Diabetic patients

Although aggressive control of blood glucose levels in type 2 diabetic patients reduces microvascular clinical outcomes, its effect on macrovascular disease outcomes remains unknown. Other traditional CHD risk factors are believed to increase dramatically the risk for clinical CHD events in these patients. Inherent in the diabetic disease process is an abnormality of lipoprotein lipase activity that is partially but not completely corrected by optimal glucose control. Any additional lipid and lipoprotein disorder(s) present in diabetic patients because of either inherited or secondary causes (obesity, alcohol consumption, etc.), accelerate atherosclerotic progression and increase the risk of clinical CHD events. Treatment of lipid disorders in diabetic patients with commensurate lowering of blood cholesterol levels suggests a similar treatment benefit in diabetic as in non-diabetic patients.2,3,5

The use of niacin in diabetic patients has traditionally not been recommended because of concerns about adverse effects on glycemic control. In the Arterial Disease Multiple Intervention Trial (ADMIT), however, niacin was given to diabetic patients in a prospective, randomized, placebo-controlled study enrolling 468 subjects, 125 of them with diabetes and diagnosed peripheral arterial disease.83 Niacin was given at 3000mg/day or to maximally tolerated dose, for up to 60 weeks. Niacin significantly increased HDL-C and decreased triglycerides and LDL-C in all participants (P< 0-01: niacin v placebo for all). It modestly raised glucose levels in all participants while HbA1c was unchanged from baseline through follow up.83 ADMIT investigators conclude that lipid-modify-ing doses of niacin can be safely used in patients with diabetes and that niacin may be considered an alternative therapy in such patients who do not tolerate statins or in whom statins do not correct hypertriglyceridemia or low HDL-C levels.83

In CARE, 586 normocholesterolemic diabetic patients with CHD (14% of total sample) were given pravastatin or placebo for 5 years. In the diabetic patients given pravastatin, there were 8% and 25% reductions respectively in absolute and relative risks of coronary events.84 Pravastatin also reduced the risk for revascularization procedures among diabetic patients by 32%. In subjects who were not diabetic but who had impaired glucose tolerance, pravastatin also substantially lowered the risk of recurrent coronary events.84 According to the pooled data in PPP, pravastatin significantly reduced relative risk of coronary events in diabetic patients.79 The HPS trial included 3980 persons with diabetes and 2930 of these had no CVD. As noted above, the event reductions seen with simvastatin occurred in diabetic patients as well. There was a 24% decrease in CVD and a 25% decrease in total CHD.4

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