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Lipid control in patients with diabetes mellitus

Nature Reviews Cardiology volume 8, pages 278–290 (2011)Cite this article

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Abstract

Patients with diabetes mellitus are at increased risk of cardiovascular disease (CVD). Dyslipidemia, an important component of the insulin resistance syndrome and type 2 diabetes, is strongly related to CVD risk and is open to therapeutic intervention. Statins have proved to be safe, very-well tolerated, and highly effective in reducing the levels of LDL cholesterol and apolipoprotein B. Primary and secondary CVD prevention trials have shown that use of statins leads to highly significant reductions in the incidence of major CVD events. A wealth of data on the outcomes of statin therapy is now available to guide clinical practice in the population of patients with type 2 diabetes. Statin therapy in patients with type 1 diabetes seems to have a similar benefit to that seen in patients with type 2 diabetes. However, despite statin therapy, high CVD risk persists in these populations. More-intensive statin therapy produces greater reduction in the incidence of CVD events, but a more-global approach to lipid management is likely to result in further risk reduction. After reductions in the levels of LDL cholesterol and apolipoprotein B, the next target of lipid-lowering therapy is to increase HDL-cholesterol levels, which tend to be low in patients with type 2 diabetes. The most effective HDL-cholesterol-raising agent currently available for use in clinical practice is niacin. Trials with surrogate end points have pointed to the cardiovascular benefit of adding niacin to statin therapy. Large CVD end point trials, which include many patients with diabetes, are underway to test the combination of a statin and niacin versus a statin alone.

Key Points

  • Both type 1 and type 2 diabetes mellitus are associated with a substantially increased burden of cardiovascular disease

  • Quantitative and qualitative changes in lipids and lipoproteins are common in type 2 diabetes and contribute to cardiovascular risk

  • Statins are highly effective in lowering the levels of LDL cholesterol and other apolipoprotein-B-containing lipoproteins in patients with type 1 and type 2 diabetes

  • Statins have been shown to reduce the incidence of major cardiovascular events in both primary and secondary prevention trials in these patient populations

  • Despite effective statin therapy, considerable residual cardiovascular risk persists in these patients; a more-global approach to lipid management that includes measures to increase HDL-cholesterol levels might be appropriate

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Figure 1: Effect of treatment with atorvastatin on primary and secondary end points in the Collaborative Atorvastatin Diabetes Study (CARDS).35
Figure 2: Cholesterol Treatment Trialists' meta-analysis on the efficacy of statin therapy in people with diabetes mellitus.41
Figure 3: Meta-analysis of cardiovascular outcomes of intensive versus moderate statin therapy.59

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  1. Department of Diabetes and Endocrinology, University College Hospital, 3rd Floor Central, 250 Euston Road, NW1 2PQ, London, UK

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D. J. Betteridge is a consultant and in the speakers bureau of the following companies: AstraZeneca, Kowa, MSD, Pfizer, Roche, and Takeda.

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Betteridge, D. Lipid control in patients with diabetes mellitus. Nat Rev Cardiol 8, 278–290 (2011). https://doi.org/10.1038/nrcardio.2011.23

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