AACE Endorses Lower LDL Targets, ApoB Testing

While statins remain the cornerstone of therapy, determining the roles fibrates and niacin should play in lowering triglycerides and raising HDL, and in which patients, is more complicated.

Several scientific studies cited in the AACE guidelines support a clinical benefit for the use of fibrates in patients whose triglycerides are greater than 200 and whose HDL is less than 40 mg/dL or 35 mg/dL for primary and secondary prevention of cardiovascular events. There remains uncertain clinical benefit in patients treated with fibrates for lesser triglyceride and HDL abnormalities.

Niacin is also recommended for increasing HDL and reducing LDL-C and triglycerides in certain patients despite results from AIM-HIGH, a randomized controlled trial that was terminated early after it became clear that patients whose LDL levels were very well controlled with simvastatin were seen not to benefit from the addition of niacin.

Dr. Jellinger said that niacin may benefit patients with less well controlled LDLand that the AACE is awaiting the results of another, larger niacin trial (HPS2-THRIVE). "You probably don’t have to start niacin if your LDL is very low. When your LDL is higher, we don’t yet know. It may be suitable," he said.

The guidelines also give more latitude as to when to order lipid testing. More frequent lipid testing may be indicated in the following circumstances: deterioration of diabetes control, the use of a new drug known to affect lipid levels, atherothrombotic disease progression, considerable weight gain, development of a new CAD risk factor and convincing new clinical trial evidence suggesting stricter lipid goals. The AACE’s position "ought to give comfort to physicians who want to order more frequent lipid profiles under certain circumstances," Dr. Jellinger said.

Dr. Jellinger disclosed receiving honoraria from Amylin Pharmaceuticals, Eli Lilly, Merck, and Novo Nordisk, and having served on advisory boards for Novo Nordisk, Merck, Boehringer Ingelheim, and Amylin. Six of the seven task force members reported disclosures of fees, honoraria, or grant support from these and/or other pharmaceutical and/or device manufacturers.