Dr George

Obesity, lipid disorders and diabetes guidelines: 

Obesity, lipid disorders and diabetes guidelines Georges Halaby WHO Beirut 2004

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Setting of diabetes, dyslipidemia and obesity: metabolic syndrome The type 2 diabetes is a chronic disease The preclinical stage is long The diagnosis is cheap and easy No data if the prevention for cardiovascular complications is cost-effective Global prevention or targeted prevention

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C. Lyon. Endocrinology 2003

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Chronic kidney disease

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Metabolic syndrome as predictor of CVD MS increases risk of CHD MS predicts 25% of all new-onset CVD 10-year risk of MS in men is between 10-20% Women with MS andlt;10% of CVD risk No advantage above Framingham risk factors

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Prevalence of different combinations of the individual components of the metabolic syndrome* in 35–70-year-old male and female subjects with NGT, IFG/IGT, and diabetic glucose tolerance NGT IFG/IGT Type 2 diabetes Male Female Male Female Male Female Obesity + dyslipidemia 25 9 41 21 51 49 Obesity + hypertension20 11 28 23 50 50 Obesity + hypertension + dyslipidemia 7 3 15 10 29 31 Hypertension + dyslipidemia 8 5 16 14 31 36 Obesity + micro 3 2 6 3 21 11 Hypertension + micro 2 2 3 3 16 10 Dyslipidemia + micro 1 1 4 2 14 9

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Unsolved problems with metabolic syndrome No consensus on definition and criteria Ethnic variability. Data on middle East populations The NCEP do not reflect an evidence based process, but an expert consensus The 5 elements for ATP III definition including recommended cut-points don’t reliably indicate presence of insulin resistance

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No consensus on insulin resistance definition, role and diagnostic criteria. Role of ectopic fat deposition , adiponectin, inflammation ? No evidence that intervention to treat the entire metabolic syndrome are efficacious or cost-effective Unsolved problems with metabolic syndrome

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Approaches to the Treatment of the Metabolic Syndrome

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Proposals on metabolic syndrome diagnosis. Waist or BMI andgt;102 in men or andgt; in women or andgt; 30Kg / m2 current or former? HTA: systolic andgt;140 or andgt;130 mmHg and / or diastolic andgt;85 or 80 Triglycerides andgt; 150mg / 100ml HDL andlt;35 mg/100 ml in men and andlt;39 in women andlt; 40 mg/100ml in men and andlt; 50 in women or andlt;40 mg/100 ml in both sexes

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Proposals on metabolic syndrome FBG andgt; 100 or andgt; 110mg/100 ml or post load andgt; 140 Insulin resistance : insulinemia, Quicky or clamp ??? CRP ??? How many criteria? Waist and 2 other criteria? IGT and diabetes or consider diabetes separately ?

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NCEP 2003

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ARIC Chong Lee Circulation 2004

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Josie M M Evans BMJ 2002

Impact of Simvastatin in Patients with Diabetes and No Prior CVDMajor Vascular Events : 

Impact of Simvastatin in Patients with Diabetes and No Prior CVD Major Vascular Events 0 5 10 15 Patients with major vascular events by year 5 (%) 33% risk reduction (p=0.0003) Placebo n=1455 13.5 n=1457 9.3 Simvastatin Adapted from Heart Protection Study Collaborative Group Lancet 2003;361:2005-2016.

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UKPDS 35 BMJ 2000

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The Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group, N Engl J Med 2003;348:2294-2303 Univariate Associations of Carotid Intima-Media Thickness, with Risk Factors Adjusted for Age, Sex, Ultrasonography Equipment Used, and Year 1 Intima-Media Thickness Measurement

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The Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group, N Engl J Med 2003;348:2294-2303 Mean Treatment-Related Difference in the Relation between the Estimated Mean Intima-Media Thickness and Age

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VAHIT study diabetes subgroup Archives 2002

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Question : Do we need a stratification of risk in diabetic patients or we have all them with statins as high risk group??

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Recommendation 1: Lipid-lowering therapy should be used for secondary prevention of cardiovascular mortality and morbidity for all patients (both men and women) with known coronary artery disease and type 2 diabetes.

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Recommendation 2: Statins should be used for primary prevention against macro vascular complications in patients (both men and women) with type 2 diabetes and other cardiovascular risk factors.

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Recommendation 3: Once lipid-lowering therapy is initiated, patients with type 2 diabetes mellitus should be taking at least moderate doses of a statin

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Recommendation 4 : In diabetics with low HDL, the fibrates can be used alone or in association with statins. Recommendation 5 : The role of niacin, CETP inhibitor, Apo A Milano is to be determined in the future.

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Recommendation 6 : microalbuminuria and chronic kidney disease in diabetic patients must be considered as risk factor and all patients must treated by statins as first choice, second choice may be niacin or fish oil.

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Recommendation 7 : The good control of diabetes with insulin may be helpful for secondary prevention immediately after a MI ?

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Recommendation 8 : Aspirin must be used in all type 2 diabetic patients, but some resistance to aspirin exists, and the doses are controversial.