( Diabetes mellitus, DM ) ( Hyperlipidemia ) ( Cardiovascular disease, CVD )

Transcription

1 <50 mg/dl > 40 mg/dl > 50 mg/dl) (<00 mg/dl >00 mg/dl < 00 mg/dl(.6 mmol/l) 30-40% < 70 mg/dl 40 mg/dl 00 9 mg/dl fibric acid derivative niacin statin fibrate statin niacin ( ) ( Diabetes mellitus, DM ) ( Hyperlipidemia ) ( Cardiovascular disease, CVD ) 70 47

2 East and West 5 4 ( UKPDS ) >00 mg/dl ( ) 7 ( ) 6 ( ) ( < 400 mg/dl ) ( ) ( ) 8 < 00 mg/dl (.6 mmol/l ) 30-40% nicotinic acid, ezetimbe, bile acid sequestrants, fenofibrate 003 Heart Protection Study ( 35 mg/dl ) simvastatin 40 mg ( 6 mg/dl ) 9-0 ( ) ( ) ( ) ( < 00 mg/dl < 50 mg/dl > 40 mg/dl > 50 mg/dl ) 9 30% 5% ( 838 ) ( Collaborative Atorvastatin Diabetes Study, CARDS ) primary prevention study ( 0 mg/dl ) atorvastatin 0 mg ( 48 ) ( p=0.00 )

3 7 37% 48% statin ( subgroup analysis ) Scandinavian Simvastatin Study ( 4S ) mg 8,9 statin fibrate statin niacin ( ) Statins 3-5 Statins < 70 mg/dl < 70 mg/dl 0 fibric acid derivative ( ) ( Helsinki Heart Study, HHS ) gemfibrozil ( ) 6 Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial ( VA-HIT ) 7 gemfibrozil ( p=0.004 ) ( 40 mg/dl ) 3% ( ) 8 8 Heart Protection Study 600 creatinine phosphokinase ( CK ) statin fenofibrate statin gemfibrozil creatinine fenofibrate fibrates niacin ( ) HMG-Co A reductase ( statin ) lovastatin fluvastatin pravastatin simvastatin atorvastatin rosuvastatin ( ) sequestrant cholestyramine colestipol colesevelam ( 3 ) Nicotinic acid nicolar lipo-nicin acipimox ( 4 ) Probucol ( 5 ) Ezetimibe( ezetrol tablets ) 7 40 mg/dl 00 9 mg/dl fibric acid derivative niacin Nicotinic acid ( ). ( severe myalgia myositis ). 3

4 7 ( ) Fibric acid gemfibrozil bezafibrate etofibrate micronised fenofibrate ( ) Nicotinic acid nicolar lipo-nicin acipimox ADA 0 A- Level evidence B- Level evidence C- Level evidence E- Expert consensus 6. ( ) 70 mg/dl (.8 mmol/l ) ( B ) mg/dl (.7 mmol/l ) 40 mg/dl (.5 mmol/l ) ( ) 50 mg/dl ( ) ( C ) 8. fibric acid derivative ( ) ( A ) 9. fibrates niacin ( E ) 0. Statin (E). ( < 00 mg/dl > 50 mg/dl < 50 mg/dl ) ( E ). ( ) ( A ) mg/dl statin 30-40% < 00 mg/dl (.6 mmol/l ) ( A ) 4. ( ) < 00 mg/dl (.6 mmol/l ) ( C ) 5. statin (A).Kannel WB, McGee DL. Diabetes and cardiovascular disease. The Framingham study. JAMA 979; 4: Kannel WB, McGee DL. Diabetes and glucose tolerance as risk factors for cardiovascular disease: the Framingham Study. Diabetes Care 979; : Herlitz J, Malmberg K, Karlson BW, Ryden L, Hjalmarson A. Mortality and morbidity during a five-year follow-up of diabetics with myocardial infarction. Acta Med Scand 988; 4: Haffner SM, Lehto S, Ronnemaa T, Pyorala K, Laakso M. Mortality from coronary heart disease in subjects with type diabetes and in nondiabetic subjects with and without prior myocardial infarction. New Engl J Med 998; 339: The UK Prospective Diabetes Study Group. Effect of intensive blood-glucose control with metformin on complications in overweight patients with type diabetes ( UKPDS 34 ). Lancet 998; 35: American Diabetes Association. Standards of medical care in diabetes ( Position Statement ). Diabetes Care 004; 7: S Haffner SM. Management of dyslipidemia in adults with diabetes ( Technical review ). Diabetes Care 998; : American Diabetes Association. Dyslipidemia management in adults with diabetes ( Position Statement ). Diabetes Care 004; 7: S Executive summary of the third report of the national cholesterol education program: ( NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). JAMA 00; 85: Grundy SM, Cleeman JI, Merz CN, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 004; 0:

