Spare the Cholesterol, Spoil the Diabetic

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Spare the Cholesterol, Spoil the Diabetic

05/07/2004

The following information is provided by Veritas Medicine. Please consult

your physician if you have questions about any of the material presented.

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 Lipitorâ„¢, Pravacholâ„¢, Zocorâ„¢,

Mevacorâ„¢, and others. At least one study suggests that an alternative

lipid-lowering drug, Lopidâ„¢, 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 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

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.

Marilyn Neves

Moderator for ~

alldiabeticinternational@...

Diabetic_Recipes

Opinions expressed are solely my opinion and should not be mistaken for

professional medical advice.