Two cholesterol drugs better than one for diabetics

NEW YORK (Reuters Health) - Combination therapy with simvastatin and fenofibrate is better than treatment with either drug alone for treating mixed dyslipidemia in patients with type 2 diabetes, according to a report in American Journal of Cardiology.

Mixed dyslipidemia is a condition in which an individual has several lipid irregularities, such as high LDLs (the "bad" cholesterol) and low HDLs (the "good" cholesterol) and high triglycerides (a cardiovascular disease risk factor.)

Simvastatin, sold under the trade names Vytorin and Zocor, belongs to a popular drug class referred to as "statins, while fenofibrate, sold under the trade names Lofibra TriCor, works through a different mechanism. When combined together, the treatment effectively returned lipid levels back to normal levels.

"I believe every diabetic should be initially treated with a statin, with an LDL goal of at least 100 and probably even 70 would be better," Dr. Joseph Brent Muhlestein told Reuters Health. "I secondarily also look at triglycerides and HDL. I then target additional lipid therapy based on which of these three lipid values remain the most off-goal."

Muhlestein from the Intermountain Medical Center and LDS Hospital, Salt Lake City, Utah, and associates investigated the effects of simvastatin alone, fenofibrate alone, and the combination of simvastatin and fenofibrate on lipid components in 498 patients with type 2 diabetes without coronary heart disease.

Combination therapy reduced very low density lipoprotein cholesterol significantly more than did fenofibrate or simvastatin monotherapy, the investigators found. Simvastatin lowered intermediate density lipoprotein cholesterol significantly more than did fenofibrate.

The percentage of LDL cholesterol pattern B constituting total LDL cholesterol was significantly reduced by fenofibrate (a 13.7 percent reduction) and by the combination (an 11.1 percent reduction), but not by simvastatin.

LDL cholesterol pattern B is characterized by small, dense LDL molecules that are more likely to lead to atherosclerosis and heart disease.

Combination therapy plus fenofibrate shifted LDL cholesterol pattern B to a more buoyant LDL cholesterol that was less inclined to form plaques on the walls of the arteries that lead to arthrosclerosis, they note in the American Journal of Cardiology.

"Diabetic dyslipidemia appears to be a very important contributor to the overall cardiovascular risk associated with diabetes," Muhlestein concluded. "This risk comes from the combination of elevated LDL, elevated triglycerides, and low HDL. Aggressive treatment of this mixed dyslipidemia may be very important in saving the lives of our diabetic patients."

SOURCE: American Journal of Cardiology, February 15, 2008.