Management of Hyperlipidaemia in patients with Type 2 DM
All patients with type 2 DM must have an annual fasting full lipid profile (including total, HDL, LDL cholesterol and triglycerides).
Target Lipid Profile
- Total Cholesterol <5 mmol/l
- LDL cholesterol <3 mmol/l
- HDL cholesterol >1 mmol/l
- Triglycerides <2 mmol/l
- Total:HDL cholesterol <4
If lipid profile abnormal please check:
- Alcohol intake
- Thyroid function
- Liver function
- HbA1c and diabetic control
Evidence has accrued showing that Statin therapy is effective in both primary and secondary prevention of cardiovascular disease in high risk patients with DM (Heart Protection Study CARDS)
Lifestyle advice
- Low fat diet - refer to dietician
- Weight reduction if overweight
- Exercise
- Smoking cessation
- Reduce alcohol intake
Other interventions
- Optimise glycaemic control
- Optimise hypertension control
Indications for Drug therapy
- Patients over the age of 30 years with diabetes and one other CV risk factor.
- Also add Aspirin 75mg OD provided there are no contraindications and blood pressure <150/80 mmHg.
Drug therapy
Raised S. total cholesterol and S. Triglycerides <5mmol/l
Raised S. total cholesterol and S. Triglycerides <5mmol/l
- Add Simvastatin (20-80 mg OD) or Atorvastatin (10-80 mg OD)
- Add Micronized Fenofibrate (160-267mg OD)
- Add Micronised Fenofibrate (160-267mg OD) or Modified release Nicotinic acid (375-1600mg OD)
There is some suggestion that fibrates and nicotinic acid will play a more prominent role in the future, however evidence from randomised controlled trials is awaited.
Monitoring on lipid lowering therapy
- Warn patient about the rare risk of rhabdomyolysis (0.1%). If muscle aches develop, stop drug and check CK and AST
- Check Fasting lipid profile and liver function 3 months after initiating therapy
- Titrate statin/fibrate dose depending on results
- Recheck Fasting lipid profile 3 -4 monthly until target lipid levels achieved
- Then check Fasting lipid profile annually
- Check liver function tests 6 monthly while on lipid lowering agents. Stop treatment if transaminases >2x normal
- Do not use a fibrate if there is significant renal impairment (S.creatinine >150 mol/l)
Combination Therapy
Statin and Fibrate
Statin and Fibrate
- Combination therapy may be used and is often necessary in patients with type 2 DM and mixed dyslipidaemia.
- However, the combination increases the risk of rhabdomyolysis
- Reduce the dose of Simvastatin or Atorvastatin to a maximum of 10mg OD unless using Fenofibrate.
No dose reduction for Atorvastatin.
- Combination therapy may be necessary in patients with type 2 DM and low HDL cholesterol
- The main side effect of modified release Nicotinic acid is flushing but the risk is minimised if taken at bedtime, with a snack and if the dose is increased slowly over a period of weeks (see titration schedule in BNF). It may also adversely affect glycaemic control so hypoglycaemic therapy may need to be adjusted.
- Nicotinic acid is contraindicated in the presence of hepatic impairment
- Reduce the dose of Simvastatin or Atorvastatin to a maximum of 10mg OD. No dose reduction for Atorvastatin.
- Useful combination in patients with elevated total cholesterol despite maximal doses of statins. Both drugs act synergistically to reduce total and LDL cholesterol. No additional benefit on serum triglycerides or HDL cholesterol.
- Combine Ezetrimibe 10mg OD with either Simvastatin or Atorvastatin
- Reduce the dose of Simvastatin or Atorvastatin to a maximum of 20mg od
- If combination of Ezetimibe and statin needed then this should be prescribed as 2 tablets. The combination formulation is very expensive and should be avoided.
Indications for Secondary Care referral
- S.total cholesterol >6 mmol/l despite maximal Statin and Ezetrimibe therapy
- S. Triglycerides >3 despite maximal fibrate or Nicotinic acid therapy
Plain printer-friendly version of this page