1. Overview & Pathophysiology
Dyslipidemia is a major risk factor for cardiovascular disease (CVD) in diabetes. The lipid profile in diabetes (especially Type 2) often presents a specific “atherogenic” pattern:
Typical Pattern:
High Triglycerides (TG).
Low HDL-Cholesterol.
Normal or slightly elevated LDL-Cholesterol (but the particles are typically small, dense, and highly atherogenic).
Primary Goal: Lowering LDL-C is the primary target because it has the strongest evidence for CVD risk reduction.
2. Screening
Who: All adults with diabetes.
When: At diagnosis and then every 1–3 years as clinically indicated.
Components: Lipid profile (TC, HDL-C, TG, LDL-C, Non-HDL-C).
3. Treatment Indications (Who Needs a Statin?)
This is one of the most high-yield areas for the CDE exam. Statin therapy is recommended based on risk category, not just baseline LDL levels.
A. Secondary Prevention (High Risk)
Indication: Any person with diabetes and Clinical Cardiovascular Disease (CVD).
Action: Start Statin.
B. Primary Prevention (Type 2 Diabetes)
Age 40 years: Start Statin (regardless of baseline LDL).
Age < 40 years: Start Statin IF one of the following is present:
Microvascular complications (retinopathy, kidney disease, neuropathy).
Assessment warrants therapy based on other guidelines (e.g., Familial Hypercholesterolemia).
C. Primary Prevention (Type 1 Diabetes)
Age 40 years: Start Statin.
Age < 40 years: Start Statin IF:
Duration of diabetes years AND age years.
Microvascular complications are present.
4. Treatment Targets
Once a patient is on a statin, you treat to a specific target.
Primary Target:
LDL-C 2.0 mmol/L
OR 50% reduction from baseline LDL-C.
Alternate Targets (if LDL is accurate):
Non-HDL-C mmol/L.
Apolipoprotein B (ApoB) g/L.
5. Pharmacotherapy Management
A. Statins (HMG-CoA Reductase Inhibitors)
First-line therapy.
Pregnancy: Contraindicated. Women of childbearing potential must use reliable contraception or stop statins before conception.
B. Second-Line Agents If targets are not met with maximally tolerated statin doses:
Ezetimibe: Can be added to statins.
PCSK-9 Inhibitors (e.g., Evolocumab, Alirocumab): Injectable agents that dramatically lower LDL; indicated if targets are missed despite statin + ezetimibe, or for Familial Hypercholesterolemia.
C. Hypertriglyceridemia
Lifestyle: Weight loss, optimal glycemic control, and restricting alcohol/refined sugars are key.
Fibrates:
Generally NOT recommended for reducing CVD risk (evidence from FIELD and ACCORD-Lipid trials was weak).
Exception: Use fibrates to prevent pancreatitis if Triglycerides are severe ( mmol/L).
6. 2018 Diabetes Canada Clinical Practice Guidelines Recommendations
Key takeaways from the “Recommendations” section.
Statin Initiation: Recommended for:
Adults with clinical CVD [Grade A, Level 1].
Adults age 40 years [Grade A, Level 1 for T2D; Grade D for T1D].
Adults age < 40 years with microvascular complications or long duration (>15 yrs duration and age >30) [Grade D, Consensus].
Targets: The primary goal is LDL-C consistently mmol/L or a reduction from baseline [Grade D, Consensus].
Fibrates: Fibrate therapy should not be used routinely for the purpose of reducing CVD risk [Grade A, Level 1A].
Severe Hypertriglyceridemia: In individuals with TG mmol/L, a fibrate may be used to reduce the risk of pancreatitis [Grade D, Consensus].
Combination Therapy: For those not at LDL target, ezetimibe or PCSK9 inhibitors may be used [Grade A/D depending on drug].