两种他汀类降脂药对老年2型糖尿病患者调脂作用的比较

脂质代谢紊乱是糖尿病代谢异常的一个组成部分，其对糖尿病及其并发症的发生、发展有极其重要的作用，故纠正血脂异常是糖尿病治疗的一个重要内容。大量前瞻性的临床研究证明，他汀类药物常为一线调脂药物。我们对96例合并血脂异常的2型糖尿病老年患者在口服降糖药有效控制血糖的基础上，分别给予阿托伐他汀与辛伐他汀．旨在探讨两种药物的调脂疗效。     

《华西医学》2005年第20卷总目次

循证医学贝特类调脂药物可减少2型糖尿病患者心血管事件——循证医学的新证据杨波田浩明205…………………………………………………………………《中华医学杂志》20年随机对照试验文献的方法学评价李蓉琼廖晓阳方荣华等207………………………………………………………《实用护理杂志》2001～2003年引文分析刘司寰马建李明凤208……………《中华男科学》随机对照临床治疗试验文献方法学评价滕东海卢一平李响等417………………………………………………………临床肾替代治疗安全性和有效性的系统评价黄朝友杨宇如魏强等418………循证之路—…     

医师培训问题解答(2)

北京市朝阳区双井社区卫生服务中心马岩医生问:早期糖尿病合并血脂异常的患者在血脂得到控制后,是否可以停用他汀类药物而通过饮食调节和运动来维持?北京市垂杨柳医院心脏中心李瑞杰主任医师答复:血脂异常的基础治疗是饮食调节和运动,然后在此基础上进行药物干预。糖尿病合并血脂异常属于高危患者,应采取如下措施:①积极治疗糖尿病;②饮食调节;③进行适量规律的有氧运动;④加用他汀类药物强化调脂治疗,使LDL-C降至<70%,并维持治疗,注意药物不良反应。⑤控制高血压、吸烟等其他危险因素。北京市朝阳区平房医院王朝霞医生问:如何鉴别糖尿病…     

他汀类药物在2型糖尿病综合治疗中的研究进展

2型糖尿病的患病率正在世界范围内逐年增加,同时与之相关的微血管并发症和大血管并发症发生率也显著增加。他汀类药物除了调脂作用以外,还可通过抑制炎症因子、保护血管内皮细胞功能及抗氧化应激等途径延缓糖尿病并发症发生发展,显著减少心血管事件。总体而言,及时启动他汀类药物对2型糖尿病的治疗是有益的,尤其是伴有心血管危险因素的糖尿病患者。     

极低体重儿胃肠外营养的护理

代谢综合征（MS）包括高体重指数（BMI）、高血糖、血脂异常、高血压及高胰岛素血症等，其中心环节是胰岛素抵抗。由于血脂异常与动脉粥样硬化、冠脉事件的发生发展关系密切，因而调脂治疗显得非常重要。4S及HHS等研究暴露出他汀类药物在改善由低HDL-C所致的CAD危险方面的局限性。近年来，人们逐渐认识到，虽然贝特类药物在降低LDL-C方面未能显示出他汀类药物的功效，但它能明显降低TG、升高HDL-C，给糖尿病（DM）及MS伴血脂异常者带来显著益处。     

糖尿病调脂药物治疗的循证医学

本文重点介绍近年来糖尿病患者调脂治疗,主要包括临床常用的他汀类、贝特类、烟酸等药物降胆固醇(TC)、甘油三酯(TG)、低密度脂蛋白-胆固醇(LDL-C)水平、升高高密度脂蛋白-胆固醇(HDL-C),以及减少心血管事件的疗效、不良反应等。     

糖尿病患者调脂治疗的临床研究及其意义

糖尿病和脂质代谢紊乱是常见的内分泌代谢性疾病，糖尿病患者血脂异常的发生率远高于非糖尿病患者，脂质代谢紊乱又有助于高血糖和糖尿病的发生。由于血脂异常与动脉粥样硬化、冠脉事件的发生发展又有着密切关系，所以糖尿病患者的调脂治疗显得非常重要。近年来许多大型临床试验证明，调脂治疗是预防糖尿病患者发生冠心病的有效措施。     

老年糖尿病患者血脂异常的护理体会

老年糖尿病患者中有93%的患者合并各种心血管并发,约80%的糖尿病患者死于心血管并发症,其中75%死于心病,血脂异常是动脉粥样硬化和冠心病的一个重要危险素[1],由于糖尿病能使脂蛋白中的某些或使血管壁中的某蛋白糖基化,这些糖代蛋白都有导致动脉粥样硬化的作,因此,糖尿病患者血脂异常的治疗和护理是一个十分重的问题,现将我科2004~2006年老年糖尿病患者中62例脂异常病人的护理体会总结如下。临床资料.1一般资料老年糖尿病患者血脂异常病人62例,男56,女6例,入选时年龄60~92岁,平均年龄75.18±8.13,病程1~23年,中位病程7年。经OGTT实验确诊…     

