2003 Clinical Practice Guidelines
for the Prevention and Management
of Diabetes in Canada
DYSLIPIDEMIA IN ADULTS WITH DIABETES*
*Updated in 2006. Leiter LA, et al for the CDA CPG Expert Committee. Can
J Diabetes. 2006;30:230-240.
DYSLIPIDEMIA
 Diabetes is associated with high risk for vascular disease, and
aggressive lipid management is generally necessary. Attention to the
full lipid profile is required, as hypertriglyceridemia and low HDLcholesterol are particularly common.
 All patients should be assessed for their risk of a vascular event. Most
patients with diabetes are at high risk.Younger patients with a shorter
duration of diabetes and without other risk factors and without
complications of diabetes would be considered at lower risk.
CDA CPG Expert Committee. Can J Diabetes. 2006;30:230-240.
DYSLIPIDEMIA
 Achieving an LDL-C of <=2.0 mmol/L is the primary goal of therapy.
 Once the LDL-C goal has been attained, consideration to achieving
the secondary target of an TC/HDL-C ratio of <4.0.
 The vast majority of patients with be able to attain the LDL-C goal on
statin therapy.
 Although not formal goals of therapy, optimal TG is <1.5 mmol/L and
apo B is 0.9 g/L
 Lifestyle modification should be seen as an important adjunct to, not
substitution for, pharmacologic therapy.
CDA CPG Expert Committee. Can J Diabetes. 2006;30:230-240
DYSLIPIDEMIA
 Effective risk reduction requires a multifaceted approach
targeting all risk factors:
- Obesity
- Hypertension
- Hyperglycemia
- Dsylipidemia
- Microalbuminuria
- Smoking
- Sedentary lifestyle
- Diet
CDA CPG Expert Committee. Can J Diabetes. 2006;30:230-240
FIRST-LINE Rx FOR DYSLIPIDEMIA
• Statins are the drugs of choice to lower LDL-C.
• At higher doses, statins have modest TG-lowering effects and
HDL-C-raising effects:
- atorvastatin (Lipitor)
- fluvastatin (Lescol)
- lovastatin (Mevachor and generic)
- pravastatin (Pravachol and generic)
- rosuvastatin (Crestor)
- simvastatin (Zocor and generic)
CDA CPG Expert Committee. Can J Diabetes. 2006;30:230-240
LIPID TARGETS
LIPID TARGETS FOR ADULTS WITH DM AT HIGH RISK FOR CVD
INDEX
TARGET VALUE
Primary target: LDL-C
<=2.0 mmol/L
Secondary target: TC/HDL-C ratio
<4.0
Clinical judgment should be used to decide whether additional LDL-C
lowering is required for patients with an on-treatment LDL-C of 2.0 to 2.5
mmol/L.
CDA CPG Expert Committee. Can J Diabetes. 2006;30:230-240
OTHER DRUGS FOR DYSLIPIDEMIA
Drug class
Principal effects
Considerations
Bile acid sequestrants
Lower LDL-C
GI intolerability
May raise TG
Cholesterol absorption
inhibitor
Lower LDL-C
Less effective than statins as
monotherapy
Fibrates
Lower TG
May increase creatinine &
homocysteine
Variable effect on LDL-C
Highly variable effect on HDL-C
Nicotinic acid
Raise HDL-C
Lower TG
Lower LDL-C
Do not use gemfibrozil with
statins
Can cause worsening of
glycemic control
Extended-release has similar
efficacy & better tolerability
than immediate-release
Do not use long-acting niacin
CDA CPG Expert Committee. Can J Diabetes. 2006;30:230-240
DYSLIPIDEMIA RECOMMENDATIONS
 People with type 1 or type 2 diabetes should be encouraged to
adopt a healthy lifestyle to lower their risk of CVD. This entails
adopting healthy eating habits, achieving and maintaining a
healthy weight, engaging in regular physical activity and smoking
cessation [Grade D, Consensus].
