These correlate with risk factors such as diabetes. Consider hs-CRP testing in patients with intermediate cardiovascular risk by the Framingham risk score. Increased CRP correlates with the presence of cardiovascular risk factors and may reflect the effect of these to vascular inflammation. Patients with diabetes are evaluated as to treatment and intensity of treatment by two primary factors: age and presence of risk factors for atherosclerotic cardiovascular disease ASCVD or the presence of ASCVD. Table I is adapted from the current standards of medical care for diabetes from the American Diabetes Association.
As per the guidelines, in diabetics not on statins, screening for lipid disorders is recommended at the time of diagnosis, at initial medical evaluation and every 5 years thereafter, or more frequently if indicated. Patients between the ages without ASCVD risk factors can be placed on moderate intensity statins, while those with positive risk factors may fare better with high intensity therapy.
Similarly, patients over 75, irrespective of their ASCVD can be started on either high or moderate intensity statins, tailoring therapy based on their response. Even in the absence of weight loss, dietary changes can improve total cholesterol, triglycerides, and LDL levels. Fibrate therapy can be helpful when the low HDL is concurrent with a high TG level, but there is an increased risk of muscle toxicity. Nicotinic acid is the most effective for high-risk patients who have a primary low HDL-cholesterol. Medical therapy is needed in most patients to reach the current lipid goals.
Lipid-reducing drugs include statins, fibric acid derivatives, bile acid sequestrants, nicotinic acid, and cholesterol absorption inhibitors. The choice of drug is dependent on the individual patient lipid abnormality. The statins have shown improvements in overall mortality in primary and secondary prevention. Based on this data, statins are the first choice in patients with LDL hypercholesterolemia, with the goal of reduction in primary or secondary cardiovascular risk.
The less potent statins such as pravastatin and lovastatin can be titrated up for LDL-lowering effect, but still do not reach the lowering seen with the more potent atorvastatin or rosuvastatin. Over time, with more generic statin options, these medications are also becoming more affordable. The statin drugs work by competitively inhibiting HMG-CoA reductase, the rate-limiting enzyme in cholesterol synthesis, and by upregulation of LDL receptors. The overall effect is a dramatic lowering of plasma levels of LDL cholesterol.
VLDL triglyceride concentrations are also reduced in many subjects with hypertriglyceridemia directly related to the reduction of LDL cholesterol. In regard to HDL, the directly-targeted HDL therapies have been limited and not successful as they have evolved through the clinical trial process. Low HDL can be seen in a number of scenarios, including familial conditions like familial primary hypoalphalipoproteinemia.
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It can also be caused by drugs such as beta blockers, anabolic steroids or benzodiazepines. Most commonly, it is found in insulin resistant states such as type 2 diabetes, obesity and hypertension. Elevated triglycerides are often found in the insulin resistant state. Emerging data has suggested that elevated triglyceride levels are independently associated with coronary risk. The goal of treatment is to decrease this risk. Treatments include weight loss in obese patients, exercise, diet modification, and medication review hormone-based treatments, etc.
In patients with diabetes, strict glycemic control is needed, as well as hypertension and smoking cessation. Beyond this level, fibrates can be used. At the very least there was no benefit in the primary analysis.
At this time, combination therapy of a statin with niacin is not recommended. Combination therapy of a statin with a fibrate is generally not recommended. However, in sub-group analyses there may be benefit or harm depending on the subgroup studied. Future studies will need to be performed to determine those individuals who would benefit most from and those who might be harmed by combination therapy with a statin or fibrate or a statin and niacin Additional studies are needed to determine optimal lipid lowering therapy in those patients who cannot tolerate any statin agent.
One new class of agents that may prove to be valuable in patients with diabetes as an add-on to statin therapy or those intolerant of statins are PCSK9 inhibitors. The data from this trial did not demonstrate an increased risk for developing diabetes in patients who did not have diabetes. However, longer follow-up while on treatment with a PSCK9 inhibitor and evaluation of other agents in this class of drugs for the development of diabetes are still needed.
