Treatment for High Total Cholesterol and Elevated LDL

Initial Assessment and Goals

Optimal lipid goals are LDL cholesterol <100 mg/dL, HDL cholesterol >35 mg/dL, and triglycerides <150 mg/dL, as recommended by the American Diabetes Association 1, 2
Lipid levels should be measured when initial glycemic control has been achieved and annually thereafter, according to the American Diabetes Association 1, 2
Target LDL cholesterol levels for adults with diabetes are <100 mg/dL, as stated by the American Diabetes Association 3

Reduce saturated fat to <7% of total daily calories, as recommended by the American Heart Association 4, 5, 2
Limit dietary cholesterol to <200 mg/day, according to the American Heart Association 4, 5, 6
Avoid trans-unsaturated fatty acids, as advised by the American Heart Association 5, 6
Replace saturated fats with monounsaturated fats or carbohydrates, as recommended by the American Heart Association 7, 5
Increase viscous (soluble) fiber intake to 10-25 g/day, as suggested by the American Heart Association 7, 5
Add plant stanols/sterols (2 g/day) to enhance LDL cholesterol lowering, according to the American Heart Association 7, 5, 6

Regular physical activity reduces plasma triglycerides and improves insulin sensitivity, as found by the American Diabetes Association 5

Modest weight loss is recommended for overweight/obese individuals, as advised by the American Heart Association 7, 5
Weight reduction leads to decreased plasma triglycerides and modest lowering of LDL cholesterol, according to the American Heart Association 5

Evaluate LDL cholesterol response after 6 weeks of lifestyle modifications, as recommended by the American Heart Association 5
If LDL goal is not achieved after 12 weeks of TLC, consider pharmacological therapy, according to the American Academy of Family Physicians 6
For patients with LDL cholesterol >130 mg/dL after 6 months of dietary intervention, initiate statin therapy with a goal of LDL <100 mg/dL, as advised by the American Diabetes Association 1, 2

Statins (HMG-CoA reductase inhibitors) are the preferred first-line pharmacological treatment for LDL reduction, as recommended by the American Diabetes Association 2, 3
For patients with diabetes or coronary heart disease (CHD) risk equivalents, statin therapy should be initiated when LDL is ≥100 mg/dL, according to the American Academy of Family Physicians 6, 3
For patients with 2+ risk factors but 10-year risk <20%, statin therapy should be initiated when LDL is ≥130 mg/dL, as advised by the American Academy of Family Physicians 6

Bile acid binding resins can be used as an alternative when statins are contraindicated, according to the American Diabetes Association 2, 3
Fibrates or niacin may be considered when HDL is low or triglycerides are elevated, as recommended by the American Diabetes Association 2, 3

For patients with persistently elevated triglycerides despite lifestyle changes, consider fibrates or niacin, as advised by the American Heart Association 7, 3
For patients with combined hyperlipidemia (elevated LDL and triglycerides), consider improved glycemic control plus statin therapy, according to the American Diabetes Association 3
For patients with diabetes, aggressive nutritional therapy should be instituted to improve the metabolic profile, as recommended by the American Heart Association 8

Failing to give adequate trial of lifestyle modifications before starting medication, as cautioned by the American Academy of Family Physicians 6
Not considering drug interactions when combining lipid-lowering medications, according to the American Diabetes Association 3
Overlooking the importance of glycemic control in diabetic patients with dyslipidemia, as emphasized by the American Heart Association 7, 3