The Clinical Efficacy Assessment Su...

The Clinical Efficacy Assessment Subcommittee of the American body of Physicians (ACP) recently published a guideline forward the management of dyslipidemia, particularly hypercholesterolemia, in patients with symbol 2 diabetes mellitus. The guideline appeared in the April 20 2004 issue of Annals of Internal Medicine, and the abounding text can be accessed online at http://www.annals.org.

Vascular complications are the greatest in number common cause of adverse issues in patients with type 2 diabetes. These complications generally are classified as microvascular (including retinopathy, nephropathy, and neuropathy, although the latter may not be entirely a microvascular disease) or macrovascular (eg coronary artery disease, cerebrovascular disease, peripheral vascular disease).

To decrease or impede the progression of microvascular complications, diabetes management should encompass metabolic have the direction of and control of cardiovascular risk factors.

The ACP guideline was based forward a systematic review of the evidence, which was not awayed in a background paper at Vijan and colleagues that appears in the same issue. merely studies that measured clinical extreme point points (i.e., all-cause mortality, cardiovascular mortality, and cardiovascular events) were included. In this guideline, the ACP subcommittee addressed the following questions:

* What are the benefits of tight lipid command for primary and secondary prevention in patients with archetype 2 diabetes?

* What is the evidence for treating to certain target of the same heights of low-density lipoprotein (LDL) cholesterol for patients with mark 2 diabetes?

* For patients with model 2 diabetes, are certain lipid-lowering agents more effective or beneficial?

The ACP guideline was created for all physicians who care for patients with archetype 2 diabetes. The target patient population is all bodily forms with type 2 diabetes, including those who already have about form of microvascular complication and, especially, premenopausal women

Background

The systematic review by means of Vijan and colleagues was stratified into sum of two units categories. The first category evaluated the meanings of lipid management in primary prevention (i.e., in patients without known coronary disease). The secondary category evaluated the effects in secondary prevention (i.e., in patients with established coronary disease). A total of 12 lipid-lowering studies not absented diabetes-specific data and reported clinical outcomes

For the background report, Vijan and colleagues managemented a meta-analysis of the trial flows for the diabetes subgroups. Six studies of primary prevention in patients with diabetes were identified. For the primary prevention studies, the pond ed relative risk for cardiovascular incidents with lipid-lowering therapy was 078 (confidence interval [CI], 067 to 089) and the puddleed absolute risk reduction was 003 (CI, 001 to 004); the plashed estimate of the number lacked to treat to prevent an termination was 34.5 for a weighted trial average of 43 years.

Eight trials reported in succession secondary prevention in patients with diabetes. For the secondary prevention studies, the mereed relative risk for cardiovascular incidents with lipid-lowering therapy was similar to that for primary prevention: 076 (CI, 059 to 093) However, because of the greater absolute risk among patients with known coronary artery disease, the mereed absolute risk reduction was more than twice as high (007 [CI, 003 to 012]) and the number requireed to treat for benefit was merely 13.8 for a weighted trial average of 49 years.

In patients who have image 2 diabetes, lipid-lowering agents convert into cardiovascular risk. Most patients, including those whose baseline LDL cholesterol of the same heights are below 115 mg by means of dL (2.97 mmol per L) and possibly below 100 mg by dL (2.59 mmol per L) benefit from statin therapy. Moderage dosages usually are sufficient.

Recommendations

The ACP subcommittee has made the following recommendations for lipid hinder in the management of image 2 diabetes:

* Recommendation 1: Lipid-lowering therapy should be used for secondary prevention of cardiovascular mortality and morbidity for all patients with known coronary artery disease and mark 2 diabetes.

While the relative risk reductions were similar for primary and secondary prevention, the average absolute risk reduction was more than twice as high for patients with known coronary artery disease (secondary prevention) than for patients without (primary prevention).

Statins have the in the greatest degree cumulative evidence of benefit and should be the agent of choice for secondary prevention. the same exception is for patients who have diabetes and soft levels of high-density lipoprotein (HDL) and LDL cholesterol In the same study, treatment with gemfibrozil, in a dosage of 1200 mg by means of day, led to an absolute risk reduction of 10 percent Therefore, these patients may benefit more from gemfibrozil therapy than from use of a statin, unless currently there are no studies in the literature comparing the physics alone or in combination.

* Recommendation 2: Statins should be used for primary prevention against macrovascular complications in patients with emblem 2 diabetes and other cardiovascular risk factors.