Cholesterol and Lipids
TIPS
Wokefield Park 15/5/2013
Just a few questions!
 What is the NDA target for total cholesterol and LDL
cholesterol?
 What are the QOF targets for cholesterol?
 What is the ideal time to take a statin and why?
 Name the most serious side effect of statins.
 What blood test would you order if you suspected it?
 Name another side effect of statins.
 All statins increase HDL cholesterol – true or false?
 What is the most typical lipid profile for type 2 diabetes?
 What is the most typical lipid profile for type 1 diabetes?
R77 Statins & Ezetimibe
For a person who is 40 yrs+
• Simvastatin (to 40 mg) unless CVS risk
from non-hyperglycaemia-related factors
is low (see R72)
R72 Consider a person to be at
high CVS risk unless……
• Not overweight
• Normotensive
• No microalbuminuria
• Non-smoker
• No high risk lipid profile
• No h/o CVS disease
• No FH of CVS disease
If low CVS risk…………
• Assess CVS risk using UKPDS risk engine
• Start simvastatin if CVS risk > 20% over
10 yrs
Once on a statin………..
• Repeat lipid profile in 1-3 months then
annually
• If total cholesterol>4.0 or LDL cholesterol
>2.0 mmol/L titrate simvastatin to 80 mg
daily
Consider intensifying if…….
• Existing/newly diagnosed CVS disease
• Choose different statin/ezetimibe
If h/o raised triglycerides…….
• Consider secondary causes
• Full lipid profile
• Prescribe fenofibrate if Tg remain > 4.5
mmol/L
• If Tg remain > 2.3 mmol/L consider
adding fenofibrate to statin
Kaplan–Meier Estimates of the Incidence of Outcome Events in the Total Study Population.
Estruch R et al. N Engl J Med 2013;368:1279-1290
Statins do not alter the risk of Low HDL
Heart Protection Study
(Diabetes subgroup)
35
30
% CHD Events
25
31.1
25.9
20
21.3
16.8
15
10
5
0
< 0.9
placebo
≥ 0.9
HDL Cholesterol (mmol/L)
simvastatin 40mg
Adapted from Heart Protection Study Collaborative Group. Lancet 2003; 361: 2005-2016.
If you needed to treat these lipids what would you prescribe?
• Total cholesterol 5.35 mmol/L
• HDL cholesterol
1.4 mmol/L
• Triglycerides
1.68 mmol/L
LIPID
LIPID RESULTS
22% reduced mortality
24% reduced CHD mortality
29% reduced all CVS outcomes
20% reduced revascularisation
P<0.001
p<0.001
p<0.001
p<0.001
LIPID – Diabetics & Nonsmokers
No (%) CHD Events
Placebo
Pravastatin
Diabetics
Non-smokers
88(23)
76(19)
167(13)
139(12)
New Eng J Med 1998; 339: 1349-57
ASCOT
• Age 40-79
• Untreated BP 160/100 or more
• Treated BP 140/90 or more
• Total cholesterol < 6.5 mmol/L
• 3+ of LVH,ischaemic ECG,type 2
diabetes,PVD,previous stroke or TIA,male,
age > 55,smoker,microalbuminuria,family
history of premature CHD
Lancet 2003;361:1149-1158
Figure 2
Source: The Lancet 2003; 361:1149-1158 (DOI:10.1016/S0140-6736(03)12948-0)
Terms and Conditions
Figure 5
Source: The Lancet 2003; 361:1149-1158 (DOI:10.1016/S0140-6736(03)12948-0)
Terms and Conditions
CARDS Recruitment Criteria
• 2838 T2DM
• Age 40-75
• No known CVS disease
• Hypertension or retinopathy or
microalbuminuria
• Serum LDL < 4.14 mmol/L
• Serum triglycerides < 6.8 mmol/L
Figure 4
Source: The Lancet 2004; 364:685-696 (DOI:10.1016/S0140-6736(04)16895-5)
Terms and Conditions
CARDS Baseline Characteristics
• Total cholesterol 5.35 mmol/L
• HDL cholesterol
1.4 mmol/L
• Triglycerides
1.68 mmol/L
Figure 2
Source: The Lancet 2004; 364:685-696 (DOI:10.1016/S0140-6736(04)16895-5)
Terms and Conditions
VA-HIT: Diabetic Subgroup Analysis
Arch Intern Med;162:2597-2604
Numbers needed to treat
to prevent one non-fatal MI or CHD death in 5
years
CARE
LIPID
HPS
VA-HIT
All Patients
Diabetics
33
28
32
23
29
29
31
12
Question
You are a bigdeal trialist designing a study to
test the efficacy of a fibrate in the prevention of
CHD in type 2 diabetes. What ideally would you
like the average baseline lipid profile to be?
FIELD Study
• 9795 participants
• Type 2 diabetes
• Age 50- 75 yrs
• No prior statin/fibrate therapy
• 2131 previous CVS disease
• 7664 no known previous CVS disease
FIELD - Recruitment Lipids
• Total cholesterol 3-6.5 mmol/L +
• Either TC:HDL cholesterol > 4
• Or triglycerides 1.0-5.0 mmol/L
Original Article
Effects of Combination Lipid Therapy in Type 2
Diabetes Mellitus
The ACCORD Study Group
N Engl J Med
Volume 362(17):1563-1574
April 29, 2010
Lipid Values
The ACCORD Study Group. N Engl J Med 2010;362:15631574
Kaplan-Meier Analyses of the Primary Outcome, Expanded Macrovascular Outcome, and
Death
The ACCORD Study Group. N Engl J Med 2010;362:15631574
Conclusion
• The combination of fenofibrate and simvastatin did not reduce the rate of
fatal cardiovascular events, nonfatal myocardial infarction, or nonfatal
stroke, as compared with simvastatin alone
• These results do not support the routine use of combination therapy with
fenofibrate and simvastatin to reduce cardiovascular risk in the majority
of high-risk patients with type 2 diabetes
Baseline Characteristics of the Patients
The ACCORD Study Group. N Engl J Med 2010;362:15631574
Conclusions
Statins are safe, benefit many diabetics and
almost all diabetics should be on them
Treat total cholesterol & LDL cholesterol to
target
There is still a place for fibrates in combination
and first line for those with HDL<1 and/or
Tg>2.3