Does the treatment of dyslipidemia differ?

Abstract

Although therapeutic options for the care of people with type 1 diabetes have improved, allowing them to live longer and better, life expectancy is still around 10 years less, with atherosclerotic cardiovascular disease (ACVD) being the number one cause of morbidity and mortality.

In addition to the typical or modifiable cardiovascular risk factors (high blood pressure, hypercholesterolemia, obesity, smoking, family cardiovascular history, etc.), long-term hyperglycemia has a significant impact by inducing oxidative stress, vascular inflammation, monocyte adhesion, arterial wall thickening and endothelial dysfunction; there are significant qualitative and functional abnormalities of lipoproteins, even in patients with good control. In addition to cardiovascular disease, there is frequently an association with nephropathy.

In addition to all the factors mentioned, known as modifiable, a non-modifiable risk factor plays a transcendental role; This is the age at diagnosis; patients with type 1 diabetes with early onset have a substantially higher cardiovascular risk.

However, even in patients with type 1 diabetes with good diabetes control and without additional cardiovascular risk factors, the risk of CVAD remains significantly higher, indicating the involvement of potential complementary factors: hypoglycemia and glucose variability, as well as immune system dysfunction, exacerbate inflammatory pathways and can worsen CVAD. Finally, often as a result of treatment, patients are overweight or obese, which aggravates CVAD with pathophysiological mechanisms similar to those observed in type 2 diabetes.

The risk of death from any cause was 1.5 times higher in type 1 diabetes at age >50 years, with a similar trend for cardiovascular death.

Assessment of LDL cholesterol, HDL cholesterol, triglycerides, and if possible apolipoprotein B (as the gold standard for dyslipidemia), albuminuria/creatininuria in a single sample, and ideally, highly sensitive C-reactive protein, is essential.

Management of dyslipidemia, especially with statins, has been shown to be of great benefit in preventing clinical ASCVD. Since many patients fail to achieve the low LDL cholesterol levels recommended in these guidelines, adjunctive therapy, such as the addition of ezetimibe, bempedoic acid, or PCSK9 inhibitors, is often required to achieve these goals.