SA JOURNAL OF DIABETES & VASCULAR DISEASE
VOLUME 8 NUMBER 4 • NOVEMBER 2011
161
Case Study 1
Type 2 diabetes patient without
CVD, not achieving lipid targets
C
linical studies suggest that people with
type 2 diabetes without cardiovascular dis-
ease (CVD) are at the same high risk of a
CVD event as those without diabetes but with CVD,
although whether this risk is equivalent is disputed by
other studies. Despite this, there is clear consensus
that individuals with type 2 diabetes should nearly
always be considered as being in the high CVD risk
category.
This excess risk is independently associated with
hyperglycaemia together with high blood pressure
and dyslipidaemia – typically low HDL cholesterol and
elevated triglycerides – which are all components
of the metabolic syndrome that is common in
these patients. It is important, therefore, that type
2 diabetes patients achieve guideline lipid targets
(4 mmol/l for total cholesterol and 1.8 mmol/l for
LDL cholesterol) to reduce their risk of CVD events.
The management of type 2 diabetes patients with
co-existent metabolic syndrome such as James (see
Presented by Prof Michael
Kirby
Visiting Professor, Faculty of Health and
Human Sciences, Centre for Research
in Primary and Community Care and
the Clinical Trials Coordinating Centre,
University of Hertfordshire, Hatfield, UK
Originally in:
Prim Care Cardiovasc J
2010;
3
(1): S6–S7
doi: 10.3132/pccj.2010.010
S Afr J Diabetes Vasc Dis
2011;
8
:
161–162
Key points
• Patients with type 2 diabetes
without CVD should be managed
as for secondary prevention pa-
tients
• Intensive LDL cholesterol lower-
ing should be considered if there
is evidence of reduced renal func-
tion; concordance may be an is-
sue if targets are not achieved
• Lifestyle changes should be en-
couraged
• Add-on treatment with a fibrate
will improve mixed dyslipidaemia,
i.e. elevated triglycerides and low
HDL cholesterol, common in these
patients
Box 1) who do not follow lifestyle advice often poses
a clinical dilemma for physicians. Possible treatment
options for James are summarised in Table 1 and
discussed below.
CLINICAL OPTIONS
According to South African guidelines (see page 155),
people with type 2 diabetes considered at high car-
diovascular risk should be managed as for second-
ary rather than primary prevention of CVD, aiming to
achieve targets of 4 mmol/l for total cholesterol and 1.8
mmol/l for LDL cholesterol, consistent with the JBS2
guidelines. In patients who fail to achieve these targets,
a number of options are recommended (see Table 1).
Intensification of cholesterol-lowering therapy
(preferably with a more effective statin) is recom-
• 62-year-old smoker (15
cigarettes/day), shift-worker
• Obese (94 kg and BMI
30 kg/m
2
)
• High blood pressure (148/88
mmHg)
• Total cholesterol 5.4 mmol/l,
HDL cholesterol 0.90 mmol/l,
LDL cholesterol 3.27 mmol/l, triglycerides
2.7 mmol/l
• HbA
1c
7.4%
• Moderately reduced renal function (eGFR 50 ml/
min/1.73 m
2
)
• Taking simvastatin 40 mg, aspirin 75 mg,
metformin 2 g, enalapril 5 mg daily
• UKPDS risk engine: 10-year risk of CHD 40.6%,
fatal CHD 26.4%, stroke 15.2% and fatal stroke
2.5%
Box 1: James, type 2 diabetes for six years
• Switch to a more effective statin; atorvastatin has a
stronger evidence base than other higher-intensity
statins
• To manage his non-LDL lipids, advise James to ex-
ercise more, lose weight and eat a healthier, more
balanced diet. Adding fenofibrate to statin therapy
is an option
• Emphasise the importance of adherence to treat-
ment
Table 1. Expert recommendations for cholesterol
management