5 Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5963 people with diabetes: a randomized placebo-controlled trial. Lancet 003; 36: Colhoun HM, Betteridge DJ, Durrington PN, et al. Primary prevention of cardiovascular disease with atorvastatin in type diabetes in the Collaborative Atorvastatin Diabetes Study ( CARDS ) : multicentre randomised placebo-controlled trial. Lancet 004; 364: Cannon CP, Braunwald E, McCabe CH, et al. Intensive versus moderate lipid lowering with after acute coronary syndromes. N Engl J Med 004; 350: De Lemos JA, Blazing MA, Wiviott SD, et al. Early intensive vs a delayed conservative simvastatin strategy in patients with acute coronary syndromes: phase Z of the A to Z trial. JAMA 004; 9: Nissen SE, Tuzcu EM, Schoenhagen P, et al. Effect of intensive compared with moderate lipid-lowering therapy on progression of coronary atherosclerosis: a randomized controlled trial. JA- MA 004; 9: Frick MH, Elo O, Haapa K, et al. Helsinki Heart Study: primary-prevention trial with gemfibrozil in middle-aged men with dyslipidemia. Safety of treatment, changes in risk factors, and incidence of coronary heart disease. N Engl J Med 987; 37: Rubins HB, Robins SJ, Collins D, et al. Diabetes, plasma insulin, and cardiovascular disease: subgroup analysis from the Department of Veterans Affairs high-density lipoprotein intervention trial ( VA-HIT ). Arch Intern Med 00; 6: Elam MB, Hunninghake DB, Davis KB, et al. Effect of niacin on lipid and lipoprotein levels and glycemic control in patients with diabetes and peripheral arterial disease: the ADMIT study: a randomized trial: arterial disease multiple intervention trial. JAMA 000; 84: Grundy SM, Vega GL, McGovern ME, et al. Efficacy, safety, and tolerability of once-daily niacin for the treatment of dyslipidemia associated with type diabetes: results of the assessment of diabetes control and evaluation of the efficacy of niaspan trial. Arch Intern Med 00; 6: American Diabetes Association. Standards of medical care in diabetes ( Position Statement ). Diabetes Care 005; 8: S4-36.

6 74 ADA Standard Recommendations for Treatment of Diabetes with Hyperlipidemia Lyh-Jyh Hao, Chwen-Yi Yang, and Ta-Jen Wu Division of Endocrinology and Metabolism, Yung Kang Veterans Hospital Division of Endocrinology and Metabolism, Department of Internal Medicine, Chi-Mei Foundation Hospital, Tainan, Taiwan Division of Endocrinology and Metabolism, Department of Internal Medicine, National Cheng Kung University Hospital Patients with type diabetes have an increased prevalence of lipid abnormalities that contributes to higher rates of CVD (Cardiovascular disease). Lipid management aimed at lowering cholesterol, raising c- holesterol, and lowering triglycerides has been shown to reduce macrovascular disease and mortality in patients with type diabetes, particularly those who have had prior cardiovascular events. Lifestyle intervention including MNT (Medical nutrition therapy), increased physical activity, weight loss, and smoking cessation should allow some patients to reach these lipid levels. Pharmacological treatment is indicated if there is an inadequate response to lifestyle modifications and improved glucose control. However, in patients with clinical CVD and >00 mg/dl, pharmacological therapy should be initiated at the same time that lifestyle intervention is started. The first priority of pharmacological therapy is to lower cholesterol to a target goal of <00 mg/dl (.60 mmol/l) or therapy to achieve a reduction in of 30 40%. For lowering, are the drugs of choice. A reduction in to a goal of <70 mg/dl is an option in very-high-risk patients with overt CVD. If the is <40 mg/dl and the is between 00 and 9 mg/dl, a fibric acid derivative or niacin might be used. Combination therapy, with a statin and a fibrate or statin and niacin, may be efficacious for patients needing treatment for all three lipid fractions(,, ), but this combination is associated with an increased risk for abnormal transaminase levels, myositis, or rhabdomyolysis. Consideration should be given to similar lipid-lowering therapy in patients with type diabetes as in type diabetes, particularly if they have other cardiovascular risk factors or features of the metabolic syndrome. ( J Intern Med Taiwan 005; 6: )