Lipid Management in Patients With Diabetes

Translating guidelines into action

“… with fat diabetes begins. From fat diabetics die, formerly of coma and recently of … arteriosclerosis.” Three-quarters of a century ago, Dr. Elliot Joslin succinctly summarized two of the lethal consequences of diabetes before (ketoacidosis) and after (cardiovascular disease [CVD]) the discovery of insulin (1). As we progressively refine our ability to normalize blood glucose with increasingly complex regimens of new oral and injectable agents, the excess cardiovascular mortality from diabetes remains unabated (2). With diabetes increasing worldwide due to decreased physical activity and an aging and more obese population, and with type 2 diabetes being diagnosed at earlier ages (3,4), without effective preventive strategies the associated atherosclerotic complications are likely to soon reach unmanageable proportions. This prediction lies in sharp contrast to a decrease in cardiovascular mortality in the general population that has been recently reported (5).

The precise link between CVD and diabetes is not completely understood, but it is clearly multifactoral, involving the deleterious effects of hyperglycemia itself, resulting in endothelial dysfunction, hypercoagulability, increased oxidative stress, and protein glycosylation. In the setting of type 2 diabetes, there are the additional contributions of obesity, hypertension, dyslipidemia, insulin resistance, and further abnormalities in fibrinolysis and endothelial function (6). With the onset of diabetic nephropathy the risk of macrovascular disease is compounded. The exact role of each of these derangements is complicated by their complex interrelationships. In the midst of such a large number and variety of risk factors, however, dyslipidemia remains a key determinant of CVD. While the U.K. Prospective Diabetes Study (UKPDS), the largest prospective trial of type 2 diabetes, showed that glucose control decreased the microvascular complications of diabetes, the trial demonstrated that elevated LDL cholesterol (LDL-C) and decreased HDL cholesterol (HDL-C) levels were among the strongest predictors of fatal and nonfatal myocardial …