The method of monitoring the effects of lipid-lowering therapy is not clear. Rather than take a rigid approach to measuring lipid profiles in patients with diabetes, current recommendations suggest that a lipid profile be obtained at the time of diagnosis of diabetes, the initial medical evaluation, and at a minimum every 5 years beyond the initial evaluation.
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A lipid profile is recommended prior to starting treatment with a statin. The major change in monitoring the effects of lipid lowering therapy is to individualize the testing frequency for LDL cholesterol to the patient rather than set intervals. With statins, lipid levels stabilize within weeks after dose adjustment. Routine monitoring of serum creatine kinase CK levels is not recommended in patients on statins. It may be helpful to have a baseline CK level to assess for any change if the patient develops symptoms later on. The main clinical side effect with the statins is myalgia. Pravastatin is not metabolized by CYP3A4.
In patients who do not tolerate any statin and are being treated for secondary prevention, other options include bile acid sequestrants, fenofibrate niacin, and ezetimide. Muscle injury is an important concern, particularly in patients who are also treated with cyclosporine, fibrates, and HIV medications. Patients can have myalgias without an elevation in serum CK. Muscle symptoms can begin within weeks to months after starting the statins.
These symptoms are reversible, and myalgias and serum CK usually return to normal over days to weeks after the drug is stopped. Of note, the CK value can also elevate in multiple contexts, including exercise and high impact sports. Patients treated with high doses of potent statins, those who are older, female, have a genetic predisposition all have a higher risk for myopathy particularly when statins are given with drugs that interfere with drug metabolism.
The risk of muscle injury is increased when the drugs are metabolized by cytochrome P 3A4 and drugs that interfere with CYP3A4. Grapefruit juice inhibits CYP3A4, and there is an increased risk of muscle injury in renal failure, obstructive liver disease, and hypothyroidism. In patients treated with gemfibrozil who need a statin, pravastatin or fluvastatin are preferred. Fenofibrate is the preferred fibrate in patients who require combined therapy with a statin. In patients with moderate symptoms or with a CK elevated to more than 5-fold, the statin should be stopped.
Awareness of these issues is key.
How does diabetes affect cholesterol?
Our Division has attracted a high caliber of fellows and they do well in both practice and academic settings after completing their fellowships , cited: Flat Belly download epub. This translates to expertise in treating diabetes blood sugar , high cholesterol and related problems , e. Diabetes and Health read epub Diabetes and Health Disparities:.
His research focuses on the molecular mechanisms of thyroid hormone action during skeletal development and in adult bone maintenance Staged Diabetes Management jtmservice.
Lipids in Diabetes - ECAB
If you're eligible to participate, you may be contacted by a nurse or study coordinator. If you select a health category rather than a specific study, doctors who have active studies in that area may contact you to ask if you would like to participate epub.
In addition to general endocrinology, her areas of interest include diabetes, thyroid and parathyroid disorders. She is married and spends her free time running after her young son and daughter. Salley grew up in Virginia Beach and attended the University of Virginia for her undergraduate studies ref.
Promotion of autoimmune diabetes by cereal diet in the presence or absence of microbes associated with gut immune activation, regulatory imbalance, and altered cathelicidin antimicrobial peptide ref. He continues to practice part-time in Florida. Mersey and his associates are actively involved in clinical research in diabetes, hypertension, lipid disorders and osteoporosis Behavioral and Metabolic read pdf Behavioral and Metabolic Aspects of.
It also serves as a resource for the study and management of hypoglycemia. Special endocrinology services include needle aspiration of thyriod nodules; diagnosis and management of pituitary tumors; and diagnosis and treatment of hypothyroidism, hypertension and general endocrine disorders.
There are three categories: clinical endocrinology, pediatric endocrinology, and reproductive physiology. The University of Utah Division of Endocrinology, Metabolism, and Diabetes offers expert care for various metabolic, pituitary, thyroid and diabetes-related conditions. Professor of Internal Medicine-Endocrinology and Metabolism; Chairman,Third Department of Medicine, Medical School-University of Athens, Greece Her research interests have focused on clinical, molecular and environmental aspects of metabolic and hormonal abnormalities in polycystic ovarian syndrome.