1.The target of lipid regulation should be more clear
Lipid is a general term for various lipids in blood, including cholesterol, triglycerides, phospholipids, etc. Dyslipidemia usually refers to an abnormal increase in plasma cholesterol and/or triglycerides. These lipids in the blood are insoluble in water and can only be transported in the blood and participate in the body’s metabolism by combining with proteins to become lipoproteins.
Therefore, elevated blood lipids are also called hyperlipoproteinemia. After elevated blood lipids are deposited on the walls of blood vessels, forming atherosclerotic plaques, which can cause narrowing of the lumen of blood vessels or even occlusion, resulting in serious consequences such as angina pectoris, acute myocardial infarction and cerebral infarction. Cui Yunzhu, Department of Endocrinology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine
It is well known that the increase of LDL cholesterol and the decrease of HDL cholesterol are the main “culprits” of atherosclerosis. In clinical treatment, we mainly adopt lipid-regulating treatment for dyslipidemia, i.e., we try to increase HDL level and lower LDL level at the same time. Studies have shown that for every 10mg/100ml increase in LDL cholesterol in the blood of diabetic patients, the risk of coronary heart disease increases by 22%.
However, in recent years, some large domestic and foreign studies have shown that although the lipid-regulating drugs currently on the market mainly target the “one high and one low” condition of lipoproteins, the results of these studies show that these drugs are more effective in lowering LDL cholesterol, but not very effective in raising HDL cholesterol. However, studies have shown that these drugs are more effective in lowering LDL cholesterol but less effective in raising HDL cholesterol. Therefore, lowering total serum cholesterol and LDL cholesterol levels has become one of the main focuses of current efforts to regulate dyslipidemia.
This reorientation does not conflict with the previous therapeutic approach, but is more clearly focused. At present, statins, which can significantly reduce total lipid cholesterol and LDL cholesterol levels, are still the more recommended lipid-lowering drugs by doctors.
2.Beatles: the recommended choice for glucose lovers to lower lipids
Most of our diabetic patients have mixed hyperlipidemia, and most of them have elevated triglycerides alone. Diabetic patients with lipid-lowering drugs should pay attention to two points: first, the early use of lipid-regulating drugs, preferably evidence-based medicine to confirm that long-term use can clearly reduce cardiovascular and cerebrovascular events; second, taking safe lipid-regulating drugs, long-term use to minimize the burden on the liver and kidneys.
The main clinically used lipid-lowering drugs in China are statins, betablockers and niacin. Statins can significantly reduce serum total cholesterol and LDL cholesterol levels, moderately reduce blood triglyceride levels and increase HDL cholesterol levels. Commonly used drugs include simvastatin (Sulforaphane), atorvastatin (Lipitor), pravastatin (Prasugrel), lovastatin (Methotrexate), and cervastatin (Lysergol). The triglyceride-lowering effect of betablockers is greater than the cholesterol-lowering effect.
Patients with diabetes with predominantly elevated triglycerides can give priority to beta drugs. Clinically used fibrates include clofibrate (Antoine, Coronary heart), fenofibrate (Lipiodol), gemfibrozil (Norstreet), benzofibrate (Must be adjusted lipid), etc. Nicotinic acid drugs can reduce triglyceride levels to some extent, clinical drugs such as niacin, Lupin and others.
The combined application of lipid-lowering drugs should also be worth exploring. In foreign countries, the combined application of lipid-lowering drugs such as statins and fibrates should also be worth exploring. In foreign countries, the combined application of lipid-lowering drugs, such as statins and fibrates, has been practiced in many clinics. In China, the safety of the combination of statins and fibrates has been controversial. As long as the drugs are used reasonably under the guidance of doctors, and the indicators of blood lipids, liver function and creatine phosphokinase are monitored regularly, and these indicators are controlled within the safe range, the combined application of lipid-regulating drugs will have a wider clinical application space.