CDA CPG Expert Committee. Can J Diabetes. 2006;30:230-240
DYSLIPIDEMIA RECOMMENDATIONS
 A fasting lipid profile (TC, HDL-C, TG and calculated LDL-C) should
be conducted at the time of diagnosis of diabetes and then every 1
to 3 years as clinically indicated. More frequent testing should be
done if treatment for dyslipidemia is initiated [Grade D, Consensus].
CDA CPG Expert Committee. Can J Diabetes. 2006;30:230-240
DYSLIPIDEMIA RECOMMENDATIONS
 Most adults with type 1 or type 2 diabetes should be considered at
high risk for vascular disease [Grade A, Level 1, Level 2]. The
exceptions are younger adults with shorter duration of disease and
without complications of diabetes (including established CVD) and
without other CVD risk factors [Grade A, Level 1]. A computerized
risk engine (e.g. UKPDS risk engine, Cardiovascular Life Expectancy
Model) can be used to estimate vascular risk [Grade D, Consensus].
CDA CPG Expert Committee. Can J Diabetes. 2006;30:230-240
DYSLIPIDEMIA RECOMMENDATIONS
 Adults at high risk of a vascular event should be treated with a statin
to achieve an LDL-C <=2.0 mmol/L [Grade A, Level 1, Level 2]. Clinical
judgment should be used to determine whether additional LDL-C
lowering is required for adults with an on-treatment LDL-C of 2.0 to
2.5 mmol/L [Grade D, Consensus].
CDA CPG Expert Committee. Can J Diabetes. 2006;30:230-240
DYSLIPIDEMIA RECOMMENDATIONS
 In adults, the primary target of therapy is LDL-C [Grade A, Level 1, Level
2]; the secondary target is TC/HDL-C ratio [Grade D, Consensus].
CDA CPG Expert Committee. Can J Diabetes. 2006;30:230-240
DYSLIPIDEMIA RECOMMENDATIONS
 In adults, if the TC/HDL-C ratio is >=4.0, consider strategies to
achieve a TC/HDL-C ratio of <4.0 [Grade D, Consensus], such as
improved glycemic control, intensification of lifestyle (weight loss,
physical activity, smoking cessation) and, if necessary, pharmacologic
interventions [Grade D, Consensus].
CDA CPG Expert Committee. Can J Diabetes. 2006;30:230-240
DYSLIPIDEMIA RECOMMENDATIONS
 In adults with serum TG >10.0 mmol/L despite best efforts at optimal
glycemic control and other lifestyle interventions (e.g. weight loss,
restriction of refined carbohydrates and alcohol), a fibrate should be
prescribed to reduce the risk of pancreatitis [Grade D, Consensus]. For
those with moderate hyper-TG (4.5 to 10.0 mmol/L), either a statin or
fibrate can be attempted as first-line therapy, with the addition of a
second lipid-lowering agent of a different class if target lipid levels are
not achieved after 4 to 6 months on monotherapy [Grade D,
Consensus].
CDA CPG Expert Committee. Can J Diabetes. 2006;30:230-240
DYSLIPIDEMIA RECOMMENDATIONS
 For adult patients not at target(s), despite optimally dosed first-line
therapy as described above, combination therapy can be considered.
Although there are as yet no completed trials demonstrating clinical
outcomes in adults receiving combination therapy, pharmacologic
treatment options include (listed in alphabetical order):
- Statin plus ezetimibe [Grade B, Level 2]
- Statin plus fibrate [Grade B, Level 2, Level 3]
- Statin plus niacin [Grade B, Level 2]
CDA CPG Expert Committee. Can J Diabetes. 2006;30:230-240
DYSLIPIDEMIA RECOMMENDATIONS
 In adults, plasma apo B can be measured, at the physician’s discretion,
in addition to LDL-C and TC/HDL-C ratio, to monitor adequacy of
lipid-lowering therapy in the high-risk patient [Grade D, Consensus].
Target apo B should be 0.9 g/L [Grade D, Consensus].
CDA CPG Expert Committee. Can J Diabetes. 2006;30:230-240