Target Audience (click to view)
This activity is designed to meet the needs of physicians.
Learning Objectives(click to view)
Upon completion of the educational activity, participants should be able to:
- Explain recommendations made in the section of the American Diabetes Association’s 2015 Standards of Care that is dedicated to managing cardiovascular disease and associated risk factors, including dyslipidemia, with lifestyle interventions and medications.
Method of Participation(click to view)
Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation. A statement of credit will be available upon completion of an online evaluation/claimed credit form at www.akhcme.com/pwOct4. You must participate in the entire activity to receive credit. If you have questions about this CME/CE activity, please contact AKH Inc. at firstname.lastname@example.org.
Credit Available(click to view)
CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s. AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.
AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Commercial Support(click to view)
There is no commercial support for this activity.
Disclosures(click to view)
It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.
Disclosure of Unlabeled Use & Investigational Product(click to view)
This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Disclaimer(click to view)
This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.
Faculty & Credentials(click to view)
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
AKH planners and reviewers have no relevant financial relationships to disclose.
Take CME(click to view)
Cardiovascular disease (CVD) has been identified as a major cause of morbidity and mortality for patients living with diabetes. In addition to hypertension, obesity and smoking, dyslipidemia has been well documented to be a common condition that coexists among people with type 2 diabetes and is an important risk factor for CVD. “Effective control of all cardiovascular risk factors has been shown to help prevent or slow the progression of CVD in people with diabetes,” says Rodica Pop-Busui, MD, PhD.
Each year, the American Diabetes Association updates its Standards of Care document to provide the best possible guidance to healthcare providers for the management of the complex diabetic patients. A section of the 2015 document has been dedicated to managing CVD and associated risk factors, including dyslipidemia, with lifestyle interventions and medications. This section offers information on lipid screening and treatment goals (Table 1). A key emphasis of these recommendations is placed on lifestyle interventions, including medical nutrition therapy, increasing physical activity, losing weight, and quitting smoking. These interventions, if adhered to, have been shown to effectively reduce risk factors for CVD as a result of lowering LDL cholesterol, blood pressure, and weight.
According to the American Diabetes Association, patients with type 2 diabetes have a higher risk of lipid abnormalities and, as such, should be considered for statin therapy. “Multiple clinical trials have shown that using statins as primary and secondary prevention can have an important effect on patient outcomes and CVD risk reduction,” explains Dr. Pop-Busui. Reductions in CVD risk tend to be greatest among people at highest risk and those with very high LDL cholesterol levels, but the overall benefits of statins in people with diabetes at moderate or high risk for CVD are also convincing, making this therapy the drugs of choice for LDL cholesterol lowering and cardioprotection.
The 2015 Standards of Care document revised recommendations on when to initiate and intensify statin therapy based on risk profiles using age and the number of additional CVD risk factors that are present, rather than on LDL cholesterol levels, (Table 2). All patients with diabetes aged 40 and older should be considered for moderate-intensity statin treatment, if clinically indicated, in addition to lifestyle therapy. For adults with diabetes older than 75, the data regarding statins are more limited. “These patients should be provided statins based on their individualized risk profile,” Dr. Pop-Busui says. “The risk-benefit profile should be routinely evaluated for these patients and titration should be performed as needed.”
Ongoing Therapy & Monitoring
In adults with diabetes, a screening lipid profile consisting of total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides should be performed when patients are first diagnosed as well as at their initial medical evaluation. This screening should also be performed beginning at age 40 or sooner if indicated. “Once patients are started on a statin, it’s important to monitor adherence and efficacy,” adds Dr. Pop-Busui. If patients are adhering to statins but without a LDL cholesterol level response, clinical judgement should be used to determine the need for and timing of lipid panels.
The American Diabetes Association recommends that hypertriglyceridemia be addressed with dietary and lifestyle changes. In cases of severe hypertriglyceridemia, immediate pharmacological therapy may be warranted to reduce the risk of acute pancreatitis. Low levels of HDL cholesterol are often associated with elevated triglyceride levels and are a prevalent pattern of dyslipidemia in persons with type 2 diabetes. However, the evidence base for drugs that target these lipids is significantly less robust than that for statin therapy.
Considering Combination Therapy
Research has shown that combining statins and fibrates may be effective for the treatment of LDL and HDL cholesterol and triglycerides, but this combination has been associated with risks for other complications. Combination therapy with statins and fibrates has not been shown to reduce rates of fatal cardiovascular events and non-fatal heart attacks or strokes when compared with statin monotherapy. Combination therapy using statins and niacin is not recommended because of the lack of efficacy on major CVD outcomes and because of the potential to increase risks for ischemic stroke as well as other side effects.
“When considering treatments for lipids in patients with diabetes, use of statins should be considered based on each person’s unique characteristics,” says Dr. Pop-Busui. “Some patients may be candidates for statins while others may require other cholesterol-lowering drugs. Close monitoring is required to see how their lipid levels react to medications and adjustments in therapy might be required. In addition, lifestyle interventions should be tailored to each patient with diabetes. The key is to take a patient-centered approach and strive to ensure that patients are adhering to treatment regimens appropriately in order to improve cardiovascular health and reduce risks of future cardiovascular events.”
Readings & Resources (click to view)
American Diabetes Association. Standards of Medical Care in Diabetes—2015. Cardiovascular Disease and Risk Management. Diabetes Care. 2015;38:S49-S57. Available at: http://care.diabetesjournals.org/content/38/Supplement_1/S49.full.
American Diabetes Association. Standards of Medical Care in Diabetes—2015. Diabetes Care. 2014;38:S1-S93. Available at: http://professional.diabetes.org/admin/UserFiles/0%20-%20Sean/Documents/January%20Supplement%20Combined_Final.pdf.
Solano MP, Goldberg RB. Lipid management in type 2 diabetes. Clin Diabetes. 2006;24:27-32. Available at: http://clinical.diabetesjournals.org/content/24/1/27.full.
Mihaylova B, Emberson J, Blackwell L, et al, Cholesterol Treatment Trialists’ (CTT) Collaborators. The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials. Lancet. 2012;380:581-590.
Taylor F, Huffman MD, Macedo AF, et al. Statins for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev. 2013;1:CD004816.