Diabetic dyslipidemia and its therapy

Patients with diabetes, including those with IDDM, NIDDM, and other types, are at an increased risk for coronary heart disease (CHD). Factors that may enhance CHD risk include hyperglycemia, hypertension, and dyslipidemia. Diabetic dyslipidemia is characterized by multiple lipoprotein defects, including moderately high serum levels of cholesterol and triglycerides, small LDL particles, and low levels of HDL cholesterol. The results of recent clinical trials reveal beneficial effects of cholesterol-lowering therapy in diabetic and nondiabetic patients, thus supporting increased emphasis on treatment of diabetic dyslipidemia. This need for intensive treatment of diabetic dyslipidemia was advocated by the recent report of the National Cholesterol Education Program's Adult Treatment Panel II. A three-step approach to treatment of diabetic patients with dyslipidemia can be recommended. First, life habits, including intakes of cholesterol and cholesterol-raising fats, total energy, and physical activity, should be modified appropriately. Second, good glycemic control, with drugs if necessary, should be achieved. Third, atherogenic lipoproteins should be effectively reduced, with drugs if necessary. Clinical trials indicate that priority should be given to reducing atherogenic lipoproteins (LDL and VLDL). An appropriate target of therapy is VLDL + LDL (non-HDL) cholesterol levels. Cholesterol-lowering drugs (hydroxymethylglutaryl [HMG] CoA reductase inhibitors [statins] and bile acid sequestrants) are first-line drug therapy for diabetic dyslipidemia. Patients with severe hypertriglyceridemia may require fibric acids to prevent development of acute pancreatitis. Although nicotinic acid seems to be an attractive drug for diabetic dyslipidemia, it worsens hyperglycemia; therefore, it must be avoided in most cases. The value of estrogen-replacement therapy in postmenopausal women with diabetes has not been determined.