LAI issues expert consensus statement on management of diabetic dyslipidemia in Indians
Rajasthan: An article published in the Journal of Clinical Lipidology reports an expert consensus statement from the Lipid Association of India (LAI) on managing diabetic dyslipidemia in Indians.
The recommendations aim to reduce cardiovascular morbidity and mortality in patients of Indian origin with diabetes. The major cause of mortality among type 2 diabetes patients is cardiovascular disease.
The guidelines of dyslipidemia management by western medical associations are formed based on their studies, with the underrepresentation of ethnic minorities and inadequate incorporation of biological features of other racial groups. The LAI released a consensus statement guided by an expert panel to adapt the western guidelines to Indians. However, the absence of Indian guidelines has led physicians to base their treatment on individuals preference, contributing to heterogeneity.
The risk of coronary artery disease (CAD) among Asian Indians is three to four times higher than among Americans, 20 times higher among Japanese and six times higher among Chinese. Additionally, in Europe and the US, cardiovascular mortality rates have decreased by about 70% among adults aged between 25 and 64 years since 1968. However, early-onset heart disease still accounted for almost 20% of all deaths among this age group in 2017.
Lifestyle modification in combination with statin therapy, supplemented with other therapies, is the cornerstone of treatment for insulin resistance and diabetes-related atherogenic dyslipidemia.
- The LAI recommends consideration of treatment with GLP-1 agonists as adjunctive therapy in patients with type 2 diabetes for glucose-lowering and reduction of atherosclerotic cardiovascular disease (ASCVD) events. Consistent with other guidelines. SGLT2 inhibitors and GLP-1 agonists can be used irrespective of metformin use or HbA1c level or target.
- The LAI recommends estimating Lp(a) levels by isoform-insensitive assay for risk stratification in all patients with diabetes regardless of the presence of ASCVD.
- The LAI recommends consideration of treatment with SGLT2i as adjunctive therapy in patients with type 2 diabetes for glucose-lowering and reducing cardiovascular events.
PCSK9 inhibitors may be a useful option in patients with diabetes and dyslipidemia to manage refractory hypercholesterolemia, especially when statin intolerance prevents high-intensity statin therapy. People with both ASCVD and diabetes have a higher absolute risk of subsequent CVD events than those with ASCVD alone and can benefit from such therapies.
LDL-C lowering to below 30 mg/dl in patients with high-risk stable ASCVD and in high-risk post-ACS patients results in further reduction in cardiovascular (CV) events.
For ASCVD prevention, lifestyle modification is the cornerstone and includes attention to regular physical activity, heart-healthy dietary habits, and avoiding the use of tobacco and alcohol. Dietary patterns with lower carbohydrate and higher fat, intermittent fasting, and high protein content are all linked with modest weight loss and triglyceride lowering. Still, dietary patterns that include whole grains and other complex carbohydrates in combination with high fibre intake may also produce modest weight loss and triglyceride lowering.
Cold-pressed oils may be better than refined oils as they retain higher levels of micronutrients and antioxidants that are degraded by high temperatures and chemicals. Overall, an Indo-Mediterranean diet that focuses on consuming vegetables, fruits, fatty fish, whole grains, nuts, flax seeds, mustard seeds, and mustard oil appears to be the most suited.
The intake of tobacco products in any form, including e-cigarettes, should be completely avoided. Alcohol increases triglyceride production and secretion of triglyceride-rich VLDL and impairs chylomicron hydrolysis and should be avoided. However, the consumption should not exceed 2 drinks/per day for men and one drink/per day for women. Patients with severe hypertriglyceridemia ideally should not consume alcohol.
Endurance training and aerobic physical activity boost triglyceride hydrolysis and fatty acid oxidation in skeletal muscle and enhance fatty acid oxidative clearance. Regular aerobic exercise decreases triglycerides by about 11%, and resistance exercise decreases triglycerides by about 6%.
It is recommended that adults should engage in at least 150 min per week of total moderate-intensity or 75 min per week of vigorous-intensity aerobic physical activity. If possible, ideal body weight should be maintained, but an achievable goal for many patients is modest weight loss. A BMI >23 kg/m2 is considered overweight, and ≥25 kg/m2 is obese according to Asian Indian-specific guidelines.
- Patients with diabetes with no ASCVD, no target organ damage, and having ≤1 risk factor are designated as high risk and an LDL-C goal of <70 mg/dl is recommended.
- Patients with diabetes and no ASCVD, with target organ damage or having ≥2 risk factors are designated as very high risk and an LDL-C goal <50 mg/dl is recommended.
- Patients with established ASCVD do not have a similar risk of future adverse CV events. Selected ASCVD patients have a higher risk because of disease in other vascular territories (e.g., prior stroke or peripheral artery disease) and/or other risk factors. The number, type and severity of risk factors determine the risk of subsequent adverse CV events. Based on the presence of risk factors and/or target organ damage, LAI proposed an Extreme risk category requiring aggressive LDL-C management. LDL-C <50 mg/dl is recommended for most extreme-risk patients (Extreme risk category A), with an optional target of ≤30 mg/dl.
- For those who continue to suffer events despite achieving an LDL-C <50 mg/dl or having one or more features of a very high-risk group with CAD (Extreme risk category B), an LDL-C goal of ≤30 mg/dl is recommended.
"Diabetes is linked with 1.5 to 2-fold greater ASCVD risk compared to patients without diabetes, which is superimposed on the high risk of early onset ASCVD seen in Indians," the authors conclude.
"In type 2 diabetes, atherogenic dyslipidemia is prevalent and an important treatment target. When diagnosed with diabetes, lipid targets for non-HDL-C, LDL-C, and Apo B should be achieved based on the ASCVD risk category. Statins remain the primary treatment for dyslipidemia in diabetes."
Reference:
"Management of diabetic dyslipidemia in Indians: Expert consensus statement from the lipid association of India," was published in the Journal of Clinical Lipidology
