org Cardiovascular Disease and Risk Management S79
LIPID MANAGEMENT Recommendations should focus on re-
c For patients with diabetes aged ducing saturated fat, cholesterol, and Recommendations .75 years without additional ath- trans fat intake and increasing plant c In adults not taking statins, it is erosclerotic cardiovascular dis- stanols/sterols, v-3 fatty acids, and vis- reasonable to obtain a lipid prole ease risk factors, consider using cous ber (such as in oats, legumes, and at the time of diabetes diagnosis, moderate-intensity statin therapy citrus). Glycemic control may also bene- at an initial medical evaluation, and and lifestyle therapy. B cially modify plasma lipid levels, particularly every 5 years thereafter, or more c For patients with diabetes aged in patients with very high triglycerides and frequently if indicated. E .75 years with additional athero- poor glycemic control. c Obtain a lipid prole at initiation sclerotic cardiovascular disease risk of statin therapy and periodically factors, consider using moderate- Statin Treatment thereafter as it may help to monitor intensity or high-intensity statin Initiating Statin Therapy Based on Risk the response to therapy and inform therapy and lifestyle therapy. B Patients with type 2 diabetes have an adherence. E c In clinical practice, providers may increased prevalence of lipid abnormal- c Lifestyle modication focusing on need to adjust intensity of statin ities, contributing to their high risk of weight loss (if indicated); the reduc- therapy based on individual patient ASCVD. Multiple clinical trials have dem- tion of saturated fat, trans fat, and response to medication (e.g., side onstrated the benecial effects of phar- cholesterol intake; increase of di- effects, tolerability, LDL cholesterol macologic (statin) therapy on ASCVD etary v-3 fatty acids, viscous ber, levels). E outcomes in subjects with and without and plant stanols/sterols intake; c The addition of ezetimibe to CHD (44,45). Subgroup analyses of pa- and increased physical activity moderate-intensity statin therapy tients with diabetes in larger trials should be recommended to im- has been shown to provide addi- (4650) and trials in patients with dia- prove the lipid prole in patients tional cardiovascular benet com- betes (51,52) showed signicant pri- with diabetes. A pared with moderate-intensity mary and secondary prevention of c Intensify lifestyle therapy and opti- statin therapy alone for patients with ASCVD events and CHD death in patients mize glycemic control for patients recent acute coronary syndrome with diabetes. Meta-analyses, including with elevated triglyceride levels and LDL cholesterol $50 mg/dL data from over 18,000 patients with di- ($150 mg/dL [1.7 mmol/L]) and/or (1.3 mmol/L) and should be consid- abetes from 14 randomized trials of low HDL cholesterol (,40 mg/dL ered for these patients A and also statin therapy (mean follow-up 4.3 years), [1.0 mmol/L] for men, ,50 mg/dL in patients with diabetes and his- demonstrate a 9% proportional reduc- [1.3 mmol/L] for women). C tory of ASCVD who cannot tolerate tion in all-cause mortality and 13% re- c For patients with fasting triglyceride high-intensity statin therapy. E duction in vascular mortality for each levels $500 mg/dL (5.7 mmol/L), c Combination therapy (statin/brate) mmol/L (39 mg/dL) reduction in LDL evaluate for secondary causes of has not been shown to improve ath- cholesterol (53). hypertriglyceridemia and consider erosclerotic cardiovascular disease As in those without diabetes, abso- medical therapy to reduce the risk outcomes and is generally not rec- lute reductions in ASCVD outcomes of pancreatitis. C ommended. A However, therapy (CHD death and nonfatal MI) are great- c For patients of all ages with diabe- with statin and fenobrate may est in people with high baseline ASCVD tes and atherosclerotic cardiovas- be considered for men with both risk (known ASCVD and/or very high LDL cular disease, high-intensity statin triglyceride level $204 mg/dL cholesterol levels), but the overall ben- therapy should be added to life- (2.3 mmol/L) and HDL cholesterol ets of statin therapy in people with di- style therapy. A level #34 mg/dL (0.9 mmol/L). B abetes at moderate or even low risk for c For patients with diabetes aged c Combination therapy (statin/niacin) ASCVD are convincing (54,55). Statins ,40 years with additional athero- has not been shown to provide ad- are the drugs of choice for LDL choles- sclerotic cardiovascular disease risk ditional cardiovascular benet above terol lowering and cardioprotection. factors, consider using moderate- statin therapy alone and may in- Most trials of statins and ASCVD out- intensity or high-intensity statin crease the risk of stroke and is not comes tested specic doses of statins and lifestyle therapy. C generally recommended. A against placebo or other statins rather c For patients with diabetes aged c Statin therapy is contraindicated than aiming for specic LDL cholesterol 4075 years without additional in pregnancy. B goals (56), suggesting that the initiation atherosclerotic cardiovascular dis- and intensication of statin therapy ease risk factors, consider using be based on risk prole (Table 9.1 and Lifestyle Intervention moderate-intensity statin and life- Table 9.2). Lifestyle intervention, including weight style therapy. A loss, increased physical activity, and The Risk Calculator. The American College c For patients with diabetes aged medical nutrition therapy, allows some of Cardiology/American Heart Associa- 4075 years with additional ath- patients to reduce ASCVD risk factors. tion ASCVD risk calculator may be a use- erosclerotic cardiovascular dis- Nutrition intervention should be tai- ful tool to estimate 10-year ASCVD risk ease risk factors, consider using lored according to each patients age, (http://my.americanheart.org). As dia- high-intensity statin and lifestyle diabetes type, pharmacologic treatment, betes itself confers increased risk for therapy. B lipid levels, and medical conditions. ASCVD, the risk calculator has limited