Vincenza Snow, MD; Mark D. Aronson, MD; E. Rodney Hornbake, MD; Christel Mottur-Pilson, PhD; Kevin B. Weiss, MD; the Clinical Efficacy Assessment Subcommittee of the American College of Physicians*
In an effort to provide internists and other primary care physicians with effective management strategies for diabetes care, the Clinical Efficacy Assessment Subcommittee (CEAS) of the American College of Physicians (ACP) decided to develop guidelines on the management of dyslipidemia, particularly hypercholesterolemia, in people with type 2 diabetes mellitus. The CEAS commissioned a systematic review of the currently available evidence on the management of lipids in type 2 diabetes mellitus. The evidence review is presented in a background paper in this issue. On the basis of this systematic review, the CEAS developed recommendations that the ACP Board of Regents then approved as policy.
The target audience for this guideline is all clinicians who care for patients with type 2 diabetes. The target patient population is all persons with type 2 diabetes, including those who already have some form of microvascular complication and, of particular importance, premenopausal women. The recommendations are as follows.
Recommendation 1: Lipid-lowering therapy should be used for secondary prevention of cardiovascular mortality and morbidity for all patients (both men and women) with known coronary artery disease and type 2 diabetes.
Recommendation 2: Statins should be used for primary prevention against macrovascular complications in patients (both men and women) with type 2 diabetes and other cardiovascular risk factors.
Recommendation 3: Once lipid-lowering therapy is initiated, patients with type 2 diabetes mellitus should be taking at least moderate doses of a statin.
Recommendation 4: For those patients with type 2 diabetes who are taking statins, routine monitoring of liver function tests or muscle enzymes is not recommended except in specific circumstances.
What are the benefits of tight lipid control for both primary and secondary prevention in type 2 diabetes?
What is the evidence for treating to certain target levels of low-density lipoprotein (LDL) cholesterol for patients with type 2 diabetes?
Are certain lipid-lowering agents more effective or beneficial in patients with type 2 diabetes?
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George B. Perlstein
April 21, 2004
drug interactions in lipid-lowering trreatment in diabetes
Since statins and many of the new oral glucose lowering agents both affect liver metabolism, should we not be cautious in using both agents together, fearing risk of hepatic injury?
New York Medical College
May 6, 2004
Statins in the Diabetic Population
The new Guidelines and Recommendations that moderate doses of statins be used in diabetics in an attempt to reduce the markedly elevated risks of cardiovascular disease is extremely important.1,2 Despite the statement that these drugs are extremely safe, they can produce side-effects of polyneuropathy3,4 and myopathy/rhabdomyolysis5 that could potentially lead to major disabilities, etc. Both of these side-effects are inherent to all statins and occur with a frequency of 4-5/10,000 with polyneuropathy and 2-3/10,000 in the non-diabetic population.6 It is theorized that the hydroxy methyl glutaryl coenzyme A(hmg-CoA) reductase inhibitor interferes with cholesterol synthesis in the nerve membrane producing aspects of axonal sensory and motor changes.3 Since diabetic peripheral neuropathy, depending on criteria, can be seen in 50-90% of individuals with diabetes for more than 10 years,7 the potential exists for early emergence in the clinically "asymptomatic" group or greater severity in the "symptomatic" group. Currently, there are no clinical studies available with endoneural nerve fiber biopsy parameters to address these potential issues.
It is unclear what the ideal strategy will be for patients with symptomatic diabetic peripheral neuropathy and perhaps physicians should consider other options such as the use of policosanol (sugarcane extract of median-chain alcohol)8 or niacin9 in these symptomatic individuals. Both of these drugs not only lower cholesterol and LDL but also raise HDL.
1. Snow V, Aronson MD, Hornbake ER, et al: Lipid control in the management of Type 2 diabetes mellitus: a clinical practice guideline from the American College of Physicians. An Int Med 2004; 140:644-649.
2. Dijan S, Hayward RA: Pharmacologic lipid-lowering therapy in Type 2 diabetes mellitus: Background paper for the American College of Physicians. An Int Med 2004; 140:650-658.
3. Gaist B, Jeppesen U, Andersen M, et al: Statins and risk of polyneuropathy. A case-controlled study. Neurology 2002; 58:1333-1337.
4. Donaghy N: Assessing the risk of drug-induced neurologic disorders. Statins and neuropathy. Neurology 2002; 58:1321-1322.
5. Phillips PS, Hahs RH, Bannykh S, et al: Statin-associated myopathy with normal creatine, kanase levels. An Int Med 2002; 137:581-585.
6. Moosmann B, Behl C: Selenoprotein synthesis and side-effects of statins. Lancet 2004; 363:892-894.
7. Weintraub MI, Wolfe GI, Barohn RA, et al: Static magnetic field therapy for symptomatic diabetic neuropathy: a randomized, double-blind, placebo-control trial. Arch Phys Med Rehabil 2003; 84:736-746.
8. Sasser H, Barringer T: Policosanol: a natural alternative for lipid management? Alt Med Alert 2004; 7:37-48.
9. McKenney J: New perspectives on the use of niacin in the treatment of lipid disorders. Arch Int Med 2004; 164:697-705.
Snow V, Aronson MD, Hornbake ER, Mottur-Pilson C, Weiss KB, . Lipid Control in the Management of Type 2 Diabetes Mellitus: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med. 2004;140:644–649. doi: 10.7326/0003-4819-140-8-200404200-00012
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Published: Ann Intern Med. 2004;140(8):644-649.
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