3.Lipid regulating treatment advocates individualization
Ensuring the safety of lipid regulating treatment for diabetic patients is mainly the work of doctors. Lipid regulating treatment depends on which aspect of the patient’s blood lipid abnormality is the main reason for the use of drugs. Nowadays, lipid-lowering drugs are mainly divided into the following categories: cholesterol-lowering drugs are statins; triglyceride-lowering drugs are beta drugs; and niacin drugs can lower both cholesterol and triglycerides, but the effects are not very strong. Cholesterol lipid-lowering drugs usually need to be taken by patients for years, even for life, in order to solve the root of the problem, delay and prevent the occurrence and process of atherosclerosis, and really play a role in the prevention of large blood vessel complications. Therefore, the safety of the medication is especially important.
These lipid-regulating drugs also have certain side effects. The biggest side effect of statins is to cause rhabdomyolysis, which can lead to kidney failure and can be life-threatening if it occurs. Betablockers may also lead to impaired liver function. Doctors must be sure of the safety of the medication. The risk of rhabdomyolysis is greatly increased if statins and beta drugs are combined.
Lipid-regulating therapy must emphasize individualized treatment. Many diabetic patients have predominantly high triglycerides and may not have high cholesterol, but doctors still use statin cholesterol-lowering drugs when treating patients. Generally doctors are very impressed with statins and think that all indicators can be lowered by statins, while for patients who do not have high cholesterol, statins will not be a good treatment.
Usually, people do not pay enough attention to HDL cholesterol and only know to bring down the bad triglycerides and cholesterol, but they do not know that low HDL cholesterol is also bad. Lipid regulating therapy should lower the high, bad cholesterol and raise the low, good cholesterol. Currently, there are not many drugs for HDL cholesterol, mainly niacin. Many doctors rarely use niacin-based drugs, and even some hospitals do not have niacin-based drugs at all.
4.Lifestyle intervention is the basic treatment
Diet, exercise and other lifestyle changes are non-pharmacological treatments in lipid regulating therapy, and they are also very important treatments.
First of all, patients should control their weight, not to be overweight and obese, and to exercise more. For foods containing high cholesterol, such as offal and egg yolk, it is important to control their intake and not to have big fish and meat often. With high triglycerides, sugars and starches should be controlled.
Through exercise, not only can blood sugar be controlled within the ideal range, but also can promote the movement of blood in the blood vessels and reduce blood lipids and blood viscosity. Many patients with mild hyperlipidemia can keep their blood lipids under control by adhering to exercise for a month or two. It is difficult for many people to stick to exercise. Patients should have perseverance and make an exercise plan for themselves, specifying the time of exercise as well as the amount of exercise. Walking, jogging, cycling, swimming, climbing stairs, etc. are all good ways to exercise, and you must not be afraid of being tired. Exercise should be persistent for a long time to achieve the therapeutic effect. Exercise for only two or three weeks is hardly effective.
Some patients are not overweight or obese and have done well with lifestyle interventions, but still do not achieve the desired effect, and then medication is needed to bring the lipids up to standard.
All patients with dyslipidemia should receive intensive lifestyle intervention treatment, including reducing the intake of unsaturated fatty acids and cholesterol, reducing body weight, increasing exercise, as well as quitting smoking, limiting alcohol and limiting salt.
5.Treatment principles for lipid metabolism disorders
(1) Blood lipids should be checked at least once a year. Those who are treated with lipid-regulating drugs need to increase the number of tests.
(2) In lipid regulating treatment, lowering LDL cholesterol should be the primary goal. All patients with diabetes who have previously developed cardiovascular disease should be treated with statin lipid-modifying drugs to reduce LDL cholesterol to below 2.07 mmol/L (80 mg/dL) or 30% to 40% from baseline status.
(3) For those without cardiovascular disease and over 40 years of age, statin lipid-modifying agents should be used if LDL cholesterol is above 2.5 mmol/L or total cholesterol is above 4.5 mmol/L: those under 40 years of age who also have other cardiovascular disease risk factors (hypertension, smoking, microalbuminuria, family history of premature cardiovascular disease and estimated increased overall risk of cardiovascular disease) when initiating statin lipid-lowering agents.
(4) All patients with dyslipidemia should be treated with intensive lifestyle interventions, including reduction of saturated fatty acid and cholesterol intake, weight loss, increased exercise and cessation of smoking, alcohol and salt restriction. — Excerpted from the “Guidelines for the Prevention and Treatment of Type 2 Diabetes in China