Pharmacotherapy: statins and new-onset diabetes mellitus--a matter for debate

Prevalence of type 2 diabetes mellitus compared between lean and overweight/obese patients with polycystic ovarian syndrome: a 5-year follow-up study

PURPOSE

To investigate the prevalence of type 2 diabetes mellitus (T2DM) at the 5-year follow-up after polycystic ovarian syndrome (PCOS) diagnosis compared between lean and overweight/obese groups.

METHODS

This retrospective cohort study included 400 prediabetes PCOS women who attended our clinic. Participants were divided into either the lean group (body mass index [BMI]: < 23 kg/m²) or the overweight/obese group (BMI: ≥ 23 kg/m²). Patient demographic, clinical characteristics, metabolic profiles, and laboratory values were collected and compared between groups at baseline and during follow-up for 5 years.

RESULTS

At the end of the follow-up, overweight/obese group had a higher risk for developing T2DM than lean group (11.5% vs. 0.5%, p < 0.001). Lean group had a lower incidence of hypertension (3% vs. 38.5%, p < 0.001) and dyslipidemia (35% vs. 53.5%, p < 0.001) than overweight/obese group. The factors found to be independently associated with increased risk for developing T2DM were BMI ≥ 23 kg/m² (odds ratio [OR]: 1.075, p = 0.047), non-use of oral combined contraceptive pills (OR: 0.312, p = 0.028), and impaired fasting glucose at baseline (OR: 38.167, p < 0.001).

CONCLUSIONS

Overweight/obese PCOS patients were found to be at significantly higher risk for developing T2DM than lean PCOS patients. Higher BMI, IFG at baseline, and non-use of oral contraceptive pills found to be independent predictors of T2DM in PCOS.

Lipids: a personal view of the past decade

The past decade has witnessed considerable progress in the field of lipids. New drugs have been "rapidly" developed and some of these drugs have already been evaluated in event-based large trials. This evidence has led to the guidelines recommending new, more aggressive treatment goals for low-density lipoprotein cholesterol (LDL-C) levels. Although LDL-C remains the principal goal for cardiovascular disease (CVD) risk reduction, there has also been considerable interest in other lipid variables, such as high-density lipoprotein cholesterol, triglycerides, and lipoprotein(a). Statin intolerance is now considered a very important topic in daily clinical practice. This has resulted in more attention focusing on non-statin drugs [e.g., ezetimibe and proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitors] and statin-related side effects. The latter mainly involve muscles, but there is also a need to consider other adverse effects associated with statin use (e.g., new onset diabetes). New specific areas of statin use have attracted interest. For example, statin-loading before procedures (e.g., coronary stenting), the prevention of stroke, and the treatment of non-alcoholic fatty liver disease (NAFLD). Statins will remain the most widely used drugs to treat dyslipidaemia and decrease CVD risk. However, we also need to briefly consider some other lipid-lowering drugs, including those that may become available in the future.

Dyslipidaemia in type 2 diabetes mellitus: bad for the heart

PURPOSE OF REVIEW

Type 2 diabetes mellitus (T2DM) is associated with increased coronary heart disease (CHD) morbidity and mortality. These patients are also more prone to heart failure, arrhythmias and sudden cardiac death. Furthermore, coronary interventions performed in such high-risk patients have worse outcomes. In this narrative review, we discuss the role of diabetic dyslipidaemia on the risk of CHD in patients with T2DM. The effects of hypolipidaemic, antihypertensive and antidiabetic drugs on lipid and glucose metabolism in T2DM are also considered.

RECENT FINDINGS

Among CHD risk factors, diabetic dyslipidaemia characterized by moderately elevated low-density lipoprotein (LDL) cholesterol, increased triglycerides and small, dense LDL particles as well as decreased high-density lipoprotein cholesterol levels may contribute to the increased CHD risk associated with T2DM. Hypolipidaemic, antihypertensive and antidiabetic drugs can affect lipid and glucose parameters thus potentially influencing CHD risk. Such drugs may improve not only the quantity, but also the quality of LDL as well as postprandial lipaemia.

SUMMARY

Current data highlight the importance of treating diabetic dyslipidaemia in order to minimize CHD risk. Both fasting and postprandial lipids are influenced by drugs in patients with T2DM; physicians should take this into consideration in clinical decision making.

Dyslipidaemia in the elderly: to treat or not to treat?

