Dyslipidemia Management

Joshua J. Joseph, M.D., Simeon Margolis, M.D.
Dyslipidemia Management is a topic covered in the Johns Hopkins Diabetes Guide.

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  • Elevated blood levels of lipids (cholesterol and triglycerides) and/or abnormalities in the blood concentrations of lipoproteins including: increased low-density lipoprotein cholesterol (LDL-C), decreased high-density lipoprotein cholesterol (HDL-C), and increased lipoprotein(a) (Lp(a)).
  • Normal fasting triglyceride levels are < 150 mg/dL. Triglycerides >500 mg/dL are considered very high.
  • Previously, desirable levels of LDL-C in patients with diabetes were < 100 mg/dL and < 70 mg/dL if high risk for cardiovascular disease.
  • HDL-C levels are considered too low when < 40 mg/dL in men and < 50 mg/dL in women.
  • Non-HDL cholesterol = total cholesterol - HDL-C.
  • Historically, physicians targeted the major components of lipids including low-density lipoprotein (LDL-C), triglycerides (TG) and high-density lipoprotein (HDL) to prevent cardiovascular disease (CVD).
  • The reduction in cardiovascular events with statin therapy is directly related to the magnitude of LDL-C lowering, with every 39 mg/dl (1 mmol/l) resulting in an additional 22% reduction in cardiovascular events in type 2 diabetes.[15]
  • Trials in TG reduction in type 2 diabetes, with a fibrate alone[19] or in combination with a statin[10]did not show a significant reduction in cardiovascular mortality.
  • In the AIM-HIGH trial (one-third of participants with type 2 diabetes), the addition of niacin incrementally to statin therapy in patients with low HDL and high TG at baseline also showed no benefit in a composite CV endpoint in participants with known CVD.[8]
  • In the HPS2-THRIVE study (one-third of participants with type 2 diabetes), extended-release niacin in combination with statin therapy for secondary prevention led to reductions in LDL and increased HDL, with no reduction in major vascular events and increased serious adverse events related to glycemic control.[2]
  • In a study of ezetimibe plus statin versus intensified statin alone in type 2 diabetes, there was no beneficial effect of addition of ezetimibe on progression of carotid atherosclerosis.[16]
  • Primary and secondary prevention of cardiovascular disease with statin therapy significantly reduces cardiovascular events and cardiovascular death in type 2 diabetes.
  • The more recent studies described above have resulted in a shift from "treating to targets" using a statin with or without an additional agent, to a new paradigm of maximizing statin usage in diabetes and determining dose and potency of statin based on cardiovascular risk, as reflected in the 2013 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines[3] and the 2015 American Diabetes Association (ADA) guidelines.[26]

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Last updated: August 29, 2015