Diabetes , dealing with residual cardiovascular risk
Dysfunctional lipids is primarily a problem for people with type 2 Diabetes however no one with or without diabetes is immune from the risk associated with elevated LDL Cholesterol , Triglycerides and low HDL .
Helping myself and my patients deal with lipid problems has been an interest of mine for many years.Multiple guidelines are available from the American Diabetes Association , Endocrine society and others. These guidelines are continually updated as more information becomes available. My initial plan was to reproduce and discuss the new guidelines . I reviewed some guidelines and decided that you can look up and read the guide lines yourself. I decided instead, to share my in the office approach to lipid management that also evolved over years.
I am not recommending my approach to you. Do not make any changes in your treatment.Your doctor knows you and is the best person to guide your treatment. My discussion below is help you become more aware of treatment options to discuss with your physician.
Most of us
To start with, most younger people ( < 40 years old )with type 1 Diabetes did not have significant lipid problems . I tried to follow their lipid profile each year and managed any lipid problems that developed.
People with type 2 Diabetes were more of a challenge and presented a number of treatment challenges. Most presented with mild abnormalities with LDL in 130 to 150 mg/dl ranges , HDL is the high 30's range and triglycerides 200 to 400 mg/dl range. These people responded to correcting their A1c to 7, Mediterranean style low fat diet ,weight loss and adding a statin if necessary. I recommended the newer more potent statins such as Lipitor ( atorvastatin) and later Crestor ( rosuvastatin )when it became available . Cost was often a problem and zocor ( simvastatin ) was my choice. The initial dose of these medications was the most effective at lowering cardiovascular risk with the lowest number of side effects. Subsequent dose increases were less effective ( see my recent discussion on the rule of 7 ) and were associated with more side effect , muscle complaints.
The initial dose along with diet and glucose management often resulted in dramatic drops in LDL and Triglyceride levels . HDL levels did not usually respond well to treatment.
My recommended target goal for LDL in this group is 70 mg/dl and Triglycerides of <150 mg/dl.
For those people with triglycerides not responding to the above approach I usually started with a trial of Omega 3 fatty acids . Initially over the counter omega 3 FA were available and the usual effective dose was 4 grams . I was always concerned about the over the counter medications but they seem to work. Finally a FDA approved omega 3 FA was approved , Lovaza and help relieve my concerns about the over the counter drug. A new formulation of purified EPA made by Amarin will hopefully be approved by the FDA in July . My reasons for chosing Omega 3 fatty acids was simple. They worked and had less side effects. I was reluctant to use Tricor ( Fenofibrate ) because of the added risk of myopathy and Niacins were just to difficult to tolerate.
The small percent
Their was a small percent of patients with higher LDL cholesterol and very high triglycerides that did not respond to the above initial approach. This group requires a more aggressive approach and adjustment of the target goals. These people have a higher risk from their disease than the risk of medicine side effects.
Persistent elevation of triglycerides in the 800 to 1000mg/dl range increases the risk for pancreatitis. In these patients , lowering the triglycerides to reduce the risk of pancreatitis is the initial goal. this may require combinations of medications including , Zetia ( ezetimibe ),Tricor( fenofibrates ) and Niacin.
Achieving Triglycerides levels in the 200 to 300 range may be the best result they can do.
The person with a LDL Cholesterol of 190 mg/dl is not likely to achieve a target goal of 70 . They can expect and average LDL reduction of 38 mg/dl reduction with the initial Statin dose and about a 25 % reduction in the risk for heart disease. Each subsequent doubling of the Statin dose lowers LDL by about another 7 % ( the rule of 7 ) . Combination of other medications including some of the above and Questran ( cholestyramine ) may be needed.
Have fun Be smart Talk to your doctor about your treatment goals
David Calder, MD
Tomorrow the new Omega 3 fatty acid waiting for FDA approval