1. Canadian Diabetes Association Clinical Practice Guidelines Dyslipidemia Chapter 24 G. B. John Mancini, Robert A. Hegele, Lawrence A. Leiter

2. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Dyslipidemia Checklist CHECK lipid profile at diagnosis then yearly or every 3-6 months when on treatment USE statins as first-line therapy ADD second line agent only when LDL-C is not at target despite statin therapy USE fibrate when TG >10.0 mmol/L 2013

3. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Repeat yearly if treatment not started Repeat q3-6mos if on treatment Fasting (8-hr) profile: – Total cholesterol, triglycerides, HDL-C, LDL-C or Non-fasting profile: – ApoB – Non-HDL-C Measure Lipids at Diagnosis

4. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Who should receive statin therapy?

5. (10269)(10267) SIMVASTATINPLACEBORate ratio & 95% CI STATIN betterPLACEBO better 9991250(23.5%)(29.4%)Previous MI 460591(18.9%)(24.2%)Other CHD (not MI) No prior CHD 172212(18.7%)(23.6%)CVD 327420(24.7%)(30.5%)PVD 276367(13.8%)(18.6%)Diabetes 24% reduction (P<0.00001) 20332585(19.8%)(25.2%)ALL PATIENTS 0.40.60.81.01.21.4 HPS Lancet 2002;360:7-22 HPS = Heart Protection Study HPS: Statin Therapy Beneficial Among Patients with Diabetes guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association

6. n = 2838 Age 40-75, no history of CVD T2DM plus one or more: – Retinopathy – Albuminuria – Hypertension – Smoking Intervention: Atorvastatin 10 mg vs. Placebo Outcome: ACS, revascularization, stroke Colhoun HM, et al. Lancet 2004;364:685. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association CARDS: Effect of Statin for PRIMARY Prevention in DM

7. CARDS: Statins Reduced CVD in Patients with DM Colhoun HM, et al. Lancet 2004;364:685. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association

8. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association ≥40 yrs old or Macrovascular disease or Microvascular disease or DM >15 yrs duration and age >30 years or Warrants therapy based on the 2012 Canadian Cardiovascular Society lipid guidelines Among women with childbearing potential, statins should only be used in the presence of proper preconception counseling & reliable contraception. Stop statins prior to conception. 2013 Who Should Receive Statins? (regardless of baseline LDL-C)

9. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association What if baseline LDL-C ≤2.0 mmol/L? Within CARDS and HPS, the subgroups that started with lower baseline LDL-C still benefited to the same degree as the whole population If the patient qualifies for statin therapy based on the algorithm, use the statin regardless of the baseline LDL-C and then target an LDL reduction of ≥50% HPS Lancet 2002;360:7-22 Colhoun HM, et al. Lancet 2004;364:685.

10. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Statin Options

11. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association If on therapy, target LDL ≤2.0 mmol/L

12. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Smoking cessation Energy-restricted diet (see CPG Chapter 11) – Low cholesterol – Low saturated and trans fatty acids – Low refined carbohydrates – Include viscous fibres, plant sterols, nuts, soy proteins – Alcohol in moderation Physical activity (see CPG Chapter 10) Statin Therapy Should be Concomitant with Lifestyle Therapy

13. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Second- Line Agents: Only if LDL-C Target not Reached with Statin Bile acid sequestrants Cholesterol absorption inhibitors Fibrates Nicotinic acid

14. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association ER = extended release; IR = immediate release; LA=long acting; TG=triglycerides; FCT=film coated tablet; SR=sustained release

15. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 2013 If Triglycerides >10.0 mmol/L… Use a FIBRATE to reduce the risk of pancreatitis Optimize glycemic control Implement lifestyle interventions – Weight loss – Optimal dietary strategies – Reduce alcohol

16. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 1.A fasting (8-hour fast) lipid profile (TC, HDL-C, TG and calculated LDL- C) or non-fasting lipid profile (apo B), should be measured at the time of diagnosis of diabetes. If lipid lowering treatment is not initiated, repeat testing is recommended yearly. Frequent testing (every 3-6 months) should be performed if treatment for dyslipidemia is initiated [Grade D, Consensus] 2013 Recommendation 1

17. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 2.For patients with indications for lipid lowering therapy treatment (see Vascular Protection chapter), treatment should be initiated with a statin [Grade A, Level 1] to achieve an LDL-C ≤2.0 mmol/L [Grade C, Level 3] 3.In patients achieving target LDL-C with statin therapy, the routine addition of fibrates or niacin for the sole purpose of further reducing cardiovascular risk should not be used [Grade A, Level 1]. 2013 Recommendation 2 and 3

18. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 4 4.For individuals not at LDL-C target despite statin therapy as described above, a combination of statin therapy with second-line agents may be used to achieve the LDL-C targets [Grade D Consensus]

19. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 5 5.For those who have serum TG >10.0 mmol/L, a fibrate should be used to reduce the risk of pancreatitis [Grade D, Consensus] while also optimizing glycemic control and implementing lifestyle interventions (e.g. weight loss, optimal dietary strategies, and reduction of alcohol). 2013

20. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Vascular Protection Checklist 2013 A A1C – optimal glycemic control (usually ≤7%) B BP – optimal blood pressure control (<130/80) C Cholesterol – LDL ≤2.0 mmol/L if decided to treat D Drugs to protect the heart (regardless of baseline BP or LDL) A – ACEi or ARB │ S – Statin │ A – ASA if indicated E Exercise / Eating healthily – regular physical activity, achieve and maintain healthy body weight S Smoking cessation

21. CDA Clinical Practice Guidelines www.guidelines.diabetes.cawww.guidelines.diabetes.ca – for professionals 1-800-BANTING (226-8464) www.diabetes.ca www.diabetes.ca – for patients