Garg A
Veterans Affairs Medical Center, Dallas, Texas.
Diabetes. 1992 Oct;41 Suppl 2:111-5. doi: 10.2337/diab.41.2.s111.
Patients with diabetes mellitus are at increased risk of morbidity and mortality from macrovascular disease manifesting as coronary heart disease, cerebrovascular accidents, and peripheral vascular disease. Increased frequency of dyslipidemia, hyperglycemia, obesity, hypertension, and associated nephropathy may contribute to accelerated atherogenesis in diabetic patients. Therefore, besides intensive control of hyperglycemia, management of dyslipidemia, hypertension, and obesity should also be emphasized in diabetic patients. Those who smoke should be strongly encouraged to quit smoking. Besides attempts to achieve normal levels of plasma lipoproteins, consideration also should be given to normalization of compositional abnormalities of various lipoproteins in patients with diabetes mellitus. The therapeutic goals for cholesterol reduction should be lower in diabetic patients than nondiabetic subjects. The first step is to achieve good metabolic control of diabetes mellitus by diet, exercise, and weight reduction and, if needed, with sulfonylureas or insulin therapy. Because most of the patients with insulin-dependent diabetes mellitus achieve normal levels of plasma lipoproteins with intensive insulin therapy, lipid-lowering medications are rarely needed. In patients with non-insulin-dependent diabetes mellitus, however, dyslipidemia often persists despite good glycemic control. Lipid-lowering medications should be considered in such patients. Because nicotinic acid can cause marked deterioration in glycemic control, and bile acid-binding resins may accentuate hypertriglyceridemia, these agents are less desirable for use by diabetic patients. Inhibitors of hydroxymethylglutaryl coenzyme A reductase may be preferred in patients with elevated LDL cholesterol and mld hypertriglyceridemia. For diabetic patients with marked hypertriglyceridemia, however, fibric acid derivatives should be the drug of choice.
糖尿病患者因大血管疾病（表现为冠心病、脑血管意外和外周血管疾病）导致发病和死亡的风险增加。血脂异常、高血糖、肥胖、高血压及相关肾病的发生率增加，可能促使糖尿病患者动脉粥样硬化加速。因此，除了强化控制高血糖外，糖尿病患者还应重视血脂异常、高血压和肥胖的管理。应大力鼓励吸烟患者戒烟。除了努力使血浆脂蛋白水平正常外，还应考虑使糖尿病患者各种脂蛋白的组成异常正常化。糖尿病患者降低胆固醇的治疗目标应低于非糖尿病患者。第一步是通过饮食、运动和减轻体重，并在必要时使用磺脲类药物或胰岛素治疗，实现糖尿病的良好代谢控制。由于大多数胰岛素依赖型糖尿病患者通过强化胰岛素治疗可使血浆脂蛋白水平正常，因此很少需要降脂药物。然而，在非胰岛素依赖型糖尿病患者中，尽管血糖控制良好，血脂异常往往仍然存在。对此类患者应考虑使用降脂药物。由于烟酸可导致血糖控制显著恶化，胆汁酸结合树脂可能会加重高甘油三酯血症，因此糖尿病患者不太适合使用这些药物。对于低密度脂蛋白胆固醇升高和轻度高甘油三酯血症的患者，羟甲基戊二酰辅酶A还原酶抑制剂可能是首选。然而，对于甘油三酯显著升高的糖尿病患者，纤维酸衍生物应是首选药物。
