VOLUME 10 NUMBER 1 • MARCH 2013
21
SA JOURNAL OF DIABETES & VASCULAR DISEASE
REVIEW
chronic pancreatitis and when an adequate trial of statins, in
combination with, as appropriate ezetimibe, fibrates and omega-3
PUFAs, fail to adequately reduce levels of triglycerides.
Omega 3 PUFA supplements
Omega 3 PUFA supplements offer a further alternative. Consuming
fish oil containing 2–4 g EPA and DHA daily can lower triglycerides
by 30–50%. Combining fish oil and statin reduces triglycerides
by an additional 30% compared with monotherapy.
24
Side effects
associated with omega 3 PUFA supplements – such as fishy
aftertaste and mild gastrointestinal upset – are usually minimal,
while bleeding effects are not clinically significant even at large
doses.
24
Some patients with hypertriglyceridaemia require triple
therapy with a fibrate, niacin, and omega-3 PUFAs, the latter at
doses between 4 and 10 g daily.
19
The JELIS study treated 18 645 Japanese patients (mean age
61 years; 69% women; 16% with diabetes) with total cholesterol
of ≥ 6.5 mmol/l using 1.800 mg EPA daily plus statin or statin
monotherapy. After a mean follow up of 4.6 years, triglyceride levels
decreased significantly from baseline (mean 1.7 mmol/l) by 9% in
the EPA group and by 4% in controls. The primary endpoint (any
major coronary event) occurred in 2.8% of the EPA group and 3.5%
of controls, equivalent to a 19% relative reduction. The number of
unstable angina cases and non-fatal coronary events declined by
24 and 19% respectively. In patients with a history of CAD, EPA
significantly reduced the rate of major coronary events by 19%
compared with controls (8.7 and 10.7% respectively). In patients
without a history of CAD, EPA reduced major coronary events by a
similar amount (18%), although the reduction was not statistically
significant (1.4 and 1.7% respectively). EPA did not significantly alter
LDL cholesterol. Therefore, the 19% reduction in major coronary
events seems to be independent of changes in LDL.
28
In general, NICE advises against prescribing fish oil for primary
CVD prevention in type 2 diabetes. However, this does not apply
to diabetic patients with hypertriglyceridaemia who are receiving
advice from a healthcare professional with special expertise. Indeed,
NICE recommends a trial of highly concentrated, licensed omega-3
fish oils for hypertriglyceridaemia if lifestyle measures and fibrate fail
to adequately reduce levels.
22
Furthermore, Omacor, which contains
460 mg EPA ethyl ester and 380 mg DHA ethyl ester, is approved
in combination with statins for type IIb/III hypertriglyceridaemia as
well as for type IV hypertriglyceridaemia as monotherapy.
29
Due to increased risk of CVD, many patients with diabetes
experience acute coronary syndrome. NICE advises eating ≥ 7 g
of omega 3 PUFA a week from two to four portions of oily fish
as secondary prevention after MI. Patients who suffered an MI
within the last 3 months and who cannot consume sufficient fish
could receive ≥1 g daily of omega 3-acid ethyl esters licensed for
secondary prevention after MI. Treatment should last for up to 4
years.
30
Conclusion
CVD in type 2 diabetes is likely to impose a growing burden on
primary care.
1
Several studies confirm that hypertriglyceridaemia
contributes to the increased likelihood of suffering CVD among
patients with diabetes
5–7
and pancreatitis.
8,9
Indeed, many
components of dyslipidaemia in type 2 diabetes might arise as
metabolic sequelae of hypertriglyceridaemia.
11
Fortunately, several
treatments effectively lower triglyceride levels, although patients
may need more than one drug.
19,23,24
Raising awareness of the
burden imposed by hypertriglyceridaemia and proactive, effective
management of this common dyslipidaemia should help reduce
the cardiovascular morbidity and mortality associated with type 2
diabetes.
Acknowledgements
Professor Sinclair has received a fee for preparing this article as
part of the educational support provision available but the content,
emphasis and direction of the article is solely due to him.
The author would like to acknowledge the assistance of Mark
Greener, medical writer, and Rock Medical Communications in the
preparation of this manuscript. The author is responsible for the
final version of the review.
Funding
The preparation of this manuscript was supported by a grant from
Abbott Healthcare Products.
Conflict of interest statement
The author declares that there is no conflict of interest.
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Key messages
Hypertriglyceridaemia contributes to the increased risk of
•
CVD and pancreatitis in diabetes
Fasting triglycerides ≥ 1.7 mmol/l requires further review
•
and may be abnormal
Finding hypertriglyceridaemia should prompt a search for
•
secondary causes
NICE suggests a fibrate if triglycerides are > 4.5 mmol/l
•
after addressing secondary causes or if 2.3–4.5 mmol/l
despite statin use
Consider highly concentrated, licensed omega-3 PUFAs
•
if lifestyle measures and a fibrate (± a statin) fail to
adequately reduce triglycerides
