Garg A, Grundy S M
Center for Human Nutrition, University of Texas Southwestern Medical Center, Dallas 75235-9052.
Diabetes Care. 1990 Feb;13(2):153-69. doi: 10.2337/diacare.13.2.153.
Coronary heart disease is the leading cause of death among patients with non-insulin-dependent diabetes mellitus (NIDDM). NIDDM patients have a high frequency of dyslipidemia, which along with obesity, hypertension, and hyperglycemia may contribute significantly to accelerated coronary atherosclerosis. Because risk factors for coronary heart disease are additive and perhaps multiplicative, even mild degrees of dyslipidemia may enhance coronary heart disease risk. Therefore, therapeutic strategies for management of NIDDM should give equal emphasis to controlling hyperglycemia and dyslipidemia. The National Cholesterol Education Program recently issued guidelines for treatment of hyperlipidemia in adults including diabetic patients. Because of the unique features of diabetic dyslipidemia, however, we suggest that certain modifications in these guidelines be made to meet specific needs of diabetic patients. For example, therapeutic goals for serum cholesterol reduction should be lower in diabetic patients than in nondiabetic subjects. Particular emphasis should be given to weight reduction in NIDDM patients. In some diabetic patients, monounsaturated fatty acids may be a better replacement for saturated fatty acids than carbohydrates. The target for cholesterol lowering should include both very-low-density lipoprotein and low-density lipoprotein (LDL) (non-high-density lipoprotein) rather than LDL alone. To obtain a substantial reduction of cholesterol levels, drug therapy may be required in many patients. However, first-line drugs for nondiabetic patients (nicotinic acid and bile acid sequestrants) may be less desirable in NIDDM patients than hydroxymethylglutaryl coenzyme A (HMG CoA) reductase inhibitors and even fibric acids. In fact, HMG CoA reductase inhibitors may be the drugs of choice for NIDDM patients with elevated LDL cholesterol and borderline hypertriglyceridemia, whereas gemfibrozil appears preferable for NIDDM patients with severe hypertriglyceridemia.
冠心病是非胰岛素依赖型糖尿病（NIDDM）患者的主要死因。NIDDM患者血脂异常的发生率很高，这与肥胖、高血压和高血糖一起，可能显著促进冠状动脉粥样硬化的加速发展。由于冠心病的危险因素具有相加甚至相乘的作用，即使是轻度的血脂异常也可能增加冠心病风险。因此，NIDDM的治疗策略应同样重视控制高血糖和血脂异常。美国国家胆固醇教育计划最近发布了包括糖尿病患者在内的成人高脂血症治疗指南。然而，由于糖尿病血脂异常的独特特征，我们建议对这些指南进行某些修改，以满足糖尿病患者的特殊需求。例如，糖尿病患者降低血清胆固醇的治疗目标应低于非糖尿病患者。应特别强调NIDDM患者的体重减轻。在一些糖尿病患者中，单不饱和脂肪酸可能比碳水化合物更适合替代饱和脂肪酸。降低胆固醇的目标应包括极低密度脂蛋白和低密度脂蛋白（LDL）（非高密度脂蛋白），而不仅仅是LDL。为了大幅降低胆固醇水平，许多患者可能需要药物治疗。然而，非糖尿病患者的一线药物（烟酸和胆汁酸螯合剂）在NIDDM患者中可能不如羟甲基戊二酰辅酶A（HMG CoA）还原酶抑制剂甚至贝特类药物理想。事实上，HMG CoA还原酶抑制剂可能是LDL胆固醇升高和边缘性高甘油三酯血症的NIDDM患者的首选药物，而吉非贝齐似乎更适合重度高甘油三酯血症的NIDDM患者。
