Management of dyslipidaemia

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Dyslipidaemia in diabetes – an approach to therapeutic intervention

Diabetes mellitus is a metabolic and cardiovascular disease and although the diagnosis is confirmed on blood glucose levels and anti-diabetic treatment is usually aimed at reducing glucose levels, the major contributor to mortality is, in fact, cardiovascular disease and in particular, coronary artery disease. This article discusses the difference between the lipid profiles of type 1 and type 2 diabetes and gives practical guidelines for pharmacological and lifestyle interventions to reduce cardiovascular mortality and hospitalisations.South African Family Practice Vol. 48 (10) 2006: pp. 42-4

The paradox of diabetes, obesity and cardiovascular risk

Weight loss to reduce cardiovascular risk is encouraged in both healthy overweight individuals and those at high cardiovascular risk, including patients with diabetes. However, a large body of studies suggest that, in comparison to overweight and even obese subjects, cardiovascular events may be more common among patients who lose weight or who fall into lower body mass index categories. In contrast, other studies confirm the traditional concept that weight loss and maintenance of a healthy body weight is not only associated with improvement in cardiovascular risk factors, such as blood pressure, lipid profile and blood glucose control, but also with a reduction in cardiovascular morbidity and mortality. Possible reasons for the difference in outcomes between these two groups of studies include differences in study design, bias and statistics, the health status of the study participants and differential treatment afforded to different patient groups. This article reviews studies supporting both pointsof view and describes potential explanations for the observed differences in outcomes according to body weight

The half-yellow man

Keywords: diffuse normolipaemic planar xanthomatosis, DNPX, lipids, liporotein metabolism, monoclonal gammopathy of unknown significance, MGU

Pituitary apoplexy masquerading as meningitis

Pituitary apoplexy is an uncommon condition and medical emergency that classically presents with abrupt onset of severe headache, nausea, fever, impaired level of consciousness, visual disturbances and a variable degree of ocular paresis. The constellation of signs, symptoms and cerebrospinal fluid findings in keeping with meningitis is considered a rare presentation of pituitary apoplexy and often leads to a misdiagnosis of infectious meningoencephalitis. We present the case of a 52 year old male admitted with a diabetic ketoacidosis who subsequently developed a severe headache with features of meningism. Haematological tests revealed an elevated white cell count and C-reactive protein, and lumbar puncture demonstrated a marked neutrophilic pleocytosis and elevated protein. Ceftriaxone was commenced for the presumptive diagnosis of bacterial meningitis, but resulted in no improvement in the patient’s condition and so imaging studies were performed which revealed the presence of an incidental pituitary macroadenoma with intra lesional haemorrhage, thus providing the diagnosis of pituitary apoplexy. The patient recovered with conservative management consisting of hormonal replacement therapy and continues to follow up at our facility.Keywords: apoplexy, endocrinology, neurosurgery, panhypopituitarism, pituitar

The implementation of guidelines in a South African population with type 2 diabetes

Objective: The aim of this study was to identify the treatment gaps that pertain to risk factors in South African patients with type 2 diabetes mellitus, using national treatment guidelines.Design: Cross-sectional study.Setting and subjects: The study consisted of 666 patients with type 2 diabetes mellitus, attending a diabetes clinic at the Charlotte Maxeke Johannesburg Academic Hospital.Outcome measures: Using a public sector database, retrospective data were obtained on the treatment of type 2 diabetes mellitus participants. Patients were randomly selected on the basis of established type 2 diabetes mellitus diagnosis, and if they were receiving oral hypoglycaemic and/or insulin therapy. Age, gender, race, blood pressure, haemoglobin A1c (HbA1c) and fasting lipids were captured and measured. The history of patients’ previous coronary artery disease, strokes, nephropathy, neuropathy and retinopathy was recorded.Results: The mean age of the patients was 63 years [standard deviation (SD) 11.9], 55% of whom were females. The HbA1c was 8.8% (SD 2.5). 26.2% of patients attained HbA1c levels of < 7%. Of the total patients, 45.8% met a < 130/80 mmHg blood pressure target, and 53.8% a low-density lipoprotein (LDL) cholesterol of < 2.5 mmol/l. Only 7.5% obtained the combined target for HbA1c , blood pressure and LDL cholesterol.Conclusion: Traditionally, type 2 diabetes mellitus treatment has centred on correcting blood glucose levels. Yet, as many as 80% of people with type 2 diabetes mellitus die from some form of cardiovascular disease  (CVD). Many trials have demonstrated the benefits of targeting CVD risk factors (HbA1c, blood pressure and lipids) in patients with type 2 diabetes mellitus. Despite the wealth of evidence, our data suggest that significant undertreatment of risk factors in patients with type 2 diabetes mellitus remains.Keywords: diabetes mellitus, risk factors, targets, managemen

