Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy.
Department of Clinical and Experimental Medicine, Internal Medicine, Garibaldi Hospital, University of Catania, Via Palermo, 636, 95122, Catania, Italy.
Acta Diabetol. 2018 Mar;55(3):209-218. doi: 10.1007/s00592-017-1089-4. Epub 2017 Dec 19.
Dyslipidemias represent a variety of quantitative and/or qualitative lipoprotein abnormalities. According to etiology, we distinguish primary dyslipidemias with strictly genetic background and secondary ones with their origin in other disease or pathological states. Diabetic dyslipidemia is a type of secondary dyslipidemia and plays an important role in determining the cardiovascular risk of subjects with type 2 diabetes. In these patients, insulin resistance is responsible for overproduction and secretion of atherogenic very low density lipoprotein. In addition, insulin resistance promotes the production of small dense low-density lipoprotein (LDL) and reduces high-density lipoprotein (HDL) production. Cardiovascular disease remains a leading cause of morbidity and mortality in diabetic patients. Previous results support the role for small, dense LDL particles in the etiology of atherosclerosis and their association with coronary artery disease. Moreover, lowering LDL cholesterol reduces the risk of cardiovascular death. Therefore, the European guidelines for the management of dyslipidemias recommend an LDL cholesterol goal < 100 mg/dL in diabetic subjects without cardiovascular events. Moreover, if triglycerides (TG) are elevated (> 400 mg/dL), they recommend a non-HDL cholesterol goal < 130 mg/dL in diabetic individuals without cardiovascular events. Statins are the first line of LDL-lowering therapy in diabetic patients and combined therapy with ezetimibe and statins could be useful in very high cardiovascular risk diabetic subjects. Furthermore, the effect of a fibrate as an add-on treatment to a statin could improve the lipid profile in diabetic individuals with high TG and low HDL cholesterol. Regarding new therapies, recent data from phase III trials show that proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors considerably decrease LDL cholesterol. Thus, they may be useful in diabetic patients with concomitant diseases such as familial dyslipidemia, recurrent cardiovascular events, and elevated LDL cholesterol after second drug administration in addition to maximal statin dose or statin intolerance.
血脂异常是指脂蛋白的数量和/或质量异常。根据病因，我们可以将其分为原发性血脂异常（具有严格的遗传背景）和继发性血脂异常（其起源于其他疾病或病理状态）。糖尿病血脂异常是一种继发性血脂异常，在确定 2 型糖尿病患者的心血管风险方面起着重要作用。在这些患者中，胰岛素抵抗导致致动脉粥样硬化的极低密度脂蛋白（VLDL）过度产生和分泌。此外，胰岛素抵抗还促进小而密的低密度脂蛋白（LDL）的产生并减少高密度脂蛋白（HDL）的产生。心血管疾病仍然是糖尿病患者发病率和死亡率的主要原因。先前的研究结果支持小而密的 LDL 颗粒在动脉粥样硬化的发病机制中的作用及其与冠心病的相关性。此外，降低 LDL 胆固醇可降低心血管死亡风险。因此，欧洲血脂异常管理指南建议无心血管事件的糖尿病患者 LDL 胆固醇目标值<100mg/dL。此外，如果甘油三酯（TG）升高（>400mg/dL），则建议无心血管事件的糖尿病患者非 HDL 胆固醇目标值<130mg/dL。他汀类药物是糖尿病患者降低 LDL 胆固醇的一线治疗药物，联合使用依折麦布和他汀类药物可能对心血管风险极高的糖尿病患者有用。此外，在 TG 高和 HDL 胆固醇低的糖尿病患者中，添加贝特类药物作为他汀类药物的辅助治疗可以改善血脂谱。关于新的治疗方法，最近 III 期临床试验的数据表明，前蛋白转化酶枯草溶菌素 9（PCSK9）抑制剂可显著降低 LDL 胆固醇。因此，对于同时患有家族性血脂异常、复发性心血管事件以及最大他汀剂量或他汀类药物不耐受后 LDL 胆固醇升高的糖尿病患者，这些药物可能会有用。
