People with type 1 or type 2 diabetes should be encouraged to adopt a healthy lifestyle to lower their risk of CVD. This entails adopting healthy eating habits, achieving and maintaining a healthy weight, engaging in regular physical activity and smoking cessation [Grade D, Consensus].
Most adults with type 1 or type 2 diabetes should be considered at high risk for vascular disease [Grade A, Level 1 (10,12,15), Level 2 (14)]. The exceptions are younger adults with type 1 or type 2 diabetes with shorter duration of disease and without complications of diabetes (including established CVD) and without other CVD risk factors [Grade A, Level 1 (11,18)]. A computerized risk engine (e.g. UKPDS risk engine, Cardiovascular Life Expectancy Model) can be used to estimate vascular risk [Grade D, Consensus].
In adults, fasting lipid levels (TC, HDL-C, TG and calculated LDL-C) should be measured at the time of diagnosis of diabetes and then every 1 to 3 years as clinically indicated. More frequent testing should be performed if treatment for dyslipidemia is initiated [Grade D, Consensus].
Adults at high risk of a vascular event should be treated with a statin to achieve an LDL-C ≤2.0 mmol/L [Grade A, Level 1 (38,40), Level 2 (42)]. Clinical judgement should be used as to whether additional LDL-C lowering is required for adults with an on-treatment LDL-C of 2.0 to 2.5 mmol/L [Grade D, Consensus].
In adults, the primary target of therapy is LDL-C [Grade A, Level 1 (38,40), Level 2 (42)]; the secondary target is TC/HDL-C ratio [Grade D, Consensus].
In adults, if the TC/HDL-C ratio is ≥4.0, consider strategies to achieve a TC/HDL-C ratio <4.0 [Grade D, Consensus], such as improved glycemic control, intensification of lifestyle (weight loss, physical activity, smoking cessation) and, if necessary, pharmacologic interventions [Grade D, Consensus].
In adults with serum TG >10.0 mmol/L despite best efforts at optimal glycemic control and other lifestyle interventions (e.g. weight loss, restriction of refined carbohydrates and alcohol), a fibrate should be prescribed to reduce the risk of pancreatitis [Grade D, Consensus]. For those with moderate hyper-TG (4.5 to 10.0 mmol/L), either a statin or a fibrate can be attempted as first-line therapy, with the addition of a second lipid-lowering agent of a different class if target lipid levels are not achieved after 4 to 6 months on monotherapy [Grade D, Consensus].
For adult patients not at target(s), despite optimally dosed first-line therapy as described above, combination therapy can be considered. Although there are as yet no completed trials demonstrating clinical outcomes in adults receiving combination therapy, pharmacologic treatment options include (listed in alphabetical order):
In adults, plasma apo B can be measured, at the physician’s discretion, in addition to LDL-C and TC/HDL-C ratio, to monitor adequacy of lipid-lowering therapy in the high-risk patient [Grade D, Consensus].Target apo B should be <0.9 g/L [Grade D, Consensus].