The Achievement of Glycaemic, Blood Pressure and LDL Cholesterol Targets in Patients with Type 2 Diabetes Attending a South African Tertiary Hospital Outpatient Clinic

Objectives: To determine differences in the control of multiple diabetes control parameters in a select group of subjects with type 2 diabetes (T2DM) after a four-year follow-up period.Design: Cross-sectional study.Setting and subjects: The initial 2009 study population consisted of 666 T2DM patients of whom only 261 (39.2%) were audited at the Charlotte Maxeke Johannesburg Academic Hospital. Outcome measures: Using a public sector database, retrospective data were obtained on the treatment of participants with T2DM attending a tertiary care setting and a descriptive analysis was done.Results: The mean age was 64 (SD 10.6) years, women represented 55% of the cohort and the mean duration of diabetes was 16 years (range 2–40 years) in 2013. Fewer patients achieved an HbA1c goal (of < 7%) in 2013 (15.5%) compared with 2009 (25.4%), whilst an additional 13.7% and 25.0% of the 261 patients reached blood pressure targets (< 140/80 mmHg) and LDL-C targets ( < 2.5 mmol/L), respectively.Conclusion: Overall, more patients in the study reached blood pressure and LDL-C targets but there were difficulties in achieving optimal glycaemic levels over the four-year period. This study highlights the complexities of managing risk factors in T2DM, especially glucose control.Keywords: Diabetes Mellitus, Management, Risk Factors, Target

South African dyslipidaemia guideline consensus statement

The European Society of Cardiology together with the European Atherosclerosis Society published updated dyslipidaemia guidelines in 2011. SA Heart and the Lipid and Atherosclerosis Society of Southern Africa officially adopt these guidelines. This statement adapts aspects of the guidelines to the South African situation. Using the updated Framingham risk charts, interventional strategies are based according to the cardiovascular risk score and low-density lipoprotein cholesterol (LDL-C) levels. The Framingham risk score refers to the 10-year risk of any cardiovascular event, and includes four categories of risk. Treatment targets are those of the European guidelines. The LDL-C goal is 1.8mmol/l for the very high-risk group (>30%), 2.5mmol/l for the high-risk group (15 - 30%), and 3mmol/l for those below 15% risk. Intensive management of dyslipidaemia in South Africa will significantly reduce the cardiovascular disease health burden

South African Dyslipidaemia Guideline Consensus Statement: A joint statement from the South African Heart Association (SA Heart) and the Lipid and Atherosclerosis Society of Southern Africa (LASSA)

The European Society of Cardiology together with the European Atherosclerosis Society published updated dyslipidaemia guidelines in 2011. SA Heart and the Lipid and Atherosclerosis Society of Southern Africa officially adopt these guidelines. This statement adapts aspects of the guidelines to the South African situation. Using the updated Framingham risk charts, interventional strategies are based according to the cardiovascular risk score and low-density lipoprotein cholesterol (LDL-C) levels. The Framingham risk score refers to the 10-year risk of any cardiovascular event, and includes four categories of risk. Treatment targets are those of the European guidelines. The LDL-C goal is 1.8 mmol/l for the very high-risk group (>30%), 2.5 mmol/l for the high-risk group (15 - 30%), and 3 mmol/l for those below 15% risk. Intensive management of dyslipidaemia in South Africa will significantly reduce the cardiovascular disease health burden