What is the most effective strategy for managing diabetic dyslipidaemia?

Trends in lipid profiles and descriptive characteristics of U.S. adults with and without diabetes and cholesterol-lowering medication use-National Health and Nutrition Examination Survey, 2003-2012, United States

BACKGROUND

With a cholesterol-lowering focus for diabetic adults and in the age of polypharmacy, it is important to understand how lipid profile levels differ among those with and without diabetes.

OBJECTIVE

Investigate the means, differences, and trends in lipid profile measures [TC, total cholesterol; LDL-c, low-density lipoprotein; HDL-c, high-density lipoprotein; and TG, triglycerides] among US adults by diabetes status and cholesterol-lowering medication.

METHODS

Population number and proportion of adults aged ≥21 years with diabetes and taking cholesterol-lowering medication were estimated using data on 10,384 participants from NHANES 2003-2012. Age-standardized means, trends, and differences in lipid profile measures were estimated by diabetes status and cholesterol medication use. For trends and differences, linear regression analysis were used adjusted for age, gender, and race/ethnicity.

RESULTS

Among diabetic adults, 52% were taking cholesterol-lowering medication compared to the 14% taking cholesterol-lowering medication without diabetes. Although diabetic adults had significantly lower TC and LDL-c levels than non-diabetic adults [% difference (95% confidence interval): TC = -5.2% (-6.8 --3.5), LDL-c = -8.0% (-10.4 --5.5)], the percent difference was greater among adults taking cholesterol medication [TC = -8.0% (-10.3 --5.7); LDL-c = -13.7% (-17.1 --10.2)] than adults not taking cholesterol medication [TC = -3.5% (-5.2 --1.6); LDL-c = -4.3% (-7.1 --1.5)] (interaction p-value: TC = <0.001; LDL-c = <0.001). From 2003-2012, mean TC and HDL-c significantly decreased among diabetic adults taking cholesterol medication [% difference per survey cycle (p-value for linear trend): TC = -2.3% (0.003) and HDL-c = -2.3% (0.033)]. Mean TC, HDL-c, and LDL-c levels did not significantly change from 2003 to 2012 in non-diabetic adults taking cholesterol medication or for adults not taking cholesterol medications.

CONCLUSIONS

Diabetic adults were more likely to have lower lipid levels, except for triglyceride levels, than non-diabetic adults with profound differences when considering cholesterol medication use, possibly due to the positive effects from clinical diabetes management.

High-density lipoprotein cholesterol and residual cardiometabolic risk in metabolic syndrome

It has long been recognized that elevated levels of low-density lipoprotein cholesterol (LDL-C) increase the risk of cardiovascular disease (CVD) and that pharmacologic therapy to decrease LDL-C significantly reduces cardiovascular events. Despite the effectiveness of statins for CVD risk reduction, even optimal LDL-lowering therapy alone fails to avert approximately 60% to 70% of CVD cases, and the incidence of CVD mortality continues to grow. A low plasma concentration of high-density lipoprotein cholesterol (HDL-C) is also associated with increased risk of CVD and is 1 component of metabolic syndrome, a cluster of interrelated CVD risk factors. HDL stimulates reverse cholesterol transport from the peripheral tissues to the liver for removal from the body, prevents deleterious effects of LDL on endothelial function, acts as an antioxidant, and also possesses anti-inflammatory, antithrombotic, and antiapoptotic effects. Some of the treatments that increase HDL-C concentrations have been shown to reduce atheroma volume and may prevent the formation of new atherosclerotic lesions, thereby reducing the risk of CVD. For these reasons, increasing HDL-C concentrations has become a potentially attractive therapeutic target for individuals who are at increased risk of CVD, including those with metabolic syndrome. Traditional strategies to increase HDL-C include the use of niacin, statins, and fibric acid derivatives. Pharmacotherapies that have recently been developed and are currently being evaluated include inhibition of the enzyme cholesteryl ester transfer protein (CETP) and antagonism of the endocannabinoid CB1 receptor. Initial studies of CETP inhibitors suggest that these agents may markedly increase HDL-C concentrations. Clinical trials with rimonabant, a CB1 receptor antagonist, have demonstrated significant weight loss as well as increased HDL-C levels and reduced triglyceride levels.

Lipoproteins in inflammation and sepsis. I. Basic science

BACKGROUND

High-density lipoproteins (HDL) have been shown to bind and neutralize lipopolysaccharide (LPS) and are regarded as possible therapeutic agents for sepsis and conditions associated with local or systemic inflammation. However, in recent years, a multitude of possible immunomodulatory properties other than LPS neutralization have become evident.

DISCUSSION

This review highlights the advances in the understanding of how HDL is protective in both in vitro and in vivo inflammatory settings, including the ability of HDL to modulate adhesion molecule expression, upregulate endothelial nitric oxide synthase and counteract oxidative stress. Also, the active components of HDL and the recent discovery of novel lipid modulators of inflammation are discussed.

Optimal care of cardiovascular disease and type 2 diabetes patients: shared responsibilities between the cardiologist and diabetologist

Type 2 diabetes and cardiovascular disease are inextricably linked. Patients with type 2 diabetes are at increased risk of cardiovascular events and mortality. However, controlling blood glucose, which until recently had often been the focus of the diabetologist, is only one component of optimal cardiovascular risk reduction. Vascular protection of the patient with diabetes also includes management of hypertension and dyslipidaemia and lifestyle changes such as smoking cessation. Now both cardiologists and diabetologists need to optimise all components of vascular protection, including glycaemic control, in patients with diabetes. An elevated blood glucose is predictive of poor outcomes in patients with acute coronary syndromes, even if frank diabetes is not present. Early control of hyperglycaemia should be achieved: a strategy that results in improved outcomes. More than two-thirds of patients with coronary artery disease (CAD) have abnormal glucose regulation, which is a predictor of poor outcome. Therefore, the presence of diabetes (and/or glucose intolerance) should be routinely screened for in cardiac patients on admission to hospital. Early identification and treatment of CAD in patients with diabetes is important for optimal prevention of cardiovascular events. However, screening all diabetes patients for CAD is not feasible, and selection of patients for non-invasive cardiac testing remains a challenge for both the diabetologist and cardiologist. Optimal care of diabetic and cardiac patients requires a multidisciplinary team approach, with key roles for the cardiologist and diabetologist.