ADA 2010

Delegates at the ADA were reminded that there is limited data to support the addition of fibrates to statin therapy to enhance the benefit of further cholesterol lowering in people with diabetes.

However the results from the ACCORD study illustrate that in people with the most pronounced lipid abnormalities, there was a strong signal for benefit when fenofibrate therapy was combined with simvastatin.

Moving on to consideration of niacin therapy Dr John Guyton pointed out that increasing HDL levels may confer cardiovascular benefits. The conference was told that whilst many things (including alcohol) increase HDL concentrations, almost all outcome studies have shown that increasing HDL levels with Niacin therapy confer benefit through reduced end points. For instance the Coronary Drug Project and the Stockholm IHD study demonstrated reduced coronary event rates with HDL elevation through Niacin therapy. Other studies have shown reduced atherogenesis (eg. Lee et al. JACC 2009; 54: 1787-94)

Carotid Intimal thickness also benefits with Niacin when compared with Ezetimibe therapy in the ARBITER-6/HALTS (Taylor AJ. NEJM 2009; 361). It should be noted however that Carotid Intimal thickness may not directly equate to cerebrovascular event rates.

Dr Guyton briefly reviewed the data which suggest that “no-flush” Niacin does not raise HDL Cholesterol, and pointed out that the ability to cause flushing is linked to the mechanism through which Niacin benefits the lipid profile.

However, whilst flushing demonstrates tachyphylaxis and will usually resolve, the HDL elevation is durable. He pointed out that it can take 6 months for flushing to fully resolve, but that most patients tolerate this phenomenon as long as suitably warned in advance of starting Niacin.

In concluding delegates were reminded that in terms of consistency of cardiovascular benefit, Niacin is second only to the statins. It was also pointed out that Niacin is the most effective HDL raising agent in use today, and that recent advances may help to reduce flushing in the future.