Combination lipid-lowering therapy in diabetes

Owing to the National Cholesterol Education Program Adult Treatment Panel III recommendations that patients with diabetes require a low-density lipoprotein (LDL) less than 100 mg/dL and a non-high-density lipoprotein (HDL) less than 130 mg/dL, frequently, combination lipid-lowering therapy is required. However, diabetic patients are commonly on multiple medications and have renal impairment. Therefore, the risk of myopathy with statin therapy is markedly increased. The safety of lipid-lowering therapy can be significantly improved by avoiding high-dose statins in combination with fibrates, especially gemfibrozil. To achieve non-HDL goals combining fenofibrate, or if glucose is well controlled, niacin, with a statin (not to exceed 40 mg), may significantly reduce the risk of myopathy. For diabetic patients who require additional LDL lowering, ezetimibe may provide a safe combination to a statin to achieve the LDL goal of less than 100 mg/dL.