Treating dyslipidaemia in non-insulin-dependent diabetes mellitus -- a special reference to statins

Patients with non-insulin-dependent diabetes (NIDDM) have an increased incidence of ischaemic heart disease (IHD) when compared with nondiabetic subjects. In addition, they have a worse prognosis after their first myocardial infarction (MI). According to the recent USA recommendations, the threshold for initiation of dietary intervention in diabetic subjects is an LDL greater than 2.6 mmol/l, with the goal to achieve levels less than 2.6 mmol/l (100 mg/dl). This is also the threshold for initiation and treatment goal for pharmacological intervention in diabetic subjects, unless they are completely free of IHD, peripheral vascular disease or cerebrovascular disease and have no other IHD risk factors. In the latter circumstances, the threshold for treatment is an LDL greater than 3.38 mmol/l (130 mg/dl), with the goal to achieve levels less than 3.38 mmol/l. The HMG-CoA reductase inhibitors (statins) can improve the lipid profile effectively and safely in NIDDM. Results from post hoc analyses of diabetic subgroups in the large intervention trials suggest that some statins significantly reduce the risk for IHD-related mortality/morbidity. However, because these results are derived from secondary prevention trials, we cannot be sure if these benefits apply to all diabetic subjects or only to those who already have IHD. Nevertheless, it seems logical to assume that this benefit also applies to NIDDM patients who do not have IHD because they share a similar vascular risk as nondiabetic subjects who have IHD. Intervention trials using statins and fibrates, alone or in combination, in NIDDM are under way. In a few years these trials will provide definitive end-point-based evidence in this high-risk group of patients.