Cholesterol and lipids - Diabetes in Berkshire West
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Transcript Cholesterol and lipids - Diabetes in Berkshire West
Cholesterol and Lipids
TIPS
Wokefield Park 15/5/2013
Just a few questions!
What is the NDA target for total cholesterol and LDL
cholesterol?
What are the QOF targets for cholesterol?
What is the ideal time to take a statin and why?
Name the most serious side effect of statins.
What blood test would you order if you suspected it?
Name another side effect of statins.
All statins increase HDL cholesterol – true or false?
What is the most typical lipid profile for type 2 diabetes?
What is the most typical lipid profile for type 1 diabetes?
R77 Statins & Ezetimibe
For a person who is 40 yrs+
• Simvastatin (to 40 mg) unless CVS risk
from non-hyperglycaemia-related factors
is low (see R72)
R72 Consider a person to be at
high CVS risk unless……
• Not overweight
• Normotensive
• No microalbuminuria
• Non-smoker
• No high risk lipid profile
• No h/o CVS disease
• No FH of CVS disease
If low CVS risk…………
• Assess CVS risk using UKPDS risk engine
• Start simvastatin if CVS risk > 20% over
10 yrs
Once on a statin………..
• Repeat lipid profile in 1-3 months then
annually
• If total cholesterol>4.0 or LDL cholesterol
>2.0 mmol/L titrate simvastatin to 80 mg
daily
Consider intensifying if…….
• Existing/newly diagnosed CVS disease
• Choose different statin/ezetimibe
If h/o raised triglycerides…….
• Consider secondary causes
• Full lipid profile
• Prescribe fenofibrate if Tg remain > 4.5
mmol/L
• If Tg remain > 2.3 mmol/L consider
adding fenofibrate to statin
Kaplan–Meier Estimates of the Incidence of Outcome Events in the Total Study Population.
Estruch R et al. N Engl J Med 2013;368:1279-1290
Statins do not alter the risk of Low HDL
Heart Protection Study
(Diabetes subgroup)
35
30
% CHD Events
25
31.1
25.9
20
21.3
16.8
15
10
5
0
< 0.9
placebo
≥ 0.9
HDL Cholesterol (mmol/L)
simvastatin 40mg
Adapted from Heart Protection Study Collaborative Group. Lancet 2003; 361: 2005-2016.
If you needed to treat these lipids what would you prescribe?
• Total cholesterol 5.35 mmol/L
• HDL cholesterol
1.4 mmol/L
• Triglycerides
1.68 mmol/L
LIPID
LIPID RESULTS
22% reduced mortality
24% reduced CHD mortality
29% reduced all CVS outcomes
20% reduced revascularisation
P<0.001
p<0.001
p<0.001
p<0.001
LIPID – Diabetics & Nonsmokers
No (%) CHD Events
Placebo
Pravastatin
Diabetics
Non-smokers
88(23)
76(19)
167(13)
139(12)
New Eng J Med 1998; 339: 1349-57
ASCOT
• Age 40-79
• Untreated BP 160/100 or more
• Treated BP 140/90 or more
• Total cholesterol < 6.5 mmol/L
• 3+ of LVH,ischaemic ECG,type 2
diabetes,PVD,previous stroke or TIA,male,
age > 55,smoker,microalbuminuria,family
history of premature CHD
Lancet 2003;361:1149-1158
Figure 2
Source: The Lancet 2003; 361:1149-1158 (DOI:10.1016/S0140-6736(03)12948-0)
Terms and Conditions
Figure 5
Source: The Lancet 2003; 361:1149-1158 (DOI:10.1016/S0140-6736(03)12948-0)
Terms and Conditions
CARDS Recruitment Criteria
• 2838 T2DM
• Age 40-75
• No known CVS disease
• Hypertension or retinopathy or
microalbuminuria
• Serum LDL < 4.14 mmol/L
• Serum triglycerides < 6.8 mmol/L
Figure 4
Source: The Lancet 2004; 364:685-696 (DOI:10.1016/S0140-6736(04)16895-5)
Terms and Conditions
CARDS Baseline Characteristics
• Total cholesterol 5.35 mmol/L
• HDL cholesterol
1.4 mmol/L
• Triglycerides
1.68 mmol/L
Figure 2
Source: The Lancet 2004; 364:685-696 (DOI:10.1016/S0140-6736(04)16895-5)
Terms and Conditions
VA-HIT: Diabetic Subgroup Analysis
Arch Intern Med;162:2597-2604
Numbers needed to treat
to prevent one non-fatal MI or CHD death in 5
years
CARE
LIPID
HPS
VA-HIT
All Patients
Diabetics
33
28
32
23
29
29
31
12
Question
You are a bigdeal trialist designing a study to
test the efficacy of a fibrate in the prevention of
CHD in type 2 diabetes. What ideally would you
like the average baseline lipid profile to be?
FIELD Study
• 9795 participants
• Type 2 diabetes
• Age 50- 75 yrs
• No prior statin/fibrate therapy
• 2131 previous CVS disease
• 7664 no known previous CVS disease
FIELD - Recruitment Lipids
• Total cholesterol 3-6.5 mmol/L +
• Either TC:HDL cholesterol > 4
• Or triglycerides 1.0-5.0 mmol/L
Original Article
Effects of Combination Lipid Therapy in Type 2
Diabetes Mellitus
The ACCORD Study Group
N Engl J Med
Volume 362(17):1563-1574
April 29, 2010
Lipid Values
The ACCORD Study Group. N Engl J Med 2010;362:15631574
Kaplan-Meier Analyses of the Primary Outcome, Expanded Macrovascular Outcome, and
Death
The ACCORD Study Group. N Engl J Med 2010;362:15631574
Conclusion
• The combination of fenofibrate and simvastatin did not reduce the rate of
fatal cardiovascular events, nonfatal myocardial infarction, or nonfatal
stroke, as compared with simvastatin alone
• These results do not support the routine use of combination therapy with
fenofibrate and simvastatin to reduce cardiovascular risk in the majority
of high-risk patients with type 2 diabetes
Baseline Characteristics of the Patients
The ACCORD Study Group. N Engl J Med 2010;362:15631574
Conclusions
Statins are safe, benefit many diabetics and
almost all diabetics should be on them
Treat total cholesterol & LDL cholesterol to
target
There is still a place for fibrates in combination
and first line for those with HDL<1 and/or
Tg>2.3