Rationale:

• Macrovascular disease is the primary complication of type 2 diabetes; up to 80% of patients with diabetes will develop or die from macrovascular complications.
• Prevention of macrovascular disease is of paramount importance, and managing risk factors such as hyperlipidemia is a critical component.

Evidence:

• Lipid-lowering therapy with an HMG-CoA reductase inhibitor substanially lowers the risk of cardiovascular events and mortality in patients with diabetes, both with and without known heart disease (e.g., it is effective in both primary and secondary prevention) (31; 32).
• In the Heart Protection Study, patients with diabetes randomized to simvastatin had a 22% reduction in cardiovascular events. This reduction was independent of baseline cholesterol levels and was also observed in patients with baseline LDL cholesterol <116 mg/dL (31).
• In the recent Collaborative Atorvastatin Diabetes Study (the first randomized trial exclusively in patients with type 2 diabetes), nearly 2838 patients with type 2 diabetes and one other risk factor (hypertension, retinopathy, microalbuminuria, macroalbuminuria, or smoking) were randomized to either atorvastatin, 10 mg, or placebo. The trial was halted 2 years prematurely because atorvastatin, 10 mg, significantly reduced the risk for any acute cardiovascular event by 32% and death from any cause by 27% (146).
• Treatment of patients with diabetes or insulin resistance, known coronary artery disease, low HDL cholesterol (<40 mg/dL) and low or normal LDL cholesterol (<140 mg/dL) with gemfibrozil also is effective in lowering the risk of cardiovascular events (147).
• Combination therapy results in an increased risk of rhabdomyolysis (about 0.1%) and has not to date been shown to improve clinical outcomes; however, combination therapy is more effective in lowering LDL cholesterol and triglycerides, and raising HDL cholesterol, than with either drug alone (148).

Comments:

• None.