158例老年糖尿病病人的心电图分析

糖尿病是由于胰岛素分泌绝对或相对不足引起的疾病,常出现心血管、肾、眼及神经等系统并发症,其中心血管并发症已成为糖尿病死亡的主要原因.冠状动脉粥样硬化性心脏病(冠心病)的发病率为非糖尿病人的3倍或4倍,糖尿病病人的死因中约30％是急性心肌梗死[J].因此,定期进行心电图(ECG)检查对及时发现和治疗糖尿病心血管并发症具有重要意义.     

糖尿病健康教育的现状及研究进展

糖尿病健康教育可提高广大群众的自我保健意识，提高现症病人就诊率，积极配合医生治疗，有利于控制病情，减少糖尿病并发症的发生，提高糖尿病人的生命质量。本文对近年来糖尿病健康教育的现状、内容及实施方法等研究进展进行综述。     

Lipids and lipoproteins in patients with type 2 diabetes

Insulin resistance and type 2 diabetes are associated with a clustering of interrelated plasma lipid and lipoprotein abnormalities, which include reduced HDL cholesterol, a predominance of small dense LDL particles, and elevated triglyceride levels. Each of these dyslipidemic features is associated with an increased risk of cardiovascular disease. Increased hepatic secretion of large triglyceride-rich VLDL and impaired clearance of VLDL appears to be of central importance in the pathophysiology of this dyslipidemia. Small dense LDL particles arise from the intravascular processing of specific larger VLDL precursors. Typically, reduced plasma HDL levels in type 2 diabetes are manifest as reductions in the HDL(2b) subspecies and relative or absolute increases in smaller denser HDL(3b) and HDL(3c). Although behavioral interventions such as diet and exercise can improve diabetic dyslipidemia, for most patients, pharmacological therapy is needed to reach treatment goals. There are several classes of medications that can be used to treat lipid and lipoprotein abnormalities associated with insulin resistance and type 2 diabetes, including statins, fibrates, niacin, and thiazolidinediones. Clinical trials have shown significant improvement in coronary artery disease after diabetic dyslipidemia treatment.     

In diabetes, treat hidden heart disease

Both diabetic and prediabetic patients have abnormal vascular reactivity and should be considered to have occult cardiovascular disease. Angiotensin-converting-enzyme (ACE) inhibitors are particularly beneficial in diabetes because they reduce the incidence of both cardiovascular events and diabetes-related complications. In prediabetic patients, ACE inhibitors also reduce the risk of a new diagnosis of type 2 diabetes. Managing hypertension is even more beneficial for diabetic patients than for nondiabetic patients. To further reduce the risk of heart disease in patients with diabetes or prediabetes, dyslipidemia should also be treated aggressively.     

关注糖尿病剩留血管风险

血脂异常为糖尿病剩留血管风险重要危险因素,糖尿病患者更应关注低密度脂蛋白胆固醇(LDL C)正常,甘油三酯（TG）升高,高密度脂蛋白胆固醇(HDL C)水平较低这种特异血脂异常,本文综述糖尿病剩留血管风险近年研究,提高对糖尿病剩留血管风险认识。     

Why, when and how should hypertriglyceridemia be treated in the high-risk cardiovascular patient?

Recent epidemiology attests that hypertriglyceridemia may be a causal risk factor for cardiovascular disease (CVD). The specific atherogenicity of hypertriglyceridemia relates to the accumulation in plasma of triglyceride-rich lipoprotein remnants. Hypertriglyceridemia also drives a 'global' atherogenic dyslipidemic profile, which is frequent in high-risk cardiovascular patients, such as Type 2 diabetics. Elevated triglyceride in fasting or nonfasting blood samples should be a trigger for assessing atherogenic components of the lipid profile, particularly HDL-cholesterol, non-HDL-cholesterol and apoB. Residual risk of CVD remains high in statin-treated diabetic patients owing to persistent atherogenic dyslipidemia, which is not fully corrected by these agents nor by the addition of ezetimibe. Hypertriglyceridemia may then be targeted with niacin, fibrates or n-3 fatty acids, after correcting aggravating factors, especially obesity and hyperglycemia. Fibrates consistently decrease coronary events in dyslipidemic patients in outcome studies. New evidence supports adding fenofibrate to a statin in Type 2 diabetics with residual hypertriglyceridemia and low HDL-cholesterol; extrapolating from a recent meta-analysis, a 15% reduction in triglycerides could translate into a further 15% reduction in coronary events. Ongoing clinical trials may provide new evidence for adding niacin to a statin. The value of higher doses of n-3 fatty acids in reducing CVD risk remains to be demonstrated. The high triglyceride/low HDL nexus is an under-recognized risk factor for CVD that merits more detailed clinical assessment and treatment, particularly in patients with Type 2 diabetes already receiving a statin.     

