Lipid Management in Diabetes - The Stronger the Better?

Lipid management is an important strategy to prevent cardiovascular disease in patients with and without diabetes mellitus. Although diabetic patients are often characterized by hypertriglyceridemia or mixed dyslipidemia LDL-cholesterol reduction translates best into risk reduction. Therefore the European and American guidelines focus on LDL-reduction using life-style modification, statins, ezetimibe and PCSK9-inhibitors. In patients with diabetes and established cardiovascular disease or additional risk factors LDL-cholesterol should be ≤70 mg/dl (1.8 mmol/l), in all other patients with diabetes the LDL-cholesterol goal is ≤100 mg/dl (2.6 mmol/l). Numerous studies (using statins, ezetimibe and PCSK9-inhibitors) clearly show that lower LDL-cholesterol levels are associated with lower risk without attenuation at very low LDL-levels. Patients at particular high absolute risk (such as patients with peripheral arterial disease or diabetic patients) may benefit particularly from very low LDL-cholesterol levels. Thus, in patients at very high risk achieving very low LDL-cholesterol levels may be of particular benefit. European guidelines also define non-HDL-cholesterol levels as secondary goals which is particularly relevant in patients with mixed dyslipidemia. These goals can be reached either by lowering triglycerides or by further lowering LDL-cholesterol. It should be noted that triglyceride-lowering with fibrates and/or niacin has not been proven successful in outcome trials. Therefore, further lowering of LDL-cholesterol may be the best strategy to also reach non-HDL-cholesterol goals. However, it is unclear in which patients non-HDL goals should be reached (besides LDL-cholesterol goals).