Treatment of dyslipidemia in patients with NIDDM

An increased emphasis is being given to treating dyslipidemia in patients with non-insulin-dependent diabetes mellitus (NIDDM) to reduce their high risk of coronary heart disease and other complications of atherosclerotic peripheral vascular disease. Recently, the National Cholesterol Education Program's Adult Treatment Panel II recommended aggressive lowering of lipids and lower treatment goals for serum lipids in patients with NIDDM. A Step Care approach to dyslipidemia is recommended for NIDDM patients, with the first step being hygienic measures including diets low in saturated fats and cholesterol combined with physical activity. These measures can be combined with energy restriction for overweight patients for effective and gradual reduction in adiposity. Step two consists of achieving good glycemic control with sulfonylureas, biguanides, or insulin therapy in conjunction with hygienic measures. If dyslipidemia persists despite the first two steps, step three is using lipid-lowering medications. For normotriglyceridemic patients with high levels of low-density lipoprotein (LDL) cholesterol, bile acid sequestrants, hydroxymethylglutaryl coenzyme A reductase inhibitors (statins), or a combination of the two drugs should be the first-line therapy. For those with borderline-high plasma triglycerides and high LDL cholesterol levels, statins are the drugs of choice. In severely hypertriglyceridemic patients, fibric acid derivatives are indicated. Nicotinic acid can cause marked deterioration of glycemic control and is therefore less desirable. Probucol should be tried only as an adjunct to other drugs in patients otherwise resistant to other lipid-lowering agents. Well-controlled studies are needed before estrogens can be recommended for postmenopausal women with NIDDM.