Rationale for New American Diabetes Association Guidelines: Are National Cholesterol Education Program Goals Adequate for the Patient with Diabetes Mellitus?

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Both the American Diabetes Association (ADA) and the National Cholesterol Education Program (NCEP) consider type 2 diabetes mellitus to be a coronary artery disease (CAD) risk equivalent and thus suggest that patients with either diabetes or CAD should have their plasma levels of low-density lipoprotein (LDL) cholesterol lowered to <2.59 mmol/L (<100 mg/dL). Recently the NCEP issued a white paper suggesting an even lower plasma LDL cholesterol goal of <1.81 mmol/L (<70 mg/dL) for patients at high cardiovascular risk, including patients with diabetes. This rationale was based partly on the higher risk of future cardiovascular disease seen in patients who have diabetes with or without preexisting cardiovascular disease than in nondiabetic subjects with preexisting cardiovascular disease. Additionally, as reported in the Pravastatin or Atorvastatin Evaluation and Infection Therapy (PROVE-IT) study, high-dose lipid-lowering therapy has been shown to further reduce CAD event rates compared with conventional therapy.

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Current Recommendations for Therapy of Diabetic Dyslipidemia

Currently both the ADA1 and the NCEP2 recommend that normalization of elevated plasma low-density lipoprotein (LDL) cholesterol is the first criterion for treating diabetic dyslipidemia (Table 1). However, the choice of secondary and tertiary targets differs slightly between the NCEP and the ADA. The NCEP recommends that after the primary target for LDL cholesterol is met, if the plasma triglyceride level is ≥2.26 mmol/L (≥200 mg/dL), the healthcare provider may consider non-high-density

Diabetes As a Coronary Artery Disease Risk Equivalent

Both the ADA1 and the NCEP2 recommend treatment of dyslipidemia in patients with diabetes to the same degree of intensity as that for patients with CAD. Three criteria are generally necessary for diabetes to be accepted as a CAD risk equivalent: (1) the risk of vascular disease should be similar in patients with diabetes or CAD, (2) intensive glycemic control should not be sufficient to eliminate the excess risk of cardiovascular disease in patients with diabetes, and (3) lipid-lowering therapy

Conclusion

Strong evidence exists to support the idea that all patients with diabetes be treated to the same lipid goals as are patients with CAD. The first priority for treating dyslipidemia in type 2 diabetes is to lower plasma levels of LDL cholesterol. There is a consensus that a minimal goal should be a plasma level of LDL cholesterol of <2.59 mmol/L (<100 mg/dL). Although definitive data do not yet exist, a still lower plasma LDL cholesterol goal (<1.81 mmol/L [<70 mg/dL]) may be considered in some

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