ACCORD Lipid trial: New research into atherogenic dyslipidemia in type 2 diabetes

Mar 15 2010

Cardiovascular risk can be reduced by an additional 31 percent in type 2 diabetes patients with atherogenic dyslipidemia, the common combination of elevated triglycerides (TG, 204 mg/dL or 2.3 mmol/L or higher) and low levels of high-density lipoprotein cholesterol (HDL-C, 34 mg/dL or 0.88 mmol/L or lower). This is achieved by adding fenofibrate to simvastatin. Only 20 of these patients need to be treated for 5 years to prevent one cardiovascular event.

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In the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Lipid trial, published on-line in the New England Journal of Medicine, the group with atherogenic dyslipidemia had 70 percent more cardiovascular events (cardiovascular death, heart attacks and strokes) than patients without. In fact, the risk associated with atherogenic dyslipidemia was comparable to that in people with previous cardiovascular disease (17.3 percent versus 18.1 percent).

Professor Jean-Charles Fruchart, President of the Residual Risk Reduction Initiative (R3i), an independent Swiss academic foundation, said: 'For the last two years, the R3i has focused on the hypothesis that residual cardiovascular risk in statin-treated patients is associated with atherogenic dyslipidemia. ACCORD Lipid confirms both the hypothesis and the value of adding fenofibrate to a statin to reduce this high residual cardiovascular risk. This is consistent with current guidelines from the American Diabetes Association and the National Cholesterol Education Program Adult Treatment Panel III.'

The benefit of fenofibrate was only seen in the pre-specified group of diabetic patients with atherogenic dyslipidemia and not in the total study population. 'While patients with atherogenic dyslipidemia only represented 17 percent of the ACCORD Lipid population, in clinical practice the size of the problem is significantly greater. We are now quantifying this in the R3i-funded REsiduAl risk Lipids and Standard Therapies (REALIST) study which is being conducted at Harvard Medical School and over 20 well-known academic centers worldwide,' said Professor Frank Sacks of Harvard Medical School, Boston, USA and Vice-President of the R3i.

In ACCORD Lipid, fenofibrate also reduced micro- and macro-albuminuria, markers of diabetic renal disease. This is consistent with results from earlier clinical trials. 'Diabetic nephropathy is a major management issue. Therefore it is important knowledge that fenofibrate provides benefit to these patients,' said Professor Michel Hermans of Cliniques Universitaires Saint-Luc, Brussels, Belgium and General Secretary of the R3i.

The study also confirmed that adding fenofibrate to simvastatin did not result in any excess risk of myopathy (muscle problems), venous thrombosis or pancreatitis. In fact, there were fewer all-cause and cardiovascular deaths in fenofibrate-treated patients than in patients treated with simvastatin alone.

R3i leads new research into atherogenic dyslipidemia in type 2 diabetes

Atherogenic dyslipidemia is common and the prevalence is markedly increasing as a result of the global epidemic of type 2 diabetes, obesity and metabolic syndrome. So, in the U.S. about half of the high- risk patients beginning statin therapy may require additional treatment to lower their triglycerides and/or to raise their HDL-C.

The R3i is responding to this critically important clinical problem. 'Given the magnitude of the global epidemic of type 2 diabetes - especially in developing regions - targeting atherogenic dyslipidemia is crucial. As the only independent global research foundation focusing on this issue, the R3i is urgently developing recommendations for evidence-based strategies to reduce residual vascular risk. Currently, we are conducting the first world-wide epidemiological study, REALIST, to establish the prevalence of atherogenic dyslipidemia and consequent residual risk of cardiovascular events. Now, as a result of ACCORD Lipid, we will also initiate a meta-analysis of the atherogenic dyslipidemic subgroups of patients (high TG and/or low HDL-C) in previous fibrate studies,' said Professor Fruchart.