Ueda2016 metabolic syndrome in different population,which one is appropriate ...
Ueda2015 d.dyslipidemia dr.khaled hadidy
1. Diabetic Dyslipidaemia
BY
الرحيم الرحمن هللا بسم
KHALED EL SAYED EL HADIDY. MD
Head of Internal Medicine Department.
Head of Diabetes and Endocrinology Unit.
Beni-Suef University.
2. • Apo A-1
• SD LDL
HDL
Apo A-1
(CETP)
(LACT)
Proteolysis of Apo B-100
Clearance LPL, APO CIII
TG
Apo B
IR-----FFA
SD
LDL
↑ Non–HDL
= Total C – HDL-C (all atherogenic lipids)
(CETP)
Apo A-1
(CETP)
3. ( Aso. accounts for about 80% of all mortality).
(75% due to CHD & 25% due to cerebral or PVD).
`(CARDS): multicentre randomised placebo-controlled trial. Lancet 2004;364:685-696.
2Third Report of the NCEP Expert Panel on Detection, Evaluation, and Treatment of
High Blood Cholesterol in Adults (ATP III). Circulation. 2002;106:3143-3421.
(NCEP) (ATP) III : patients with diabetes should be
regarded as having CHD risk equivalent to that of patients with
known CHD.
European guidelines : risk of developing an MI is the
same for diabetic patients as it is for nondiabetic patients with a
prior MI.
Therefore, the same aggressive lipid treatment goals
should be applied to both diabetic and CHD patients,
even if the diabetic have no evidence of existing CHD.
5. four groups of individuals were identified for whom an
extensive body of RCT evidence demonstrated a reduction in
atherosclerotic cardiovascular disease (ASCVD) events
with a good margin of safety from statin therapy:
No LDL-C or non-HDL-C treatment targets
6. Four Statin Benefit Groups:
• Individuals with clinical ASCVD (acute coronary
syndromes, or a history of MI, stable or unstable angina,
coronary or other arterial revascularization, stroke, TIA, or
peripheral arterial disease presumed to be of
atherosclerotic origin ) without New York Heart Association
(NYHA) class II-IV heart failure or receiving hemodialysis.
• Individuals with primary elevations of LDL-C ≥ 190 mg/dl.
• Individuals 40-75 years of age with diabetes, and LDL-C
70-189 mg/dl without clinical ASCVD.
• Individuals without clinical ASCVD or diabetes, who are 40-
75 years of age with LDL-C 70-189 mg/dl, and have an
estimated 10-year ASCVD risk of 7.5% or higher.
Pooled Cohort Equations for (ASCVD) risk assessment
7.
8.
9. Patient is at High-Risk of ASCVD
Implement treatment recommendations:
• A – Aspirin / Antiplatelet therapy
• B – Blood pressure control
• C – Cholesterol control /Cigarette smoking cessation
• D – Diet and weight management / Diabetes and blood
sugar control
• E – Exercise
10. Standards of Medical Care in Diabetes—2015
Dyslipidemia/Lipid Management (1)
Screening
• Most:
measure fasting lipid. / y. (B)
• low-risk lipid values:
(LDLc <100 , HDLc >50 , and TG <150) (mg/dL)
measure fasting lipid. / 2 y. (E)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2014;37(suppl 1):S38
11. Standards of Medical Care in Diabetes—2015
Dyslipidemia/Lipid Management (2)
Treatment recommendations
lifestyle modification (A)
– Reduction of saturated fat, trans fat, cholesterol intake.
– Increased n-3 fatty acids, viscous fiber, plant stanols/sterols.
– Reduction of Weight. (if indicated)
– Increased physical activity.
ADA. VI. Prevention, Management of Complications. Diabetes Care 2014;37(suppl 1):S38
12. Standards of Medical Care in Diabetes—2015
Dyslipidemia/Lipid Management (3)
Treatment recommendations
Statin therapy
• should + lifestyle .
(( regardless of baseline lipid levels)).
– with overt CVD. (A)
– without CVD > 40 y. + 1 or >1 other CVD. RF. (A)
• Consider + lifestyle .
– with lower risk (e.g., without overt CVD, < 40 years of age). (C)
* LDLc remains >100 mg/dL.
* Multiple CVD. RF.
ADA. VI. Prevention, Management of Complications. Diabetes Care 2014;37(suppl 1):S38
13. Standards of Medical Care in Diabetes—2015
Dyslipidemia/Lipid Management (4)
Treatment recommendations
• Combination therapy has been shown not to provide
additional cardiovascular benefit above statin therapy
alone and is not generally recommended (A)
• Statin therapy is contraindicated in pregnancy (B)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2014;37(suppl 1):S38
14. Standards of Medical Care in Diabetes—2015
Dyslipidemia/Lipid Management (2015)
Treatment (LDLc cholesterol) goals
• without overt CVD
– < 100 mg/dL (2.6 mmol/L) (B)
• with overt CVD
– < 70 mg/dL (1.8 mmol/L), (using a high dose of a statin, is an option ) (B)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2014;37(suppl 1):S38
If targets not reached on maximal tolerated statin therapy
Alternative goal: reduce
LDLc ~30–40% from baseline (B)
TG < 150 mg/dL (1.7 mmol/L),
HDLc > 40 mg/dL (1.0 mmol/L) in men and
> 50 mg/dL (1.3 mmol/L) in women, are desirable (C)
However, LDL cholesterol–targeted statin therapy remains the preferred strategy (A)
15.
16. • Intensify lifestyle and optimize glycemic control for patients with C
– Triglyceride >150 mg/dL.
– HDL cholesterol >40 mg/dL in men and >50 mg/dL in women
• For fasting triglyceride > 500 mg/dL , evaluate for secondary causes and consider
medical therapy to reduce the risk of pancreatitis C
• In clinical practice, providers may need to adjust intensity of statin therapy based
on individual patient response to medication (e.g. side effects, tolerability, LDL
cholesterol levels.) E
• Cholesterol laboratory testing may be helpful in monitoring adherence to therapy
but may not be needed once the patient is stable on therapy E
• Combination therapy has been shown not to provide additional cardiovascular
benefit above statin therapy alone and is not generally recommended A
• Statin therapy is contraindicated in pregnancy B
Recommendations:
Dyslipidemia/Lipid Management
17. Primary Objectives of Effective Management
A
B
C
45 50 55 60 65 70 75 80 85 90
9
8
7
130
100
145
140
Patient Age
Reduction
of both
micro- and
macro-
vascular
event
rates
…by 75%
lGæde P, Vedel P, Larsen N, Jensen GVH, Parving H-H, Pedersen O. Multifactorial intervention and cardiovascular disease in patients with type 2
diabetes. N Engl J Med. 2003;348:383-393.
18. Mechanisms of action of lipid-lowering drugs
CETP Inhibitors
FDA approved supplement
Omega 3 Fish oil
LDL size
