![](media/image1.png){width="4.15625in" height="1.1666666666666667in"}

The Importance of Eliminating Poor Lipid Control in Patients with Type 2
Diabetes

Although treatment of blood sugar can help prevent devastating eye,
kidney, and nerve complications, we must never forget that the most
common causes of death and morbidity in type 2 diabetes are related to
cardiovascular disease. Therefore, we must aggressively treat modifiable
cardiovascular risk factors and substantial elevations of LDL must be
one of our highest treatment priorities.^1^

The optimal LDL-cholesterol level in patients with type 2 diabetes is
uncertain. Some evidence suggests that there may be benefit in pushing
levels below 100 mg/dL (as recommended by the ADA).^2-4^ However, it is
likely that the majority of the excess mortality risk occurs at LDL
levels above 130 mg/dL. Even for those with known coronary artery
disease (CAD) extreme lowering of LDL values has mainly been associated
with fewer non-fatal events, not with improved survival. Recent studies
suggest that patients with diabetes with known CAD may achieve more
benefit than the general population when those with LDLs greater than
130 mg/dL are treated with statins.^1,4^ Elimination of substantially
elevated LDL levels in individuals with type 2 diabetes is likely to be
highly cost-effective and must be one of the highest priorities for VA
diabetes care. In addition, since diabetics have a high annual incidence
of cardiovascular events, it is critical to get LDL-C below this
high-risk level within 4-6 months whenever possible.

Just when and how aggressively triglycerides and low HDL syndrome should
be treated in type 2 diabetes remains controversial. It is well
established that low HDL, particularly in combination with elevated
triglycerides, is an independent risk factor for CAD in patients with
type 2 diabetes.^3,5-8-^ However, there is no clear evidence that
treatment of this syndrome is beneficial in patients with type 2
diabetes.^8^ Recently, a study of patients with low HDL and low LDL
syndrome demonstrated substantial improvement in cardiovascular events
with gemfibrozil treatment.^9^

# Recommendation

Lipid profiles should be obtained on patients with diabetes annually or
as indicated to guide therapy

Treatment with aggressive lipid lowering therapy should be instituted as
needed to achieve an LDL value \< 130 mg/d.

Get LDL-C under-control within 4-6 months whenever possible (by dosing
statins so as to meet goals quickly and arranging 1-2 month follow-up
until the minimum LDL-C goal (\< 130mg/dl) is achieved

1\. The CDC Diabetes Cost-effectiveness Group. Cost-effectiveness of
Intensive Glycemic Control, Intensified Hypertension Control, and Serum
Cholesterol Level Reduction for Type 2 Diabetes. JAMA. 2002;287:2542-51.

2\. Pyorala K, Pedersen TR, Kjekshus J, Faergeman O, Olsson AG,
Thorgeirsson G. Cholesterol lowering with simvastatin improves prognosis
of diabetic patients with coronary heart disease. A subgroup analysis of
the Scandinavian Simvastatin Survival Study (4S). *Diabetes Care.*
1997;20:614-20.

3\. Haffner SM. Management of dyslipidemia in adults with diabetes.
*Diabetes* *Care.* 1998;21:160-78.

4\. Haffner SM, Lehto S, Ronnemaa T, Pyorala K, Laakso M. Mortality from
coronary heart disease in subjects with type 2 diabetes and in
nondiabetic subjects with and without prior myocardial infarction \[see
comments\]. *N Engl J Med.* 1998;339:229-34.

5\. Haffner SM. The Scandinavian Simvastatin Survival Study (4S)
subgroup analysis of diabetic subjects: implications for the prevention
of coronary heart disease \[editorial; comment\]. *Diabetes Care.*
1997;20:469-71.

6\. Lehto S, Ronnemaa T, Haffner SM, Pyorala K, Kallio V, Laakso M.
Dyslipidemia and hyperglycemia predict coronary heart disease events in
middle-aged patients with NIDDM. *Diabetes.* 1997;48:1354-9.

7\. Uusitupa MI , Niskanen LK , Siitonen O , Voutilainen E , Pyorala K.
Ten-year cardiovascular mortality in relation to risk factors and
abnormalitites in lipoprotein composition in type 2
(non-insulin-dependent) diabetic and non-diabetic subjects.
*Diabetologia.* 1993;36:1175-84.

8\. Uusitupa MI, Niskanen LK, Siitonen O, Voutilainen E, Pyorala K.
5-year incidence of atherosclerotic vascular disease in relation to
general risk factors, insulin level, and abnormalities in lipoprotein
composition in non-insulin-dependent diabetic and nondiabetic subjects.
*Circulation.* 1990;82:27-36.

9\. Rubins HB, Robins SJ, Collins D, et al. Gemfibrozil for the
secondary prevention of coronary heart disease in men with low levels of
high-density lipoprotein cholesterol. Veterans Affairs High-Density
Lipoprotein Cholesterol Intervention Trial Study Group. *N Engl J Med.*
1999;341:410-8.