Dyslipidemia is a common problem for people with diabetes. The most frequent lipid alteration in type 2 Diabetes Mellitus is hypertriglyceridemia associated with low HDL cholesterol. This leads to many complications, including increased risk of pancreatitis, cardiovascular events, and even death.
Initially, the treatment for dyslipidemia must be focused on the use of statins, as they hold the largest evidence for cardiovascular benefit. What does this mean? Statins reduce mortality. But when relevant, agents like statins, that primarily lower triglycerides, have the greatest potential in minimizing the risk of acute pancreatitis as well and should be used.
To manage dyslipidemias effectively, cholesterol goals must first be established. To start, every patient must be classified according to their cardiovascular risk.
Cardiovascular Risk Categories
All current guidelines on the prevention of cardiovascular diseases (infarction, angina, stroke, heart failure) in clinical practice recommend the assessment of total cardiovascular disease (CVD) risk. Prevention for each person should relate to his or her total CVD risk: people with higher risk have different cholesterol targets and should have a more intense approach and management. Many risk assessment systems are available worldwide.
For individuals with diabetes, the guidelines recommend this stratification by age and presence of risk factors to develop cardiovascular disease such as:
- Type 2 DM over 10 years of diagnosis
- Familiar history of Premature Coronary disease (coronary events in father, mother, or siblings before the age of 55 for men or 65 for women)
- Metabolic Syndrome
- Arterial hypertension (treated or not)
- Smoking
- Diabetes related complications: autonomic neuropathy, nephropathy, and retinopathy
- Subclinical Atherosclerotic disease such as carotid plaque and impaired ankle – brachial index
Four risk categories were defined based on the annualized rate of occurrence of cardiovascular events in ten years: low risk, intermediate risk, high risk and very high risk.
Treatment
Lifestyle modification with 5-10% weight loss and increased physical activity will lead to decreased triglycerides and increased HDL cholesterol levels with modest reduction of LDL cholesterol levels. Smoking cessation is also recommended.
Patients with diabetes who are overweight/obese should be given a prescription for medical nutritional therapy and for increased physical activity to 300 minutes per week. The proportion of saturated fat mainly found in fatty milk, butter, cheese, meat products such as sausage and bacon, ice cream and fast food should be reduced in a balanced meal plan.
Cholesterol Goals
Cholesterol goals are recommended according to cardiovascular risk, with the treatment more intensive as cardiovascular risk increases. The table below summarizes the recommended targets for each risk category:
| Risk | Statin | LDL goal (mg/dl) |
| Low | Optional | < 100 |
| Intermediate | Any | <100 |
| High | Any | <70 |
| Very high | High potency and/or another additional treatment | <55 |
Triglycerides and HDL target
Restricted intake of saturated fats, incorporation of monounsaturated fats (olive oil, nuts, avocados), reduction of carbohydrate intake, and reduction of alcohol consumption is the initial therapy for hypertriglyceridemia. In the case of severe hypertriglyceridemia, severe dietary fat restriction is recommended (<10% of calories per day of fat).
Interventions to improve glycemia usually lower triglyceride levels modestly. Lowering triglycerides to <150 mg/dl and raising HDL cholesterol to >40 mg/dl is recommended. Lowering triglycerides and increasing HDL cholesterol with a fibrate is associated with a reduction in cardiovascular events.
At GluCare, we take the guesswork out of determining your risk score and cholesterol goals by using artificial intelligence enhanced programs combined with connected wearable devices to guarantee the best management for your cholesterol levels.