INTRODUCTION

The elderly population (i.e. aged ≥ 65 years) is increasing worldwide. Ageing is associated with a higher incidence and prevalence of cardiovascular disease (CVD). Areas covered: The prevalence of CVD risk factors including type 2 diabetes mellitus, hypertension and dyslipidaemia also increases with advancing age, contributing to the higher absolute CVD risk observed in the elderly. The present narrative review comments on the associations of dyslipidaemia with CVD as well as the effects of lifestyle measures and lipid-lowering drugs on lipids and CVD risk with a special focus on the elderly population. Individual treatment goals and therapeutic options according to current guidelines are also reviewed. Finally, we discuss special characteristics of the elderly that may influence the efficacy and safety of drug therapy and should be considered before selection of hypolipidaemic pharmacotherapy. Expert commentary: There may be a greater CVD benefit in older patients following drug therapy compared with younger ones. Treatment goals and therapeutic options should be individualized according to current guidelines. Specific characteristics that may influence the efficacy and safety of drug therapy in the elderly should be considered in relation to dyslipidaemia treatment.

The effect of bergamot on dyslipidemia

BACKGROUND

Statins are the most common used lipid lowering drugs but they may cause adverse effects and despite their well-established therapeutic benefits residual cardiovascular (CV) risk remains. The use of other lipid lowering drugs and nutraceuticals alone or as add-on lipid-modifying therapy can be an option in such cases. Several studies have reported health-related properties of the Citrus fruits, among which bergamot (Citrus bergamia Risso) differs from others by particularly high content of certain compounds.

PURPOSE

This narrative review summarizes the current evidence on the effects of bergamot on lipid parameters based on studies involving animals and humans.

MAIN EVIDENCE

This natural supplement may lead to effective lipid-lowering treatment. Its lipid-lowering activity is attributed to different flavonoids. However, the exact mechanisms involved remain unclear.

CONCLUSION

It is expected that ongoing and future studies will confirm the benefit of bergamot in dyslipidemic and other cardiometabolic disorders, potentially leading to reduced overall CV risk.

Statin Use and the Risk for Incident Diabetes Mellitus in Patients with Acute Coronary Syndrome after Percutaneous Coronary Intervention: A Population-Based Retrospective Cohort Study in Taiwan

OBJECTIVES

The purpose of this study was to examine the association between statin use by individuals and the risk for incident diabetes mellitus in patients with acute coronary syndrome (ACS) following percutaneous coronary intervention (PCI).

METHODS

We conducted a retrospective cohort study of patients who were hospitalized for ACS between January 1, 2006, and December 31, 2010, and who had undergone PCI (n=30,665); the data were retrieved from the Taiwan National Health Insurance Research Database. A propensity score technique was used to establish a 1:1 matched cohort for statin users and non-statin users (n=9043 for each group). The risk for incident diabetes mellitus in statin users compared to non-statin users for patients with ACS after PCI was estimated by the multivariable Cox proportional hazards regression model.

RESULTS

Statin use was associated with a significant increase of 27% in the risk for new-onset diabetes mellitus (adjusted hazard ratio [HR] 1.27, 95% CI 1.14 to 1.41) compared to non-statin use in the matched cohort. The matched cohort analysis indicated that almost all individual statins were associated with a statistically significant increase in the risk for new-onset diabetes mellitus compared to those without statin use.

CONCLUSIONS

Our study indicated an association between increased risk for new-onset diabetes mellitus and statin use. Because the benefits of statins in prevention of morbidity and mortality in patients with ACS are well-established, clinical decision making should not be changed for patients with existing cardiovascular disease in whom statin therapy is recommended.

