Patients with
insulin-dependent diabetes mellitus (
IDDM) are at an increased risk for
coronary heart disease. Factors that may enhance the risk include
dyslipidemia,
hypertension, and
hyperglycemia. Until recently, the importance of
dyslipidemia in
IDDM was ignored because the prevalence of
high cholesterol levels was similar to that in the nondiabetic population. However, unique abnormalities in the composition and metabolism of
lipoproteins may occur in
IDDM patients. Management of
IDDM patients, therefore, should include control of
dyslipidemia as well as control of
hyperglycemia and
hypertension. The therapeutic goals for serum
cholesterol reduction in
IDDM patients should be lower than that for nondiabetic patients, and the goals for children should be even lower than those for adults. Both
very-low-density lipoprotein and
low-density lipoprotein (
LDL) levels should be the targets for therapeutic interventions and not just the
LDL alone. Because of the unique features of
dyslipidemia in
IDDM patients, the therapeutic options may not be the same as that for nondiabetic patients.
Hyperglycemia should be controlled by matching daily energy intake and activity with appropriately timed doses of
insulin. The diets should be low in saturated
fats and
cholesterol. If
dyslipidemia persists despite diet and
hyperglycemia management, drug therapy may be initiated. For
IDDM children > or = 10 years of age with elevated
LDL-cholesterol levels, the first-line
therapy should be
bile acid sequestrants. For adults with
IDDM,
bile acid sequestrants also may be the drugs of choice, particularly for normotriglyceridemic patients.
Nicotinic acid therapy should be avoided. Among other drugs, hydroxymethyl-
glutaryl coenzyme A reductase inhibitors may be preferable for patients with elevated
LDL cholesterol and borderline
hypertriglyceridemia.
Fibric acid derivatives should be used for markedly hypertriglyceridemic patients. The role of
probucol for
dyslipidemia in
IDDM patients is not clear.