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The following information is provided by Veritas Medicine. Please consult your physician if you have questions about any of the material presented.

Patients with diabetes usually know about the perils of high blood sugar, which includes damage to the eyes, kidneys, and nerves. These are major issues, and there is no more ardent supporter than I am of maintaining glucose levels as close to normal as possible. The fact remains, however, that people with diabetes are much more likely to develop and/or die from cardiovascular disease than any of these other problems. Up to 80% of type 2 diabetics will suffer a heart attack, stroke, or peripheral vascular disease. In many cases, cardiovascular disease will result in significant neurological damage, amputation, and

even death.

These statistics demonstrate why it is critical for patients with diabetes to maintain 'good vascular hygiene'. What is good vascular hygiene? Three things: quitting smoking, reducing blood pressure, and keeping cholesterol levels in check.

The cholesterol recommendation in particular has been around for a long time" despite an absence of evidence on whether lowering cholesterol works in diabetes. Surprisingly, lingering questions remain about cholesterol-lowering in diabetes. Do patients with diabetes benefit as much as non-diabetics from lipid lowering therapy? Which drugs are the best to use in diabetes? What target level of cholesterol is appropriate?

To address these important issues, a committee of the American College of Physicians (ACP) commissioned a review of the world's literature on lipid lowering in type 2 diabetes. The ACP then used this information as the basis for detailed, specific recommendations for patients and their doctors. The ACP review looked at a large number of published clinical trialsâ"none of which, it is important to note, were specifically dedicated to studying type 2 diabetics. All of the studies, however, included at least some diabetics, and this allowed the ACP to essentially lump together all the information from the diabetics in different studies and assess their response to cholesterol-lowering therapy.

The studies were of two major types, known as primary prevention and secondary prevention. In a primary prevention trial, researchers looked for people who had not yet shown any sign of cardiovascular disease. They then put these folks on a drug, or a placebo, and tested whether the drug resulted in fewer cases of heart attack or stroke. When the ACP looked at six, large, primary prevention studies, they found that for every 34 patients with type 2 diabetes who were treated with cholesterol-lowering meds for more than 4 years, one heart attack or stroke was prevented. This may sound small, but compares favorably with many other disease prevention strategies in common medical practice. The secondary prevention trials were even more dramatic.

Secondary prevention is for people who have already had a heart attack or stroke. The goal is to prevent a second episode. For people with type 2 diabetes known to have cardiovascular disease, there was a highly significant benefit to treating with lipid-lowering therapy. This seems to be true regardless of what level of cholesterol you start out with. For every 14 such patients treated for 5 years, one cardiovascular event was prevented.

These findings led the ACP to the following four recommendations:

1. All men and women with type 2 diabetes and known cardiovascular disease should be on lipid-lowering therapy. The drugs with the most proven efficacy are members of the statin class, including Lipitorâ¢, Pravacholâ¢, Zocorâ¢, Mevacorâ¢, and others. At least one study suggests that an alternative lipid-lowering drug, Lopidâ¢, might be useful in diabetic patients with low levels of both LDL and HDL cholesterol.

2. For patients with type 2 diabetes who are not known to have

cardiovascular disease, a statin should be used to reduce cholesterol levels, especially if there is another cardiovascular risk factor. This means that if you have type 2 diabetes and any one of the following conditions, you should be taking a statin: age greater than 55, high blood pressure, smoking, or dysfunction of the left side of the heart. That ends up covering most people in the average adult type 2 diabetes clinic.

3. Donât skimp on the statin! Patients should be taking at least moderate doses of these drugs. This translates to daily doses of Pravachol⢠(40 mg), Mevacor⢠(40-80 mg), Zocor⢠(40 mg), and Lipitor⢠(20 mg).

4. Finally, there has been a lot of hype about the potential side effects of statins, including muscle and liver damage. In fact, more people are hurt by NOT taking these drugs than by taking them. In fact, it is no longer recommended that patients even be monitored for liver and muscle enzyme levels while on statins (except in specific cases). This includes the rare cases where symptoms of jaundice or muscle pain develop while taking the drug, elevated levels of these enzymes are discovered before taking the statin, or in cases where other drugs are also being used that are known to damage the muscle and liver In case you haven't noticed, there are no specific recommendations about any particular "magic number." There is no cholesterol number above which one would automatically treat with drugs, and no target level at which one could be satisfied that the cholesterol was low enough. Several studies have shown that reducing cholesterol levels as low as possible may confer additional benefit.

In other words, it's not clear that we know how low is low enough, and at present, there appears to be little downside (other than cost) for using higher doses of statins than we all previously thought were good enough.

The bottom line is this: The majority of people with type 2 diabetes should be taking a statin, and a pretty decent dose at that. This is not a substitute for good glucose control, but an incredibly important adjunct therapy that will save a lot of lives.

Reference:

Snow V, Aronson MD, Hornbake ER, Mottur-Pilson C, Weiss KB; Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Lipid control in the management of type 2 diabetes mellitus: a clinical practice guideline from the American College of Physicians. Annals of Internal Medicine. 2004 Apr 20;140(8):644-9.