Donald A. Smith, MD, MPH

ABSTRACT: Low-density lipoproteins are the most common atherogenic particles in diabetic dyslipidemia; therefore statins, which dramatically reduce low-density lipoprotein (LDL) cholesterol, are first-line therapy for patients with diabetes. These agents produce equivalent relative risk reductions in those with and without diabetes but confer greater absolute risk reduction because of the increased incidence of ischemic cardiovascular events in those with diabetes. The LDL cholesterol goal for patients with diabetes who do not have coronary heart disease is below 100 mg/dL. For secondary prevention, the goal is below 70 mg/dL. High-dose statin therapy may be required to achieve these goals. Fibric acids are a reasonable initial option for patients with triglyceride levels above 200 mg/dL and high-density lipoprotein (HDL) cholesterol levels below 40 mg/dL; in such patients they reduce risk as effectively as statins. Intermediate-release niacin raises HDL cholesterol levels; the effect is enhanced when niacin is combined with a statin.