Spare the Cholesterol, Spoil the Diabetic

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Spare the Cholesterol, Spoil the Diabetic

05/07/2004

Patients with diabetes usually know about the perils of high blood

sugar, which includes damage to the eyes, kidneys, and nerves. These

are major issues, and there is no more ardent supporter than I am of

maintaining glucose levels as close to normal as possible. The fact

remains, however, that people with diabetes are much more likely to

develop and/or die from cardiovascular disease than any of these

other problems. Up to 80% of type 2 diabetics will suffer a heart

attack, stroke, or peripheral vascular disease. In many cases,

cardiovascular disease will result in significant neurological

damage, amputation, and even death.

These statistics demonstrate why it is critical for patients with

diabetes to maintain 'good vascular hygiene'. What is good vascular

hygiene? Three things: quitting smoking, reducing blood pressure, and

keeping cholesterol levels in check.

The cholesterol recommendation in particular has been around for a

long time—despite an absence of evidence on whether lowering

cholesterol works in diabetes. Surprisingly, lingering questions

remain about cholesterol-lowering in diabetes. Do patients with

diabetes benefit as much as non-diabetics from lipid lowering

therapy? Which drugs are the best to use in diabetes? What target

level of cholesterol is appropriate?

To address these important issues, a committee of the American

College of Physicians (ACP) commissioned a review of the world's

literature on lipid lowering in type 2 diabetes. The ACP then used

this information as the basis for detailed, specific recommendations

for patients and their doctors. The ACP review looked at a large

number of published clinical trials—none of which, it is important to

note, were specifically dedicated to studying type 2 diabetics. All

of the studies, however, included at least some diabetics, and this

allowed the ACP to essentially lump together all the information from

the diabetics in different studies and assess their response to

cholesterol-lowering therapy.

The studies were of two major types, known as primary prevention and

secondary prevention. In a primary prevention trial, researchers

looked for people who had not yet shown any sign of cardiovascular

disease. They then put these folks on a drug, or a placebo, and

tested whether the drug resulted in fewer cases of heart attack or

stroke. When the ACP looked at six, large, primary prevention

studies, they found that for every 34 patients with type 2 diabetes

who were treated with cholesterol-lowering meds for more than 4

years, one heart attack or stroke was prevented. This may sound

small, but compares favorably with many other disease prevention

strategies in common medical practice.

The secondary prevention trials were even more dramatic. Secondary

prevention is for people who have already had a heart attack or

stroke. The goal is to prevent a second episode. For people with type

2 diabetes known to have cardiovascular disease, there was a highly

significant benefit to treating with lipid-lowering therapy. This

seems to be true regardless of what level of cholesterol you start

out with. For every 14 such patients treated for 5 years, one

cardiovascular event was prevented.

These findings led the ACP to the following four recommendations:

1. All men and women with type 2 diabetes and known cardiovascular

disease should be on lipid-lowering therapy. The drugs with the most

proven efficacy are members of the statin class, including Lipitor™,

Pravachol™, Zocor™, Mevacor™, and others. At least one study

suggests that an alternative lipid-lowering drug, Lopid™, might be

useful in diabetic patients with low levels of both LDL and HDL

cholesterol.

2. For patients with type 2 diabetes who are not known to have

cardiovascular disease, a statin should be used to reduce cholesterol

levels, especially if there is another cardiovascular risk factor.

This means that if you have type 2 diabetes and any one of the

following conditions, you should be taking a statin: age greater than

55, high blood pressure, smoking, or dysfunction of the left side of

the heart. That ends up covering most people in the average adult

type 2 diabetes clinic.

3. Don't skimp on the statin! Patients should be taking at least

moderate doses of these drugs. This translates to daily doses of

Pravachol™ (40 mg), Mevacor™ (40-80 mg), Zocor™ (40 mg), and Lipitor™

(20 mg).

