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org Cardiovascular Disease and Risk Management S79

LIPID MANAGEMENT Recommendations should focus on re-

c For patients with diabetes aged
ducing saturated fat, cholesterol, and
Recommendations .75 years without additional ath-
trans fat intake and increasing plant
c In adults not taking statins, it is erosclerotic cardiovascular dis-
stanols/sterols, v-3 fatty acids, and vis-
reasonable to obtain a lipid prole ease risk factors, consider using
cous ber (such as in oats, legumes, and
at the time of diabetes diagnosis, moderate-intensity statin therapy
citrus). Glycemic control may also bene-
at an initial medical evaluation, and and lifestyle therapy. B
cially modify plasma lipid levels, particularly
every 5 years thereafter, or more c For patients with diabetes aged
in patients with very high triglycerides and
frequently if indicated. E .75 years with additional athero-
poor glycemic control.
c Obtain a lipid prole at initiation sclerotic cardiovascular disease risk
of statin therapy and periodically factors, consider using moderate- Statin Treatment
thereafter as it may help to monitor intensity or high-intensity statin Initiating Statin Therapy Based on Risk
the response to therapy and inform therapy and lifestyle therapy. B Patients with type 2 diabetes have an
adherence. E c In clinical practice, providers may increased prevalence of lipid abnormal-
c Lifestyle modication focusing on need to adjust intensity of statin ities, contributing to their high risk of
weight loss (if indicated); the reduc- therapy based on individual patient ASCVD. Multiple clinical trials have dem-
tion of saturated fat, trans fat, and response to medication (e.g., side onstrated the benecial effects of phar-
cholesterol intake; increase of di- effects, tolerability, LDL cholesterol macologic (statin) therapy on ASCVD
etary v-3 fatty acids, viscous ber, levels). E outcomes in subjects with and without
and plant stanols/sterols intake; c The addition of ezetimibe to CHD (44,45). Subgroup analyses of pa-
and increased physical activity moderate-intensity statin therapy tients with diabetes in larger trials
should be recommended to im- has been shown to provide addi- (4650) and trials in patients with dia-
prove the lipid prole in patients tional cardiovascular benet com- betes (51,52) showed signicant pri-
with diabetes. A pared with moderate-intensity mary and secondary prevention of
c Intensify lifestyle therapy and opti- statin therapy alone for patients with ASCVD events and CHD death in patients
mize glycemic control for patients recent acute coronary syndrome with diabetes. Meta-analyses, including
with elevated triglyceride levels and LDL cholesterol $50 mg/dL data from over 18,000 patients with di-
($150 mg/dL [1.7 mmol/L]) and/or (1.3 mmol/L) and should be consid- abetes from 14 randomized trials of
low HDL cholesterol (,40 mg/dL ered for these patients A and also statin therapy (mean follow-up 4.3 years),
[1.0 mmol/L] for men, ,50 mg/dL in patients with diabetes and his- demonstrate a 9% proportional reduc-
[1.3 mmol/L] for women). C tory of ASCVD who cannot tolerate tion in all-cause mortality and 13% re-
c For patients with fasting triglyceride high-intensity statin therapy. E duction in vascular mortality for each
levels $500 mg/dL (5.7 mmol/L), c Combination therapy (statin/brate) mmol/L (39 mg/dL) reduction in LDL
evaluate for secondary causes of has not been shown to improve ath- cholesterol (53).
hypertriglyceridemia and consider erosclerotic cardiovascular disease As in those without diabetes, abso-
medical therapy to reduce the risk outcomes and is generally not rec- lute reductions in ASCVD outcomes
of pancreatitis. C ommended. A However, therapy (CHD death and nonfatal MI) are great-
c For patients of all ages with diabe- with statin and fenobrate may est in people with high baseline ASCVD
tes and atherosclerotic cardiovas- be considered for men with both risk (known ASCVD and/or very high LDL
cular disease, high-intensity statin triglyceride level $204 mg/dL cholesterol levels), but the overall ben-
therapy should be added to life- (2.3 mmol/L) and HDL cholesterol ets of statin therapy in people with di-
style therapy. A level #34 mg/dL (0.9 mmol/L). B abetes at moderate or even low risk for
c For patients with diabetes aged c Combination therapy (statin/niacin) ASCVD are convincing (54,55). Statins
,40 years with additional athero- has not been shown to provide ad- are the drugs of choice for LDL choles-
sclerotic cardiovascular disease risk ditional cardiovascular benet above terol lowering and cardioprotection.
factors, consider using moderate- statin therapy alone and may in- Most trials of statins and ASCVD out-
intensity or high-intensity statin crease the risk of stroke and is not comes tested specic doses of statins
and lifestyle therapy. C generally recommended. A against placebo or other statins rather
c For patients with diabetes aged c Statin therapy is contraindicated than aiming for specic LDL cholesterol
4075 years without additional in pregnancy. B goals (56), suggesting that the initiation
atherosclerotic cardiovascular dis- and intensication of statin therapy
ease risk factors, consider using be based on risk prole (Table 9.1 and
Lifestyle Intervention
moderate-intensity statin and life- Table 9.2).
Lifestyle intervention, including weight
style therapy. A
loss, increased physical activity, and The Risk Calculator. The American College
c For patients with diabetes aged
medical nutrition therapy, allows some of Cardiology/American Heart Associa-
4075 years with additional ath-
patients to reduce ASCVD risk factors. tion ASCVD risk calculator may be a use-
erosclerotic cardiovascular dis-
Nutrition intervention should be tai- ful tool to estimate 10-year ASCVD risk
ease risk factors, consider using
lored according to each patients age, (http://my.americanheart.org). As dia-
high-intensity statin and lifestyle
diabetes type, pharmacologic treatment, betes itself confers increased risk for
therapy. B
lipid levels, and medical conditions. ASCVD, the risk calculator has limited