Hosted by Ray Shields, MD

At minimum, perform a complete lipid profile annually.  This includes total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides.  More frequent testing may be required to assess therapeutic measures, including Medical Nutrition Therapy (MNT) and pharmacotherapy.  
 

While a 9-12 hour fasting lipid profile is preferable, it is possible to make reasonable assessments of the lipid status on a non-fasting profile.  If the triglycerides are too high to calculate a reliable LDL, a direct LDL may be ordered; non-fasting status does not affect the direct LDL measurement.  The calculation of the non-HDL cholesterol may also be of benefit in therapeutic decision-making (see below).  It is sometimes difficult for patients traveling significant distances to come in fasting.  We recommend point-of-care testing, if possible, so that timely decisions can be made in regards to therapy.  
 

Lifestyle intervention, including MNT addressing fat and cholesterol intake, increased physical activity, weight loss, and smoking cessation is indicated for any patient with type 2 diabetes because of the increased risk of CVD, even with “normal” lipid levels.  Glycemic control is also important for modifying plasma lipid levels and should be addressed to help reduce hypertriglyceridemia.

Goals for Lipid Control in Patients with Type 2 Diabetes:  

Primary Target

Although lifestyle modification including MNT is always the foundation of therapy, we recommend pharmacotherapy for those without known CVD who have not attained the LDL target of 100 mg/dL through lifestyle interventions within 3 months.  HMG–CoA reductase inhibitors (statins) are considered first-line therapy for the primary LDL target, but providers may consider other agents depending on the triglyceride and HDL levels.  Consider initiating statin therapy in conjunction with lifestyle modification for those with LDL levels above 130 mg/dL.  

Providers should consider all individuals with diabetes and known CVD for statin therapy regardless of initial LDL levels to achieve a reduction of 30-40%; a goal LDL of 70 mg/dL is an option.

Secondary Targets

Triglyceride and HDL targets outlined above are secondary goals of therapy for dyslipidemia and present a special challenge.  Although it may not always be possible to attain the target levels, optimal use of lifestyle modifications and glycemic control should help in attaining these goals.  In selected patients and especially those at higher risk, combining a fibrate or niacin with a statin may be warranted, although no large-scale clinical outcome trials have evaluated these combinations.   For those with near normal LDL levels and known clinical cardiovascular disease, fibrates are associated with a reduction in CVD events.  Some patients may be appropriate candidates for fibrate or niacin alone, depending on their initial triglycerides and HDL levels, reaction to medications, or other clinical considerations.

Setting goals for HDL presents a special challenge.  A low HDL should be defined as a level of <40 mg/dl in both men and women.  Although clinical trials suggest that raising HDL will reduce the risk for CVD, effective pharmacologic therapies are limited.  Therefore, a specific goal for HDL is not identified by the National Cholesterol Education Program ATP-III guidelines.  We support the recommendation that non-drug and drug therapies that raise HDL and are part of management of other lipid and non-lipid risk factors should be part of a lipid management strategy for adults with diabetes.

Non-HDL is an important secondary goal for lipid therapy following successful interventions for LDL level.  The non-HDL cholesterol is a simple calculation of subtracting the HDL from the total cholesterol and represents the total “atherogenic load.”    This has been validated as a useful tool in identifying CVD risk and can be performed in the non-fasting state. The target, as identified above, is 30 mg/dL higher than the LDL target.  Statin therapy to improve CVD risk would be considered first line when addressing the non-HDL.  

Monitoring for HMG–CoA reductase inhibitors (statins) therapy  

Before initiating statin therapy, you should document baseline measurements, including a liver and lipoprotein profile, which will be used to follow the drug’s efficacy and safety. We also recommend a baseline thyroid stimulating hormone (TSH) since hypothyroidism is a secondary cause of high cholesterol.