Previously, we explored blood pressure control in a patient with diabetes. Now, we’ll discuss the value of a fasting lipid panel and treatment for dyslipidemia in this population.
Mr. W completed a fasting lipid panel, which revealed the following: triglycerides, 145 mg/dL; high-density lipoprotein (HDL) level, 32 mg/dL; and low-density lipoprotein (LDL) level, 108 mg/dL. He is currently receiving low-dose statin therapy. Based on these results, Mr. W fits the criteria for dyslipidemia.
Dyslipidemia marked by elevated LDL levels—as observed in Mr. W—is a well-known contributing factor to development of cardiovascular disease in patients with diabetes. Elevated triglycerides and low HDL levels also are often noted in these patients. Patients with diabetes are particularly vulnerable to atherosclerosis due to a combination of pro-inflammatory factors and hyperglycemic effects. Both the ADA and the AACE agree that lipid management, including fasting lipid panels and appropriate treatment, is of paramount importance in patients with diabetes.7,8
Fasting Lipid Panels
The AACE recommends administering at least annual fasting lipid panels in all adults with diabetes, and LDL goal levels should be based on the cardiovascular risk of the patient.7 For patients with
- established ASCVD, the LDL goal is < 55 mg/dL
- risk factors for ASCVD (eg, hypertension, tobacco use, family history of ASCVD) in addition to diabetes, the LDL goal is < 70 mg/dL
- no risk factors, the LDL goal is < 100 mg/dL.7
Research indicates that statins reduce the risk for cardiovascular events and are recommended as first-line treatment for dyslipidemia.2,7 Statin therapy is recommended for patients with LDL levels above goal without contraindications.10 Higher-dose statins have been shown to help improve cardiovascular outcomes, and most—if not all—guidelines recommend up-titration of these medications as tolerated by the patient. 7,8,29 After initiation of statin therapy, clinicians should continue to monitor lipid levels every 4 to 12 weeks after a change in lipid therapy and then schedule monitoring annually.2
Unfortunately, a recent large-scale retrospective study of the medical records of 125,464 patients with type 2 diabetes showed that although 99% of the patients were at high risk for or already had ASCVD, only 63% were receiving the recommended statin therapy.30 Therefore, all patients with diabetes at risk for ASCVD require evaluation to determine the need for statins.
Additional treatments. If the patient’s levels remain above goal, strong consideration should be given to additional therapies. Ezetimibe has been shown to have some benefit in reducing LDL levels and cardiovascular risk.31 PCSK9 inhibitors are a newer treatment for cardiovascular disease and are particularly beneficial for patients with known ASCVD. The FOURIER and ODYSSEY trials demonstrated that PCSK9 inhibitors had relative risk reductions of 48% to 53% for major ASCVD events and showed that these medications help reduce LDL levels and, most importantly, cardiovascular risk.32,33
Continue to: Recommendations for other lipid components