糖尿病降脂.ppt

血脂不是动脉粥样硬化性疾病唯一的危险因素 胆固醇不是血脂谱中唯一的有害成分 他汀不是唯一的调脂药物 为全面控制心血管危险，仅仅他汀降胆固醇是不够的 羟甲基戊二酰辅酶A还原酶抑制剂 * 2007ADA指南在血脂管理部分列出了对LDL-C，HDL－C，TG和混合性血脂异常的治疗方案，其中在第二选择中有推荐他汀和其他血脂类别药物的联用。 生活方式改变和他汀作为一线药物推荐, 烟酸/依则麦布/胆酸螯合剂/贝特作为第二选择. 而对于HDL-C的控制, 生活方式改变是首选, 烟酸或贝特药物治疗作为第二选择. 对于TG的控制, 生活方式改变和血糖控制是首选, 贝特/烟酸/他汀作为第二选择. 对于混合型高脂血症, 血糖控制和大剂量他汀作为首选, 血糖控制+他汀+贝特/血糖控制+他汀+烟酸是第二选择. 他汀是降低LDL-C比较有效的药物. 而贝特和烟酸都是升高HDL-C,降低TG比较有效的药物. 贝特不会影响血糖控制, 而烟酸会影响患者的糖代谢. 他汀与非诺贝特的联用是安全的. 他汀与烟酸的联用应该考虑对糖代谢的影响, 加强血糖水平监控. According to the 2007 ADA guidelines, to decrease LDL-C levels in patients with diabetic dyslipidemia, statins are recommended as first-line treatment followed by bile acid resin or fenofibrate as second-line choices.1 When attempting to decrease a TG level, glycemic control is the first priority. Pharmacologic options for decreasing TG include fibric acid derivatives (eg, gemfibrozil or fenofibrate) and statins, which the guidelines state are moderately effective at high doses in patients with elevated TG and LDL-C levels.1,2 To increase an HDL-C level, nonpharmacologic changes are recommended, including weight loss, increased physical activity, and smoking cessation.1,2 Raising the HDL-C level pharmacologically in patients with diabetes is difficult because nicotinic acid, which can raise HDL-C, is relatively contraindicated in patients with diabetes. However, fibrates can raise HDL-C levels significantly without affecting glycemic control.1,2 The combination of statins with nicotinic acid and especially with gemfibrozil or fenofibrate has been associated with increased risk of myositis. The combination of statins with nicotinic acid is effective in modifying diabetic dyslipidemia, but the combination may significantly worsen hyperglycemia. Statin/nicotinic acid combinations should be used with caution in patients with diabetes; low doses of nicotinic acid (≤ 2 g/d) may not have much of a harmful effect on glycemic control, and any modest changes in glucose are generally amenable to adjustment