Diabetes is associated with significantly increased morbidity and mortality from atherosclerotic vascular disease. Type 2 diabetes is frequently associated with dyslipidaemia, particularly elevated triglycerides and low high density lipoprotein cholesterol (HDL), whereas this abnormality is uncommon in well controlled type 1 diabetes. Additionally, elevated low density lipoprotein cholesterol (LDL) is common and other abnormalities such as accumulation of small dense LDL particles and triglyceride-rich lipoproteins further add to vascular risk.
In people with diabetes without vascular disease who are less than 60 years of age, absolute risk of cardiovascular disease (CVD) should be assessed using a risk calculator. In people at low 5 year risk, (<10%), diet and lifestyle measures are recommended. In people at moderate risk (10-15%) with LDL-C >2.5mmol/L, pharmaco therapy should be instituted and there is good evidence that statin therapy is first line. High risk (>15%), individuals should receive statin therapy regardless of the baseline LDL. The statin dose may be titrated to achieve an LDL-C of <1.8 mmol/L or a non-HDL-C of <2.5mmol/L. In moderate risk patients without a previous CV event, an LDL-C target of <2.0 mmol/L or a non-HDL-C target of <2.7mmol/L can be used. If the LDL remains above target despite maximal tolerated statin therapy, ezetimibe, or bile acid binding resins and be added.
If the LDL is at target or maximal tolerated statin dose is reached, and dyslipidaemia is still present (triglycerides ≥2.3 mmol/L and low HDL), fenofibrate has been shown to significantly reduce CVD risk. Therapy with fenofibrate is also indicated in all patients with type 2 diabetes with diabetic retinopathy, as 2 separate trials have shown benefit, regardless of baseline lipids and glycaemic control. Fenofibrate has also been shown to reduce lower limb amputation, independent of the presence of large vessel disease, and has been shown to slow the progression of diabetic nephropathy.