Systematic review and meta-analysis of Statins-Fibrates therapy in diabetic dyslipidemia patients

AIM: To evaluate the efficacy,effect of preventing cardiovascular diseases and safety of statins-fibrates combination therapy in diabetic dyslipidemia patients.METHODS: We searched the databases of MEDLINE,EMBASE,web of knowledge and Cochrane central register of Controlled Trials for literatures about the coadministration of statins and fibrates as the treatment of patients with dyslipidemia and type 2 diabetes mellitus.We included related randomized controlled trials,controlled clinical trials and cross-sectional studies and excluded animal trials and clinical observations.The primary endpoints outcomes were the concentration of plasma total cholesterol(TC),triglyceride(TG),high density lipoprotein cholesterol(HDL-C) and low density lipoprotein cholesterol(LDL-C).The secondary outcomes were cardiovascular diseases(CVD) and adverse events.RESULTS: Ten studies were included in this metaanalysis.For lipid modifying efficacy,the combination of statins and fibrates therapy had more significant effecton reducing TC [P = 0.004,weighted mean difference(WMD) =-8.19,95%CI:-13.82--2.56] and TG concentration(P 0.001,WMD =-47.29,95%CI:-68.66--25.92) and increasing HDL-C concentration(P 0.00001,WMD = 3.79,95%CI: 2.25-5.33) when compared with statins monotherapy,while the effect of reducing LDL-C concentration(P = 0.50,WMD =-2.52,95%CI:-9.76-4.72) was insignificant.To fibrates monotherapy,the combination therapy was more effective on reducing TC(P 0.00001,WMD =-48.51,95%CI:-57.14--39.89),TG(P 0.00001,WMD =-26.07,95%CI:-30.96--21.18),LDL-C concentration(P 0.00001,WMD =-45.74,95%CI:-53.35--38.13) and increasing HDL-C concentration(P = 0.04,WMD = 1.38,95%CI: 0.04-2.73).For cardiovascular diseases,the coadministration therapy had no significant effect on reducing the incidence of these events when compared with monotherapy(For primary clinical endpoints,P = 0.12,OR = 0.61,95%CI: 0.33-1.14); for secondary clinical endpoints,P = 0.13,OR = 0.66,95%CI: 0.38-1.14).For adverse events happened during the follow-up,both the incidence of hepatic-related(alanine aminotransferase and/or aspartate aminotransferase of patients were ≥ 3 times of upper limit of normal)(P = 0.38,OR = 0.55,95%CI: 0.15-2.06) and muscular-related(myopathy and/or creatine phosphokinase ≥ 3 times of upper limit of normal) adverse events(P = 0.10,OR = 1.62,95%CI: 0.91-2.86) had no significant difference between these two therapies.CONCLUSION: The results showed statins-fibrates combination therapy was more effective on lipid modification and well tolerated but there was no significant effect on preventing cardiovascular diseases.     

Aggressive lipid lowering does not improve endothelial function in type 2 diabetes: the Diabetes Atorvastatin Lipid Intervention (DALI) Study: a randomized,double-blind,placebo-controlled trial

OBJECTIVE: Endothelial dysfunction is considered an important early marker of atherosclerosis and cardiovascular risk and is currently used as a surrogate end point for cardiovascular risk in clinical trials. Type 2 diabetic patients show a characteristic dyslipidemia. Aggressive lipid lowering might be an effective method to improve endothelial function in these patients. RESEARCH DESIGN AND METHODS: A randomized, double-blind, placebo-controlled trial was completed to study the effect of 30 weeks' administration of atorvastatin 10 mg and 80 mg on endothelial function, as assessed by B-mode ultrasound of the brachial artery, in 133 patients with type 2 diabetes without a history of cardiovascular disease. RESULTS: Patients with diabetes and diabetic dyslipidemia had considerable endothelium-dependent and endothelium-independent dysfunction; mean flow-mediated vasodilation (SD) was 3.16% (3.56), and mean response on sublingual nitroglycerin was 6.58% (6.04). Despite substantial lowering of all atherogenic lipid parameters, no improvement of endothelium-dependent vasodilatation was found (P > 0.8). CONCLUSIONS: We observed considerable baseline endothelium-dependent and endothelium-independent dysfunction in patients with diabetes and diabetic dyslipidemia without a history of cardiovascular disease. Aggressive lipid lowering by administration of atorvastatin, resulting in substantial improvement of the lipid profile, did not reverse endothelial dysfunction.     

