A).
ADA Guidelines,January 2014
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Case 3: Would you Intensify This Patient’s Statin?OR
Would you change her statin to more potent agent
50 years-old lady
T2DM for 12 years, Hypertension, non-smoker
Meds: metformin 1gm BID, lisinopril 20mg/day,
simvastatin10mg/day
BMI 26.5
Bp: 135/85 mmHg
Total cholesterol: 6 mmol/l
LDL-cholesterol: 2.7 mmol/L
HDL-cholesterol: 1.0 mmol/L
Triglycerides: 2.4 mmol/L
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Case 3
Framingham CV Risk Score= 3.44%
SCORE risk= 1%
The patient will be in the moderate risk group
DM, age 40-75,LDL-C 1.8-4.9mmol/L: moderate intensity statin unless score>7.5%,then high –intensity statin
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Case 4: Would you decrease this patient’s statin dose? OR Would you add a fibrate?
65year-old lady,
T2DM, PCI for STEMI 6 months ago
no current CV symptoms
Meds: ASA, clopidogrel, lisinopril, atorvastatin 80 mg/day
BMI 29.0
Blood pressure: 125/85 mmHg
Total cholesterol: 3.1 mmol/L
LDL-cholesterol: 0.9 mmol/L
HDL-cholesterol: 0.9 mmol/L
Triglycerides: 3.4 mmol/L
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Total cardiovascular risk estimation
Risk Level Very High Risk
High Risk Moderate Risk
Low Risk
SCORE 10yrs CVD Risk
≥ 10% ≤10%≥5% ≤5%≥1% ≤1%
CVD/PAD/Stroke
+
T2DM +
CKD +
Risk Factors(FH/Severe HTN)
++ +++
ESC/EAS Guidelines 2011
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Case 4: ADA Guidelines 2014
Combination therapy with statin and fibrates or statin and niacin maybe efficacious for treatment for all three lipid fractions, but this combination is associated with an increased risk of abnormal transaminase levels, myositis or rhabdomyolysis and does not provide additional CVS benefit. Hence, combination therapy can not be broadly recommended.(Level A)
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ACC/AHA Guidelines 2013
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Case 5: What will be your Approach to Solve this patient problem?
50 year-old lady
T2DM 5 years, Hypertension 5 years
Had pain in her arms and legs for 6 months
Meds: Lisinopril 10mg/d, atorvastatin 20mg/d,aspirin 75mg/d
LFT:N
CK:700 (40-176 IU/L)
Total cholesterol:4.0mmol/L
LDL-C:1.8mmol/L
HDL-C:0.9mmolL
TG:2.0mmol/L
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Case5:ESC/EASGuidelines 2011
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Conclusion-The prevalence of T2DM is continuing to rise.
- Diabetes increases the risk of CVD which is the major cause of death in this population, and is treated as CVD equivalent.
-Dyslipidemia should be the key management target.
-There is little evidence for any threshold below which the lower LDL-C is not associated with lower risk.
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- Life style measures are an important cornerstone in the management.
-Glycemic Control can also beneficially modify plasma lipid levels particularly in patients with very high TG.
-Statin therapy is highly effective at reducing the risk of CVD in primary & secondary prevention trials.
Conclusion
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-Combination therapy of statins and other lipid lowering agents can not be broadly recommended.
-Despite statin therapy, high CVD risk persists suggesting that further intervention in addition to intensive statin therapy are needed in the very high-risk diabetic patients.
Conclusion
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Thank you