Using Lipid Guidelines in Diabetes Care
Experts discuss the various guidelines for lipid management.
Lipid guidelines from various associations have the same goal of reducing cardiovascular disease (CVD) risk, but they differ somewhat in terms of treatment targets and management strategies. At AADE 2015, the annual meeting of the American Association of Diabetes Educators, 2 experts discussed these guidelines and how best to incorporate them into clinical practice.
During their presentation at Evan Sisson, PharmD, MSHA, CDE, and Dave Dixon, PharmD, BCPS, CDE, both of whom are assistant professors at the Virginia Commonwealth University School of Pharmacy, said management of dyslipidemia is now based on the following:
- 2013 American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines1
- 2015 American Diabetes Association (ADA) Guidelines2
- 2014 National Lipid Association (NLA) Guidelines3
- 2015 American Association of Clinical Endocrinologists (AACE) Guidelines4
Non-HDL cholesterol is the best predictor of atherosclerotic cardiovascular disease (ASCVD) risk, according to Sisson. Although the 2013 ACC/AHA guidelines represent a population approach to management, the 2014 NLA guidelines actually provide the best strategy to tailor care for individual patients with dyslipidemia.
He said many patients are not treated aggressively enough and do not meet their treatment goals, and endocrinologists need to be aware of this. A multipronged approach to management is best for patients with diabetes who are at high risk for CVD and its complications.
“Non-HDL cholesterol is a better predictor of ASCVD risk than LDL cholesterol, especially in patients with diabetes. Patients with ASCVD or diabetes plus more than two risk factors should be treated to a non-HDL cholesterol goal of less than 100 mg/dL,” Sisson told Endocrinology Advisor.
“As many as 40% of patients treated with high-intensity statins do not reach their non-HDL cholesterol goal of less than 100 mg/dL.”
He said there is an urgent need to combat heart disease and its risk factors since about 600,000 people die of heart disease in the United States every year, translating into approximately one of every four deaths. He encouraged clinicians to tailor their messages about diet, exercise and how best to manage lipids to each individual patient. Setting goals and regularly reviewing them can be highly beneficial, Sisson noted.
Dixon said there are now better treatments available for preventing and treating heart disease and evidence-based guidelines are better able to help guide clinicians.
The current data show that combination therapy may be appropriate for patients who do not achieve their non-HDL cholesterol goal on statin monotherapy. However, Dixon noted that understanding adverse effects and potential drug interactions of available options can help with treatment decisions.
Patient education about lifestyle changes and strict adherence to the various medications are crucial for control of triglycerides, he said. Additionally, newer agents are also improving outcomes.
“PCSK9 inhibitors, such as imp, represent a valuable addition to statin therapy in patients who do not achieve their non-HDL cholesterol goals,” Dixon told Endocrinology Advisor.
Five years ago, the prevailing strategy focused on LDL cholesterol reduction, based on the 2001 ATP-III lipid guidelines, Sisson said. However, the 2013 ACC/AHA recommendations shifted the emphasis to getting patients on the appropriate dose of statins and decreased the importance of specific LDL cholesterol targets. The 2014 NLA recommendations combine these two approaches into a more patient-centered middle ground.
“Because non-HDL cholesterol better predicts future events than LDL cholesterol, it was selected as a primary target of therapy. Like ACC/AHA, the NLA guidelines reinforce the need to start patients on appropriately intensive statin doses based on heart disease risk, but also suggest roles for non-statin therapies in patients who do not achieve their non-HDL cholesterol goals,” Sisson said.
“Data from the IMPROVE-IT study with ezetimibe, subgroup analyses from HPS-2 THRIVE and FDA approval of alirocumab help substantiate the value of combination therapy. While the ACC/AHA provides a simplified approach to starting statin therapy, the NLA guidelines offer a pragmatic approach for continued management and reduction of cardiovascular risk.”
- Stone NJ et al. Circulation. 2014;129:S1-S45.
- Jacobson TA et al. J Clin Lipidol. 2014;8:473-488.
- American Diabetes Association. Diabetes Care. 2015; 38(Suppl. 1):S49–S57.
- Garber AJ et al. Endocr Pract. 2014;doi:10.4158/EP15693.CS.
- Sisson E, Dixon D. W07 – Lipid Guidelines: What is Best for My Patient? Presented at: AADE 2015; Aug. 5-8, 2015; New Orleans.