Future directions in lipid therapies

Cholesterol management to reduce the burden of cardiovascular disease is a major public health concern. Despite widespread recognition of lipid abnormalities as cardiovascular risk factors, significant cardiovascular event reductions with cholesterol-lowering therapies, and dissemination of treatment guidelines, most high-risk patients are not at target lipid levels. In addition to lifestyle changes, four major drug classes are available to modify lipid levels: fibrates, niacin, resins, and statins. High efficacy and tolerability in clinical trials make statins the most widely prescribed of these agents. Newer, more potent members of this class and novel formulations of niacin and resins may provide more effective therapy for dyslipidemia with fewer side effects. Several agents in development (cholesterolabsorption inhibitors and ACAT inhibitors) exploit mechanisms of action complementary to those of current treatments and combined with statins may produce greater improvements in lipid profiles than are now possible. These innovations should enable a greater number of patients to achieve more aggressive cholesterol goals, thereby reducing the risk of cardiovascular events.     

Management of hypertriglyceridemia

Hypertriglyceridemia is associated with an increased risk of cardiovascular events and acute pancreatitis. Along with lowering low-density lipoprotein cholesterol levels and raising high-density lipoprotein cholesterol levels, lowering triglyceride levels in high-risk patients (e.g., those with cardiovascular disease or diabetes) has been associated with decreased cardiovascular morbidity and mortality. Although the management of mixed dyslipidemia is controversial, treatment should focus primarily on lowering low-density lipoprotein cholesterol levels. Secondary goals should include lowering non-high-density lipoprotein cholesterol levels (calculated by subtracting high-density lipoprotein cholesterol from total cholesterol). If serum triglyceride levels are high, lowering these levels can be effective at reaching non-high-density lipoprotein cholesterol goals. Initially, patients with hypertriglyceridemia should be counseled about therapeutic lifestyle changes (e.g., healthy diet, regular exercise, tobacco-use cessation). Patients also should be screened for metabolic syndrome and other acquired or secondary causes. Patients with borderline-high serum triglyceride levels (i.e., 150 to 199 mg per dL [1.70 to 2.25 mmol per L]) and high serum triglyceride levels (i.e., 200 to 499 mg per dL [2.26 to 5.64 mmol per L]) require an overall cardiac risk assessment. Treatment of very high triglyceride levels (i.e., 500 mg per dL [5.65 mmol per L] or higher) is aimed at reducing the risk of acute pancreatitis. Statins, fibrates, niacin, and fish oil (alone or in various combinations) are effective when pharmacotherapy is indicated.     

Diabetes and cardiovascular diseases

Diabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetic people have cardiovascular disease (CVD) risk factors comparable to those of nondiabetics who have had a myocardial infarction or stroke. Physiologic changes in diabetic hypertensive people include endothelial dysfunction, altered platelet activity, and microalbuminuria, all of which may increase coronary heart disease risk. Hyperglycemia and dyslipidemia have been shown to effect physiologic changes in the vasculature; therefore, establishing normoglycemia, reducing cholesterol levels, and controlling blood pressure are the primary and initial goals in the management of diabetic hypertensive patients. The atherosclerotic risk is greatest in poorly controlled patients, possibly because of associated hypercholesterolemia and hypertriglyceridemia. Aggressive management of risk factors such as hypertension, dyslipidemia, and platelet dysfunction in diabetics has been shown to reduce morbidity and mortality in prospective randomized controlled clinical trials. In this article we review the impact of diabetes mellitus on cardiovascular morbidity and mortality.     

Dyslipidemia in type 2 diabetes

Type 2 diabetes mellitus is associated with a cluster of lipid abnormalities:elevated plasma triglycerides, reduced high-density lipoprotein cholesterol, and smaller and denser low-density lipoproteins,which have been associated with an increased risk of cardiovascular disease. Insulin resistance may contribute to dyslipidemia associated with type 2 diabetes by increasing hepatic secretion of large,triglyceride-rich very low-density lipoprotein particles and by impairing the clearance of lipoprotein particles from plasma. Lifestyle interventions may be effective in improving the diabetic dyslipidemia syndrome. For patients who do not respond to lifestyle changes, pharmacologic therapies (lipid-lowering medications and anti-diabetic agents) are available. Clinical trials demonstrate that the use of such pharmaceutics to treat diabetic dyslipidemia concomitantly reduces the risk of coronary artery disease.