## Type 2 Diabetes and Management of Hyperlipidemias 

**Step 1: Ensure triglyceride (TG) level is not dangerously high.** If
triglycerides \> 500mg/dL, restrict dietary fat intake, intensify blood
glucose control, rule-out hypothyroidism or other causes of elevated TG.
Consider using Gemfibrozil, Fish Oil, or Niaspan.

**Step 2:** Check LDL levels. LDL goal is \< 100mg/dL; consider LDL \<
70mg/dL for patients with known cardiovascular disease.

If LDL is \> 100 mg/dL, initiate therapeutic lifestyle changes
recommended by ATP III Guidelines (see reference below). Start
Simvastatin 40mg at bedtime (HS). If goal LDL is not achieved with
Simvastatin 80mg, consider switching to Atorvastatin 80mg daily.

**Step 3:** Check Triglycerides: Triglyceride goal is \< 150 mg/dL. If
triglycerides are \> 150mg/dL, start or add Fish Oil, Gemfibrozil 600mg
twice daily (BID), or Niaspan 500mg at bedtime (HS).

**For all adults with diabetes older than age 30,** give aspirin (ASA)
81mg daily if there is no history of cardiovascular disease.

**Table 1. Medications, effect on blood lipid levels and dosages**

<table style="width:100%;">
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<tbody>
<tr class="odd">
<td colspan="2"><strong>Medication</strong></td>
<td colspan="3"><strong>LDL</strong></td>
<td colspan="3"><strong>HDL</strong></td>
<td colspan="3"><strong>TG</strong></td>
<td colspan="4"><strong>Starting Dose</strong></td>
<td><strong>Max Dose</strong></td>
</tr>
<tr class="even">
<td><p><strong>Statins:</strong></p>
<p>Simvastatin (Zocor ®)</p></td>
<td colspan="3">-20 to 50%</td>
<td colspan="3">+5 to10%</td>
<td colspan="3">-15 to 30%</td>
<td colspan="4">40mg HS</td>
<td colspan="2">80mg HS</td>
</tr>
<tr class="odd">
<td>*Atorvastatin (Lipitor ®)</td>
<td colspan="3">-20 to 55%</td>
<td colspan="3">+5 to10%</td>
<td colspan="3">-15 to 30%</td>
<td colspan="4">10 to 20mg/day</td>
<td colspan="2">80mg/day</td>
</tr>
<tr class="even">
<td><p><strong>Fibrates:</strong></p>
<p>Gemfibrozil (Lopid ®)</p></td>
<td colspan="3">-0 to20%</td>
<td colspan="3">+10 to 25%</td>
<td colspan="3">-20 to 35%</td>
<td colspan="4">600mg BID</td>
<td colspan="2">600mg BID</td>
</tr>
<tr class="odd">
<td>*Fenofibrate (Tricor ®)</td>
<td colspan="3">-20%</td>
<td colspan="3">+9 to15%</td>
<td colspan="3">-20 to 35%</td>
<td colspan="4">145mg daily</td>
<td colspan="2">145mg daily</td>
</tr>
<tr class="even">
<td colspan="3"><p><strong>Others:</strong></p>
<p>Niacin</p></td>
<td colspan="3">-5%</td>
<td colspan="3">+10%</td>
<td colspan="3">-10%</td>
<td>500mg/day</td>
<td colspan="3">2 to 3g/day</td>
</tr>
<tr class="odd">
<td colspan="3">(Niaspan ®)</td>
<td colspan="3">-20%</td>
<td colspan="3">-30%</td>
<td colspan="3">-35%</td>
<td>HS</td>
<td colspan="3">HS</td>
</tr>
<tr class="even">
<td>*Ezetimibe (Zetia®)</td>
<td colspan="3">-13%</td>
<td colspan="3">+1 to 4%</td>
<td colspan="3">-8 to 11%</td>
<td colspan="4">10mg/daydaily</td>
<td colspan="2">10mg/day</td>
</tr>
<tr class="odd">
<td>*Cholesevalam (Welchol ®)</td>
<td colspan="3">-15 to 20%</td>
<td colspan="3">+3%</td>
<td colspan="3">+0 to 5%</td>
<td colspan="4">3 tab BID or 6 tab daily</td>
<td colspan="2">3 tab BID or 6 tab daily</td>
</tr>
<tr class="even">
<td>*Fish Oil (Omacor ®)</td>
<td colspan="3">+45%</td>
<td colspan="3">+9%</td>
<td colspan="3">-45%</td>
<td colspan="4">4g/day</td>
<td colspan="2">4g/day</td>
</tr>
<tr class="odd">
<td>*Fish Oil OTC</td>
<td colspan="3">+5 to10%</td>
<td colspan="3">+1 to 3%</td>
<td colspan="3">-25 to 40%</td>
<td colspan="4">2 to 4g/day EPA plus DHA</td>
<td colspan="2">2 to 4 g/day EPA plus DHA</td>
</tr>
</tbody>
</table>

\*These drugs are not on the IHS National Core Formulary.

Note: Atorvastatin 80mg is on the formulary while lower doses are not.

### Contraindications: 

**Statins:** active liver disease, alcohol abuse, pregnancy & lactation

**Niacin:** active gout or peptic ulcer disease, active liver disease,
pregnancy & lactation

**Gemfibrozil:** active liver disease, gallbladder disease, pregnancy &
lactation

### Lab Monitoring: use Alanine aminotransferase (ALT) levels\*

Simvastatin - Baseline, 6 months and then yearly

Simvastatin 80mg - Baseline, 3 months and 6 months and then yearly

Atorvastatin 80mg - Baseline, 12 weeks and then every 6 months

Niacin - Baseline, every 3 months for 1 year and then every 6 months

Gemfibrozil - Baseline, every 3 months for 1 year and then every 6
months

Omacor -- Periodic ALT

\*Note: Discontinue or restart medications at a lower dosage if the ALT
is \> 3 times the normal level.

### Other Lab Tests 

Check creatine phosphokinase (CK) if patient complains of muscle pain

When giving Niacin, follow the blood glucose levels of CK closely. Check
uric acid levels at baseline and when dose is stable; may need to be
checked in patients suspected of gout.

### Combination Therapy 

[Fibrates (Gemfibrozil) & Statin]{.underline}: begin with low doses of
Simvastatin (5 to 20mg); obtain baseline CK and recheck if patient
complains of muscle pain.

[Other Combinations:]{.underline} Obtain baseline ALT and CK. Follow
strictest monitoring guidelines.

### 

### References

American Diabetes Association Clinical Practice Recommendations 2007 -
<http://care.diabetesjournal.org/content/vol30/supple_1>

ATP III - <http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm>