How Should Lipid Levels Be Managed for Persons With Diabetes?
Kim A. Carmichael, MD—Series Editor
Carmichael KA. How should lipid levels be managed for persons with diabetes? Consultant. 2016;56(10 Suppl):S8-S9.
Q. Which lipid disorders are most common in persons with diabetes?
A. Type 2 diabetes, particularly with poor glycemic control, is commonly associated with increased levels of low-density lipoprotein cholesterol (LDL-C, particularly small, dense LDL-C particles), triglycerides, and apolipoprotein B, and decreased levels of high-density lipoprotein cholesterol (HDL-C). These are all associated with increased cardiovascular disease (CVD) risk.1,2 Patients with type 1 diabetes typically do not have low HDL-C or high triglyceride levels but still need lipid management due to increased CVD risk.1,2
Q. When should persons with diabetes have lipid testing?
A. Children with diabetes who are 10 years of age or older should be screened at diagnosis and again every 3 to 5 years thereafter to maintain LDL-C levels less than 100 mg/dL, according to American Diabetes Association (ADA) guidelines.3 The National Institutes of Health expert panel recommends lipid screening in children with diabetes as young as 2 to 8 years.4
Adult screening and testing guidelines differ among major specialty organizations. According to the ADA,1 lipid testing should be performed at the time of diagnosis and every 5 years thereafter if the person is not on statin therapy, or periodically if the person is taking lipid-lowering medication. The American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) dyslipidemia guidelines2 recommend annual screening, reassessment 6 weeks after starting or adjusting therapy, and then every 6 to 12 months. The American Heart Association/American College of Cardiology Foundation (AHA/ACCF) recommendations5 are to check fasting lipids 4 to 12 weeks after starting therapy or changing doses, and every 3 to 12 months once stable. The National Lipid Association (NLA)6 recommends testing every 4 to 12 months once lipid goals have been achieved.
Q. What lifestyle modifications may help persons with diabetes to manage lipid levels?
A. The ADA recommends reducing saturated fat, trans-fat, and cholesterol intake; increasing ω-3 fatty acid, viscous fiber, and plant sterol intake; increasing physical activity; and promoting weight loss, if appropriate.1 The AACE/ACE guidelines also recommend a reduced-calorie diet as well as an exercise program that includes at least 30 minutes of moderate-intensity physical activity 4 to 6 times per week, with a minimum of 200 kcal/d.2
Q. Which medications should be considered for persons with diabetes?
A. Statin therapy, if tolerated, is the basis for all major recommendations for dyslipidemia in persons with diabetes, both for primary and secondary prevention of cardiovascular events. The American College of Physicians7 recommends statin therapy for all patients with diabetes plus other CVD risk factors. In contrast, the AHA/ACCF5 promotes statin therapy for adults with diabetes and an LDL-C level of 70 mg/dL or greater if aged 40 to 75 years and supports therapy for those from 21 to 40 years and those older than 75 years.5 High-intensity statin therapy is recommended for all persons aged 21 to 75 years with documented CVD, for the same age group with CVD risk plus an LDL-C level from 70 to 190 mg/dL, and all adults with an LDL-C level greater than 190 mg/dL. According to the ADA,1 moderate-intensity statin therapy should be considered for persons with diabetes from 40 to 75 years of age without CVD risk and for persons younger than 40 or older than 75 years with high CVD risk. High-intensity statin therapy should be initiated for persons aged 40 to 75 years with concomitant CVD risk.1
Other drugs for consideration to reduce LDL-C levels include ezetimibe, bile-acid sequestrants, and niacin.1,2 In order to reduce triglyceride levels in select populations, fibrates and ω-3 fish oil may be considered. In patients with refractory hyperlipidemia, PCSK9 inhibitor therapy (ie, alirocumab or evolocumab) may be considered, but no current guidelines exist for this option in persons with diabetes. Extended-release niacin has been shown to increase HDL-C levels.8
Q. What lipid targets, if any, should be considered in persons with diabetes?
A. The ADA1 and AHA/ACCF guidelines5 do not provide specific target LDL-C levels for statin therapy. The AACE/ACE guidelines2 recommend a target LDL-C of less than 100 mg/dL, and the NLA6 recommends that the LDL-C level be less than 100 mg/dL, but less than 70 mg/dL if there are more than 2 additional CVD risk factors or is evidence of end-organ damage. A triglyceride target level of less than 150 mg/dL is recommended by the ADA1 and AACE/ACE.2 The HDL-C level should be greater than 40 mg/dL in men and greater than 50 mg/dL in women.1 The non-HDL-C level (total cholesterol minus HDL-C) should be less than 130 mg/dL in general but less than 100 mg/dL in persons at high risk for CVD.6
Kim A. Carmichael, MD, is an associate professor of medicine in the Department of Medicine, Division of Endocrinology, Metabolism and Lipid Research, at Washington University School of Medicine in St Louis, Missouri. He discloses that he is on the speakers bureaus for Merck and Janssen, which may be relevant to the content of this article.
- American Diabetes Association. 8. Cardiovascular disease and risk management. Diabetes Care. 2016;39(suppl 1):S60-S71.
- Jellinger PS, Smith DA, Mehta AE, et al; AACE Task Force for Management of Dyslipidemia and Prevention of Atherosclerosis. American Association of Clinical Endocrinologists’ guidelines for management of dyslipidemia and prevention of atherosclerosis. Endocr Pract. 2012;18(suppl 1):1-78.
- American Diabetes Association. 11. Children and adolescents. Diabetes Care. 2016;39(suppl 1):S86-S93.
- Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung, and Blood Institute. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: summary report. http://www.nhlbi.nih.gov. Accessed September 7, 2016.
- Smith SC, Benjamin EJ, Bonow RO, et al. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation. 2011;124(22):2458-2473.
- Jacobson TA, Ito MK, Maki KC, et al. National Lipid Association recommendations for patient-centered management of dyslipidemia: part 1 – executive summary. J Clin Lipidol. 2014;8(5):473-488.
- Snow V, Aronson MD, Hornbake ER, et al; Clinical Efficacy Assessment Subcommittee. Lipid control in the management of type 2 diabetes mellitus: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2004;140(8):644-649.
- Fazio S, Guyton JR, Polis AB, et al. Long-term safety and efficacy of triple combination ezetimibe/simvastatin plus extended-release niacin in patients with hyperlipidemia. Am J Cardiol. 2010;105(4):487-494.