addition of PCSK9 inhibitors (human antibodies), such as evolocumab or alirocumab, added to the maximum tolerated dose of statin in individuals who are at ...
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Newer Data on the Treatment of Dyslipidemia and Atherosclerosis in the Patient with Diabetes Mellitus. V.G. Athyros, Prof. of Internal Medicine, University of Thessaloniki, Greece. Diabetes (DM) is one of the most prevalent and lethal chronic diseases worldwide (Figure 1). Figure 1
Type 2 Diabetes Prevalence Globally, 387 million people are living with diabetes1
This will rise to 592 million by 20351
All-cause mortality by disease status of participants at baseline2 Hazard ratio (95% Cl)a
Disease status at baseline Diabetes, stroke, and MI
6.9 (5.7, 8.3)
Stroke and MI
3.5 (3.1, 4.0)
Diabetes and stroke
3.8 (3.5, 4.2)
Diabetes and MI
3.7 (3.3, 4.1)
MI
2.0 (1.9, 2.2)
Stroke
2.1 (2.0, 2.2)
Diabetes
1.9 (1.8, 2.0)
Hazard ratio (95% CI)
None 1,0
2,0
4,0
8,0
1.0 (Ref)
16,0
1. IDF Diabetes Atlas 6th Edition 2014 http://www.idf.org/dia betesatla s; 2. The Emerging Risk Factors Collaboration. JAMA. 2015;314(1):52-60.
2
The leading causes of morbidity and mortality for people with DM (dyslipidemia, hypertension, obesity, smoking, etc) have the largest contribution to the social and economic cost of DM. These common conditions that coexist with DM (especially type 2), such as dyslipidemia, hypertension, smoking are also the major risk factors for atherosclerotic cardiovascular disease (ASCVD) and not only contribute to the development of DM, who alone adds an independent increase in ASCVD risk to a degree that it is characterized to be an equivalent to the established ASCVD (Figure 2), but also has a geometrical synergy with them to maximize the risk.
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Figure 2
DM – Strongest RF for CVD
Therefore, dyslipidemia (and hypertension), which are the main risk factors for both DM and ASCVD (Figure 3), are associated with the development of all atherosclerotic events such as acute coronary syndromes (ACS) Myocardial infarction (MI), stable or unstable angina, coronary arterial revascularization, stroke, transient vascular stroke or peripheral arterial disease. Figure 3
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A plethora of studies have shown the effectiveness of various drugs in controlling ASCVD risk factors in preventing or slowing ASCVD progression in people with DM. The American Diabetes Association (ADA) is the only Society that publishes guidelines exclusively for diabetic patients for treating dyslipidaemia. ADA recommends in the 2017 guidelines the following: 1. Lifestyle modification focusing on weight loss (if any), reduction in saturated or trans fats and cholesterol uptake, increased consumption of omega-3 fatty acids, fiber, and intake of plant stanols / sterols, as well as increased physical activity to improve the lipid profile in patients with DM. Recommendation A. 2. Optimization of glycemic control for patients with elevated triglyceride levels (> 150 mg / dL [1,7 mmol / L]) and / or low HDL cholesterol (40 mg / dL [1,0 mmol / L] 50 mg / dL [1.3 mmol / L] for women). Recommendation C 3. For patients of all ages with DM and ASCVD, use of high-intensity statin. Treatment should begin immediately after diagnosis and be added to lifestyle change. Recommendation A. 4. For patients with 75 years with DM without additional risk factors ASCVD is a moderate-intensity statin and a lifestyle change. Recommendation Β 8. For elderly patients > 75 years with DM without additional ASCVD risk factors is recommended a moderate-intensity statin or high-intensity statin (similar to the years patients have DM) and a change in lifestyle. Recommendation Β 9. The addition of ezetimibe to moderate-intensity statin therapy has been shown to provide additional cardiovascular benefits compared to moderate statin alone. Recommendation Ε 10. Combination therapy (statin / fibrate) has not been shown to improve ASCVD in all diabetics. However, statin and fenofibrate treatment may be used in men with
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triglyceride levels > 204 mg / dL (2.3 mmol / L) and HDL cholesterol
