Table 3—

Order of priorities for treatment of diabetic dyslipidemia in adults*

I. LDL cholesterol lowering*
 First choice
  HMG CoA reductase inhibitor (statin)
 Second choice
  Bile acid binding resin (resin) or fenofibrate
II. HDL cholesterol raising
 Behavioral interventions such as weight loss, increased physical activity, and smoking  cessation may be useful
 Difficult except with nicotinic acid, which should be used with caution, or fibrates
III. Triglyceride lowering
 Glycemic control first priority
 Fibric acid derivative (gemfibrozil, fenofibrate)
 Statins are moderately effective at high dose in hypertriglyceridemic subjects who also  have high LDL cholesterol
IV. Combined hyperlipidemia
 First choice
  Improved glycemic control plus high-dose statin
 Second choice
  Improved glycemic control plus statin plus fibric acid derivative (gemfibrozil, fenofibrate)
 Third choice
  Improved glycemic control plus resin plus fibric acid derivative (gemfibrozil, fenofibrate)
  Improved glycemic control plus statin plus nicotinic acid (glycemic control must be   monitored carefully)
  • *

    * Decision for treatment of high LDL before elevated triglyceride is based on clinical trial data indicating safety as well as efficacy of the available agents.

  • The combination of statins with nicotinic acid and especially with gemfibrozil or fenofibrate may carry an increased risk of myositis. See text for recommendations for patients with triglyceride levels >400 mg/dl.