Managing dyslipidaemia in type 2 diabetes mellitus

Glucose-control has a modest beneficial effect on cardiovascular outcomes in patients with type 2 diabetes mellitus. Thus, managing other atherogenic risk factors including hypertriglyceridemia, low HDL-cholesterol and moderately elevated LDL-cholesterol levels with increased small dense LDL-cholesterol fraction, is crucial. Insulin resistance is a key pathophysiologic factor in this population. Treatment starts with lifestyle modifications, but current best programmes have not translated into positive cardiovascular outcomes. Lowering LDL-cholesterol with statins is currently the main treatment strategy, but significant residual risk remains. Attempts to elevate HDL-cholesterol and to reduce triglycerides levels, with niacin or fibrates have not improved cardiovascular prognosis, but addition of ezetimibe, or fibrates in specific patients subgroups, have shown modest benefit. Some glucose-lowering medications and bariatric surgery may also improve diabetic dyslipidemia. Results of three major cardiovascular outcome trials evaluating the effect of lowering LDL-cholesterol with PCSK9 inhibitors in large cohorts that include thousands of diabetic patients are pending.