4. Finally, there has been a lot of hype about the potential side

effects of statins, including muscle and liver damage. In fact, more

people are hurt by NOT taking these drugs than by taking them. In

fact, it is no longer recommended that patients even be monitored for

liver and muscle enzyme levels while on statins (except in specific

cases). This includes the rare cases where symptoms of jaundice or

muscle pain develop while taking the drug, elevated levels of these

enzymes are discovered before taking the statin, or in cases where

other drugs are also being used that are known to damage the muscle

and liver

In case you haven't noticed, there are no specific recommendations

about any particular " magic number. " There is no cholesterol number

above which one would automatically treat with drugs, and no target

level at which one could be satisfied that the cholesterol was low

enough. Several studies have shown that reducing cholesterol levels

as low as possible may confer additional benefit. In other words,

it's not clear that we know how low is low enough, and at present,

there appears to be little downside (other than cost) for using

higher doses of statins than we all previously thought were good

enough.

The bottom line is this: The majority of people with type 2 diabetes

should be taking a statin, and a pretty decent dose at that. This is

not a substitute for good glucose control, but an incredibly

important adjunct therapy that will save a lot of lives.

Reference:

Snow V, Aronson MD, Hornbake ER, Mottur-Pilson C, Weiss KB; Clinical

Efficacy Assessment Subcommittee of the American College of

Physicians. Lipid control in the management of type 2 diabetes

mellitus: a clinical practice guideline from the American College of

Physicians. ls of Internal Medicine. 2004 Apr 20;140(8):644-9.

[Guest guest]

In a message dated 5/12/2004 3:25:23 PM Pacific Standard Time,

robertatdiabetes@... writes:

Hi , a few points I would like to make.

> they found that for every 34 patients with type 2 diabetes

> who were treated with cholesterol-lowering meds for more than 4

> years, one heart attack or stroke was prevented. This may sound

> small, but compares favorably with many other disease prevention

> strategies in common medical practice.

Does this seem strange to anyone else that they would know this for sure?

> For every 14 such patients treated for 5 years, one

> cardiovascular event was prevented.

>

> These findings led the ACP to the following four recommendations:

>

> 1. All men and women with type 2 diabetes and known cardiovascular

> disease should be on lipid-lowering therapy. The drugs with the most

> proven efficacy are members of the statin class, including Lipitorâ„¢,

> Pravacholâ„¢, Zocorâ„¢, Mevacorâ„¢, and others.

>

Statins are very effective. I have a total chol level of 172, and do take 20

mg of lipitor daily. My husband on the other hand, has a problem with a gene

that is hereditary that causes his chil to be rediculously high. It was 415

when he was 20. Has been on statins since they came out. Did have a BAD

muscle problem at 80MG's a day of lipitor and is now on Crestor and Zetia. They

seem to be working, and a much lower doses. He is not diabetic, but has many

health issues since he broke his back then had 6 strokes......

> 2. For patients with type 2 diabetes who are not known to have

> cardiovascular disease, a statin should be used to reduce cholesterol

> levels, especially if there is another cardiovascular risk factor.

>

> 3. Don't skimp on the statin! Patients should be taking at least

> moderate doses of these drugs. This translates to daily doses of

> Pravacholâ„¢ (40 mg), Mevacorâ„¢ (40-80 mg), Zocorâ„¢ (40 mg), and Lipitorâ„¢

> (20 mg).

>

> 4. Finally, there has been a lot of hype about the potential side

> effects of statins, including muscle and liver damage. In fact, more

> people are hurt by NOT taking these drugs than by taking them. In

> fact, it is no longer recommended that patients even be monitored for

> liver and muscle enzyme levels while on statins (except in specific

> cases). This includes the rare cases where symptoms of jaundice or

> muscle pain develop while taking the drug, elevated levels of these

> enzymes are discovered before taking the statin, or in cases where

> other drugs are also being used that are known to damage the muscle

> and liver.

Don must be the rare case, but remember he was on a dose designed for the

jolly green giant. It was quite dramatic, and subsided fairly quickly when the

lipitor was removed from his med list.

>

>

> The bottom line is this: The majority of people with type 2 diabetes

> should be taking a statin, and a pretty decent dose at that. This is

> not a substitute for good glucose control, but an incredibly

> important adjunct therapy that will save a lot of lives.

>

> Yes, this is really true, we have enough to deal with every day, we do not

need to complicate our lives any further ;-) Statins are wonderful medications.

Marilyn