New Strategies for the Treatment of Diabetic Dyslipidemia
- Steven M. Haffner, MD1 and
- Ronald B. Goldberg, MD2
- 1Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas
- 2Diabetes Research Institute, University of Miami, Miami, Florida
Type 2 diabetes is associated with a marked increase in coronary heart disease (CHD) (1). In some cases, the magnitude of the increase in CHD in diabetic subjects without preexisting CHD is as great as that in nondiabetic subjects with CHD (2,3). The possible equivalent risk of diabetes and prevalent CHD has led to the suggestion that diabetic subjects be treated as CHD-risk equivalents by a variety of organizations, including the American Diabetes Association (ADA) (4) and the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) (5). Further amplifying the importance of early and aggressive risk factor interventions is the increased case fatality rate in diabetic subjects who have a myocardial infarction (6). In the latter report, 50% of diabetic men died prior to hospitalization before their first myocardial infarction, suggesting that a strategy based on secondary prevention may not be completely effective.
Given that diabetic subjects have a marked increase in CHD, what are appropriate strategies to reduce their risk of CHD? Diabetic subjects tend to have markedly increased triglyceride levels and decreased HDL cholesterol (7). In addition, LDL cholesterol levels in diabetic subjects are often similar to those of nondiabetic subjects. Additionally, diabetic subjects have an increased proportion of smaller, denser, potentially more atherogenic LDL particles than nondiabetic subjects (8). In early prospective studies (9), increased triglyceride levels and decreased HDL cholesterol levels were generally more powerful predictors of CHD than LDL cholesterol. Based on these observations, earlier recommendations for the treatment of diabetic dyslipidemia often focused on correction of the abnormal triglyceride HDL cholesterol levels in diabetic subjects (10). The initial strategy focused on the use of fibric acids because nicotinic acid was felt to be relatively contraindicated due to its effects on worsening glycemic control (11). Indeed, Koskinen et al. (12 …
