Lipid Management for Patients With Diabetes

Diabetes is associated with a greater risk of developing cardiovascular disease (CVD), especially when the disease is not well controlled.¹ According to the American Heart Association, people with diabetes are 2 to 4 times more likely than those without diabetes to die of CVD.¹ Moreover, an estimated 68% of people with diabetes older than 65 die of some form of CVD, and at least 16% die from stroke.¹

Individuals with diabetes often present with dyslipidemia and frequently have decreased high-density lipoprotein cholesterol (HDL-C) levels and elevated triglyceride levels.² People with diabetes also tend to have in their bloodstream a greater rate of smaller and denser low-density lipoprotein (LDL) particles, which augment the risk of CVD.³ Managing diabetic dyslipidemia, which is recognized as a modifiable risk factor, is critical to the reduction or prevention of CVD in patients with type 2 diabetes (T2D).⁴ Maintaining tight glycemic control and target cholesterol levels may reduce CVD risks.⁵

Lifestyle modifications are often considered first-line therapy in the management of diabetic dyslipidemia.⁶ Recommended interventions include weight loss, diet modifications, and aerobic exercise.⁶ Obesity increases insulin resistance and is related to increased triglyceride levels and LDL cholesterol (LDL-C) and decreased HDL-C. Research has demonstrated that weight loss may enhance lipid levels and decrease other CVD risk factors, including the incidence of T2D, as well as improve glycemic control and glycated hemoglobin levels; consequently, weight loss should be recommended in overweight/obese patients with diabetes.⁶ The American Diabetes Association (ADA) recommends that patients with diabetes establish an exercise regimen, such as brisk walking for more than 30 minutes a d day, 5 days a week, when appropriate.⁴

The 2017 ADA Standards of Care⁵ recommend various measures for lipid management in patients with diabetes, including the following:

• Initiate lifestyle modifications that focus on weight loss if warranted; a reduction of saturated fat, trans fat, and cholesterol intake; an increase in intake of omega-3 fatty acids, viscous fiber, and plant stanols/sterols; and an increase in physical activity. Tailor dietary modifications to each patient’s age, diabetes type, pharmacologic therapy, lipid levels, and comorbid medical conditions.
• For patients of all ages with diabetes and atherosclerotic CVD (ASCVD), add high-intensity statin therapy to lifestyle modifications.
• For patients with diabetes aged 40 to 75 without additional ASCVD risk factors, consider the use of moderate-intensity statin therapy and lifestyle modifications.
• For patients with recent acute coronary syndrome and LDL-C >50 mg/dL (1.3 mmol/L) and patients with diabetes and a history of ASCVD who cannot tolerate high-intensity statin therapy, add ezetimibe to moderate-intensity statin therapy. Ezetimibe was proven to provide additional cardiovascular benefit compared with moderate-intensity statin therapy alone.

The complete list of 2017 ADA recommendations for lipid management in patients with diabetes can be found at professional.diabetes.org/ sites/professional.diabetes.org/files/media/dc_40_ s1_final.pdf.

When counseling patients with diabetes, pharmacists should seize every opportunity to ensure that patients are fully aware of the significance of routine blood glucose monitoring, compliance with their prescribed therapy, and regular medical care to effectively control diabetes and to prevent or reduce the occurrence of diabetes-related complications, including CVD. Pharmacists should also recommend to patients web-based resources that they can read at their leisure.^7—9

Ms. Terrie is a clinical pharmacist and medical writer based in Haymarket, Virginia.

References

• American Heart Association. Cardiovascular disease & diabetes. The American Heart Association website. heart.org/HEARTORG/Conditions/More/Diabetes/WhyDiabetesMatters/Cardiovascular-Disease-Diabetes_UCM_313865_Article.jsp#.WTrKUWjys2w. Published April 14, 2017. Accessed June 7, 2017.
• Solano M. Goldberg R. Lipid management in type 2 diabetes. Clin Diabetes. 2006;24(1):27-32.
• Haffner SM; American Diabetes Association. Dyslipidemia management in adults with diabetes. Diabetes Care. 2004;27(suppl 1):68-71.
• Daniel MJ. Lipid management in patients with type 2 diabetes. Am Health Drug Benefits. 2011;4(5):312-322.
• American Diabetes Association. Standards of medical care in diabetes—2017. Diabetes Care. 2017:40(suppl 1):1—135.
• Schofield JD, Liu Y, Rao-Balakrishna P, et al. Diabetes dyslipidemia. Diabetes Ther. 2016;7(2):203-219.
• American Diabetes Association. All about cholesterol. The American Diabetes Association website. diabetes.org/are-you-at-risk/lower-your-risk/cholesterol.html?referrer=https://www.google.com. Accessed June 17, 2017.
• National Diabetes Education Initiative. The relationship between type 2 diabetes and cardiovascular disease—it’s complicated. The National Diabetes Education Initiative website. ndei.org/uploadedFiles/Common/NDEI/Home/Whats_New/T2DandCVD.pdf. Accessed June 17, 2017.
• American Heart Association. Cholesterol abnormalities and diabetes. The American Heart Association website. heart.org/HEARTORG/Conditions/More/Diabetes/WhyDiabetesMatters/Cholesterol-Abnormalities-Diabetes_UCM_313868_Article.jsp#.WT3bxWjys2w. Accessed June 17, 2017.