First AD

Second AD

TK is a 51-year-old woman who presents to the clinic for diabetes follow-up. Her past medical history includes type 2 diabetes (T2DM), hypertension, and dyslipidemia. She has no known drug allergies and is a non-smoker.


  * Metformin 1000 mg twice daily
  * Losartan/HCTZ 100/25 mg daily
  * Aspirin 81 mg daily


  * HbA1c, 7.1%
  * Complete metabolic panel: WNL (SCr, 0.7; Na+, 139; K+, 4.5; AST,  23; ALT, 26)  
  * Lipid panel: TC, 230; TG, 365; HDL, 41; LDL, 124  



  * Weight, 82 kg; BMI, 33; blood pressure in clinic, 124/80 and 128/76 mmHg;
    pulse,  82 beats/min 

B. Add atorvastatin 10 mg daily and niacin SR 1000 mg twice daily

C. Add atorvastatin 10 mg daily and fenofibrate 160 mg daily

E. Encourage lifestyle modifications and continue current medications

Most appropriate answer: A. Add atorvastatin 10 mg daily 

In patients with T2DM, statin monotherapy has shown significant impact on reducing  atherosclerotic cardiovascular disease (ASCVD) events and death.

 Therefore, statins alone remain the drug of choice in guidelines to lower LDL cholesterol and for cardioprotection in patients with diabetes.

The evidence shows clear cardiovascular benefit for the use of moderate intensity statins such as atorvastatin 10 mg daily in patients aged 40-75 years with diabetes, especially those with a calculated ASCVD risk <7.5 %. High-intensity statin therapy can also be considered, especially in those with higher ASCVD risk or who need additional lipid lowering effect. Guidelines currently suggest treating hypertriglyceridemia with dietary and lifestyle changes. In the case of severe hypertriglyceridemia (at least >500 mg/dL), non-statin therapies may be considered in order to decrease triglyceride levels and prevent acute pancreatitis.

Monotherapy with niacin has been proven to decrease triglycerides and increase HDL levels. The AIM- HIGH trial evaluated the use of a statin in combination with extended-release niacin in patients with a history of CVD and elevated triglyceride levels, one-third of which also had diabetes

The trial was halted early due to a lack of effect seen on the primary CVD outcome and due to possible safety concerns in the combination treatment arm. Additionally, niacin therapy may not be well tolerated by patients and can lead to hepatotoxicity and hyperglycemia.  Therefore, the combination of a statin and niacin is not recommended initially in any patient, including those with diabetes, even in the presence of elevated triglycerides (<500mg/dL).

While fenofibrate can reduce triglyceride levels, combination therapy with a statin may increase the risk of side effects. Additionally, in the lipid arm of the ACCORD study, patients with T2DM were given a combination of fenofibrate and simvastatin. This combination did not reduce the rate of cardiovascular events compared to simvastatin alone-additional support for a statin alone as the drug of choice in this patient.

. In the absence of severe hypertriglyceridemia, therapy targeting tryiglyerides lacks benefit especially compared to statin therapy. Trials such as the FIELD study, that have evaluated fenofibrate use alone, have failed to show a significant benefit on CVD outcomes of fibrate therapy alone in patients with diabetes.

Lifestyle modifications such as increased exercise, weight loss, and dietary changes can improve the lipid profile in patients with diabetes; however, this therapy alone is not likely to have the same benefit as statins on primary CVD prevention. Lifestyle modifications should however be recommended to all patients, including those who start statin therapy.

 Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014. 24;129(25 Suppl 2):S1-45.

 Colhoun HM, Betteridge DJ, Durrington PN, et al. CARDS investigators. Primary preventionof cardiovascular disease with atorvastatin In type 2 diabetes in the Collaborative AtorvastatinDiabetes Study (CARDS): multicentre randomized placebo-controlled trial. Lancet. 2004;364:685–696.

 Standards of Medical Care in Diabetes in 2015. Diabetes Care 2015;38(Suppl. 1):S1–S2.

. Boden WE, Probstfield JL, Anderson T, et al. AIM-HIGH Investigators. Niacin in patients with low HDL cholesterol levels receiving intensive statin therapy. N Engl J Med. 2011;365:2255– 2267.

. Ginsberg HN, Elam MB, Lovato LC, et al. ACCORD Study Group. Effects of combination lipid therapy in type 2 diabetes mellitus. N Engl J Med. 2010;362:1563–1574.

 Keech A, Simes RJ, Barter P, et al.; FIELD study investigators. Effects of long-term fenofi- brate therapy on cardiovascular events in 9795 people with type 2 diabetes mellitus (the FIELD study): randomised controlled trial. Lancet. 2005;366:1849–1861.

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What do current guidelines recommend as first-line treatment for patients like 51-year-old TK? Check out these options. 

Elevated Triglycerides in a Woman with Type 2 Diabetes