dyslipedemia dr.saeid

Canadian Diabetes Association Clinical Practice Guidelines

Dyslipidemia

Dr.Saeid Khezer Family physician Kurdistan / Duhok

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association

Dyslipidemia Checklist

CHECK lipid profile at diagnosis then yearly or every 3-6 months when on treatment

USE statins as first-line therapy

ADD second line agent only when LDL-C is not at target despite statin therapy

USE fibrate when TG >10.0 mmol/L

2013


• Repeat yearly if treatment not started

• Repeat q3-6mos if on treatment

• Fasting (8-hr) profile:– Total cholesterol, triglycerides, HDL-C, LDL-C

or • Non-fasting profile:

– ApoB – Non-HDL-C

Measure Lipids at Diagnosis


Who should receive statin therapy?

(10269) (10267)SIMVASTATIN PLACEBO Rate ratio & 95% CI

STATIN better PLACEBO better

999 1250(23.5%) (29.4%)Previous MI

460 591(18.9%) (24.2%)Other CHD (not MI)

No prior CHD172 212(18.7%) (23.6%)CVD327 420(24.7%) (30.5%)PVD

276 367(13.8%) (18.6%)Diabetes

24%reduction(P<0.00001)

2033 2585(19.8%) (25.2%)ALL PATIENTS

0.4 0.6 0.8 1.0 1.2 1.4

HPS Lancet 2002;360:7-22

HPS = Heart Protection Study

HPS: Statin Therapy Beneficial Among Patients with Diabetes


• n = 2838• Age 40-75, no history of CVD• T2DM plus one or more:

– Retinopathy– Albuminuria– Hypertension– Smoking

• Intervention: Atorvastatin 10 mg vs. Placebo• Outcome: ACS, revascularization, stroke

Colhoun HM, et al. Lancet 2004;364:685.


CARDS: Effect of Statin for PRIMARY Prevention in DM

CARDS: Statins Reduced CVD in Patients with DM

Colhoun HM, et al. Lancet 2004;364:685.



• ≥40 yrs old or • Macrovascular disease or• Microvascular disease or• DM >15 yrs duration and age >30 years or• Warrants therapy based on the 2012 Canadian

Cardiovascular Society lipid guidelines

Among women with childbearing potential, statins should only be used in the presence of proper preconception counseling &

reliable contraception. Stop statins prior to conception.

2013Who Should Receive Statins? (regardless of baseline LDL-C)


What if baseline LDL-C ≤2.0 mmol/L?

• Within CARDS and HPS, the subgroups that started with lower baseline LDL-C still benefited to the same degree as the whole population

• If the patient qualifies for statin therapy based on the algorithm, use the statin regardless of the baseline LDL-C and then target an LDL reduction of ≥50%

HPS Lancet 2002;360:7-22 Colhoun HM, et al. Lancet 2004;364:685.


Statin Options


If on therapy, target

LDL ≤2.0 mmol/L


• Smoking cessation• Energy-restricted diet (see CPG Chapter 11)

– Low cholesterol– Low saturated and trans fatty acids– Low refined carbohydrates– Include viscous fibres, plant sterols, nuts, soy proteins– Alcohol in moderation

• Physical activity (see CPG Chapter 10)

Statin Therapy Should be Concomitant with Lifestyle Therapy


Second- Line Agents: Only if LDL-C Target not Reached with Statin

• Bile acid sequestrants

• Cholesterol absorption inhibitors

• Fibrates

• Nicotinic acid


Drug Class• Generic name (Trade

name)

Principal Effects Other Considerations

Bile Acid Sequestrant•Cholestyramine resin (Questran)•Colestipol HCl (Colestid)•Colesevalam (Lodalis)

Lowers LDL-C Gastrointestinal intolerabilityTG elevationColesevelam: A1C lowering effect

Cholesterol Absorption Inhibitor•Ezetimibe (Ezetrol)

Lowers LDL-C Effective in combination with statin

Fibrate•Bezafibrate (Bezalip SR)•Fenofibrate (Lipidil)•Gemfibrozil (Lopid)

Lowers TG Variable LDL-C effectVariable HDL-C effect

May creatinine + homocysteine (but long term fenofibrate use has favorable renal effects)Do not combine gemfibrozil + statin

Nicotinic Acid•ER Niacin (Niaspan, Niaspan FCT)•IR Niacin (non-prescription)•LA (“no-flush”) Niacin – not recommended

Lower TG + LDL-CRaise HDL-C

Dose related deterioration in glycemiaER Niacin more tolerable than IR Long-acting niacin should NOT be used

ER = extended release; IR = immediate release; LA=long acting; TG=triglycerides; FCT=film coated tablet; SR=sustained release


2013If Triglycerides >10.0 mmol/L…

• Use a FIBRATE to reduce the risk of pancreatitis

• Optimize glycemic control

• Implement lifestyle interventions– Weight loss– Optimal dietary strategies– Reduce alcohol


1. A fasting (8-hour fast) lipid profile (TC, HDL-C, TG and calculated LDL- C) or non-fasting lipid profile (apo B), should be measured at the time of diagnosis of diabetes.

If lipid lowering treatment is not initiated, repeat testing is recommended yearly.

Frequent testing (every 3-6 months) should be performed if treatment for dyslipidemia is initiated [Grade D, Consensus]

2013Recommendation 1


2. For patients with indications for lipid lowering therapy treatment (see Vascular Protection chapter), treatment should be initiated with a statin [Grade A, Level 1] to achieve an LDL-C ≤2.0 mmol/L [Grade C, Level 3]

3. In patients achieving target LDL-C with statin therapy, the routine addition of fibrates or niacin for the sole purpose of further reducing cardiovascular risk should not be used [Grade A, Level 1].

2013

Recommendation 2 and 3


Recommendation 4

4. For individuals not at LDL-C target despite statin therapy as described above, a combination of statin therapy with second-line agents may be used to achieve the LDL-C targets [Grade D Consensus]


Recommendation 5

5. For those who have serum TG >10.0 mmol/L, a fibrate should be used to reduce the risk of pancreatitis [Grade D, Consensus] while also optimizing glycemic control and implementing lifestyle interventions (e.g. weight loss, optimal dietary strategies, and reduction of alcohol).

2013


Vascular Protection Checklist 2013

A • A1C – optimal glycemic control (usually ≤7%) B • BP – optimal blood pressure control (<130/80) C • Cholesterol – LDL ≤2.0 mmol/L if decided to treat D • Drugs to protect the heart (regardless of baseline BP or LDL)

A – ACEi or ARB │ S – Statin │ A – ASA if indicated

E • Exercise / Eating healthily – regular physical

activity, achieve and maintain healthy body weight S • Smoking cessation

CDA Clinical Practice Guidelines

www.guidelines.diabetes.ca – for professionals

1-800-BANTING (226-8464)

www.diabetes.ca – for patients

http://guidelines.diabetes.ca/

http://diabetes.ca/

dyslipedemia dr.saeid

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