Most everyone worries about their cholesterol these days. Even when you are relaxing watching a sports game on TV it seems like every other advertisement seems to mention heart disease and cholesterol levels and tells you which pills you should ask your doctor about to lower your cholesterol level. There is good reason for this. Cholesterol is a kind of fat that floats around in your blood and can become deposited in the lining of your arteries to increase your risk of getting heart attacks, and strokes, and other bad things. So in addition to eating a healthy diet and getting exercise it is important for many people with diabetes to take a drug that can lower the LDL cholesterol (often called the "bad cholesterol"). The most common, powerful and effective types of drug to lower LDL cholesterol and protect you from getting heart attacks and strokes are the statindrugs (like simvastatin [Zocor], atorvastatin [Lipitor] and others). Most people with diabetes who are over age 40 should consider taking a statin drug.
But there is another type of fat that floats around in our blood called triglycerides and that can sometimes cause problems, too. The normal range for triglycerides in your blood is less than 150 mg/dl (1.7 mmol/L). If the triglyceride level gets very high (above 500 mg/dl, or 5.6 mmol/L) it can cause a very dangerous inflammation of your pancreas (called pancreatitis) and so most doctors know that they should treat very high levels of triglycerides. But what if your triglyceride is just a bit higher than normal but not really high? Suppose your triglyceride level is between 150-350 mg/dl. Should you take drugs to bring that down into the normal range? Another part of the famous ACCORD trial looked at this question and came up with a very interesting results.
I have written about the ACCORD trial in several other posts in this blog. In this part of the ACCORD trial 5,518 people with type 2 diabetes (at an average age of 62), many of whom already had heart disease or two or more risk factors for heart disease were studied. These patients were already taking simvastatin, one of the powerful statin drugs to help lower their LDL cholesterol and protect them from having heart attacks and other bad cardiovascular events in the future. Many of these people also had triglyceride levels that were in the 150-350 mg/dl range. The ACCORD researchers wanted to know if outcomes would be even better if they added another type of drug called fenofibrate. Fenofibrate is a drug that can lower triglyceride levels. So half the subjects got fenofibrate added to their drug treatment while the other half got "dummy pills" (or placebos) that looked like the fenofibrate pills but didn't contain any active drug.
After almost five years of follow up the levels of triglyceride in the blood were quite a bit lower in the group who were taking fenofibrate than in the group taking the placebo pills. However, the number of bad cardiovascular events (like heart attacks and strokes, some of which were fatal) was notany lower in the subjects who took fenofibrate compared to those who took the dummy pills. In fact among women in the study the overall rate of bad events was higher(9.1%) in those taking the fenofibrate compared to those taking the placebos (6.6%)!
What lesson can we learn from this study? First of all it teaches us that focusing on an improvement in a lab test is much less important that focusing on outcomes that really matter to us (like preventing heart attacks,strokes and deaths). It also teaches us that sometimes the side effects of a drug cause more harm than the condition it is trying to treat. So if you have diabetes and are already taking a statin drug to get your LDL cholesterol under 100 mg/dl and if your triglycerides are only slightly above the upper end of the normal range then taking a drug like fenofibrate is not likely to protect you from heart attacks in the future and may even increase that risk, if you are a woman.
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