Managing dyslipidemia in HIV/AIDS patients: challenges and solutions

Human immunodeficiency virus (HIV) is a chronic disease associated with dyslipidemia and insulin resistance. In addition, the administration of combination antiretroviral therapy is associated with an increase in the incidence of metabolic risk factors (insulin resistance, lipoatrophy, dyslipidemia, and abnormalities of fat distribution in HIV patients). HIV dyslipidemia is a common problem, and associated with an increase in incidence of cardiovascular disease. Further challenges in the management of HIV dyslipidemia are the presence of diabetes and metabolic syndrome, nonalcoholic fatty liver disease, hypothyroidism, chronic kidney disease, the risk of diabetes associated with statin administration, age and ethnicity, and early menopause in females. Dyslipidemia in patients with HIV is different from the normal population, due to the fact that HIV increases insulin resistance and HIV treatment not only may induce dyslipidemia but also may interact with lipid-lowering medication. The use of all statins (apart from simvastatin and lovastatin) is safe and effective in HIV dyslipidemia, and the addition of ezetimibe, fenofibrate, fish oil, and niacin can be used in statin-unresponsive HIV dyslipidemia. The management of dyslipidemia and cardiovascular disease risks associated with HIV is complex, and a certain number of patients may require management in specialist clinics run by specialist physicians in lipid disorders. Future research is needed to address best strategies in the management of hyperlipidemia with HIV infection.

The 2013 American College of Cardiology/American Heart Association guidelines for the treatment of dyslipidemia: mind the gaps!

Abstract The ACC/AHA lipid guidelines need to be reconsidered before full implementation. A new cardiovascular disease (CVD) risk estimation, preferably based in interventional multiethnic studies, will be ideal. Specific LDL-C targets may also be necessary because there are data pointing out that they are useful and pragmatic. The risk/benefit ratio should be a key issue because medicine is all about this concept (Hippocrates 460 - c. 370 BC: "first do not harm"; and then in the Hippocratic Oath: "I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous").

Cardiovascular complications in diabetic patients undergoing regular hemodialysis: a 5-year observational study

We aimed to study the vascular outcomes in hemodialysis (HD) patients based on their diabetic status. A cohort observational study was conducted among patients undergoing regular HD with a 5-year follow-up. Of the 252 consecutive HD patients, 60% were diabetic. Compared with nondiabetics, diabetics were 11 years older, 4 years lesser on HD, and more likely to have prior cerebrovascular and coronary artery disease (CAD). Overall 5-year follow-up showed that diabetic patients had higher rates of HD vascular accesses (57% vs 41%, P = .01), CAD (64% vs 33%, P = .001), major amputations (8.6% vs 0%, P = .003), and mortality (66% vs 23%, P = .001). On multivariate analysis, independent predictors of mortality included number of vascular accesses in nondiabetics and HD duration, CAD, and peripheral artery disease in diabetic patients. Diabetes mellitus is associated with a significant vascular burden and mortality among HD patients. Moreover, our finding highlights the vascular impact of renal failure and HD.

Statins and cardiovascular outcomes in elderly and younger patients with coronary artery disease: a post hoc analysis of the GREACE study

INTRODUCTION

The effect of cardiovascular disease (CVD) prevention measures aimed at elderly patients requires further evidence. We investigated the effect of statin treatment (targeted to achieve guideline goals) on CVD outcomes in different age groups to determine whether statins are more beneficial in the elderly.

MATERIAL AND METHODS

The primary endpoint of this post hoc analysis of the GREek Atorvastatin and Coronary-heart-disease Evaluation (GREACE) study (n = 1,600 patients with established coronary heart disease (CHD), mean follow-up 3 years) was the absolute and relative CVD event (a composite of death, myocardial infarction, revascularization, unstable angina, heart failure and stroke) risk reduction in age quartiles (each n = 200). Patients on "structured care" with atorvastatin (n = 800) followed up by the university clinic and treated to lipid goal were compared with the corresponding quartiles on "usual care" (n = 800) followed up by specialists or general practitioners of the patient's choice outside the hospital.

RESULTS

In the elderly (mean age 69 ±4 and 70 ±3 years in the "structured" and "usual care", respectively) the absolute CVD event reduction between "structured" and "usual care" was 16.5% (p < 0.0001), while in the younger patients (mean age 51 ±3 years and 52 ±3 years in the "structured" and "usual care", respectively) this was 8.5% (p = 0.016); relative risk reduction (RRR) 60% (p < 0.0001) vs. 42% respectively (p = 0.001). The elderly had higher rates of chronic kidney disease and higher uric acid levels, plus an increased prevalence of diabetes, metabolic syndrome and non-alcoholic fatty liver disease. These factors might contribute to the increased CVD risk in older patients.

CONCLUSIONS

All age groups benefited from statin treatment, but the elderly on "structured care" had a greater absolute and relative CVD risk reduction than the younger patients when compared with the corresponding patients assigned to "usual care". These findings suggest that we should not deprive older patients of CVD prevention treatment and lipid target achievement.