Implications of rosiglitazone and pioglitazone on cardiovascular risk in patients with type 2 diabetes mellitus.

Clinical data suggest that thiazolidinediones--specifically, rosiglitazone and pioglitazone--may improve cardiovascular risk factors through multiple mechanisms. Low insulin sensitivity has been described as an independent risk factor for coronary artery disease and cerebrovascular disease. Patients with insulin resistance often have several known risk factors, such as obesity, dyslipidemia, and hypertension. Other emerging risk factors may be prevalent in patients with insulin resistance, such as hyperinsulinemia, elevated C-reactive protein, elevated plasminogen activator inhibitor levels, and small, dense, low-density lipoproteins. The only available drug class that primarily targets insulin resistance is the thiazolidinediones. These drugs have shown efficacy in affecting surrogate markers of cardiovascular risk in patients with diabetes mellitus. Alterations in these risk factors are likely due to their effects on improving insulin sensitivity and/or glycemic control. Trials to assess whether thiazolidinediones actually reduce cardiovascular outcomes are continuing.

Lipid levels and use of lipid-lowering drugs for patients in pharmacist-managed lipid clinics versus usual care in 2 VA Medical Centers.

OBJECTIVE: The objective of this study was to assess the effectiveness of pharmacist- managed dyslipidemia clinics at 2 Veterans Affairs medical centers since the release of the 2001 National Cholesterol Education Panel Adult Treatment Panel III (NCEP ATP III) guideline compared with the usual care (UC) provided by other health care professionals in the same setting. METHODS: Analysis was performed through retrospective chart review of patients with a diagnosis of dyslipidemia who received care in either the Amarillo or Lubbock, Texas, pharmacist-managed lipid clinics (LCs) or UC from a primary care physician. Data from medical charts were abstracted for dates of service from July 2001 to December 2003 for 115 patients selected randomly from LC rolls matched with 115 patients with a diagnosis of dyslipidemia selected randomly from UC. All patients had to have had at least 3 visits with the LC or 3 visits in UC with a billing code of dyslipidemia; they were followed for at least 6 months after an initial visit in July 2001 or thereafter and were enrolled in the VA health care system for at least 1 year. Baseline lipid values were available for LC but not UC patients. Cholesterol target goals were determined according to NCEP ATP III guideline. RESULTS: After an average of 21.6 months of follow-up, the proportion of patients in the LC group that attained goal level increased from 45.2% at baseline to 82.6% for total cholesterol (TC) and from 36.5% at baseline to 64.3% for lowdensity lipoprotein cholesterol (LDL-C [P <0.001 for both comparisons]). There was an average 24.5 mg/dL absolute reduction (relative reduction, 19.4%) in LDL-C along with significant improvements in the other lipid levels (P <0.001 for TC and LDL-C, P = 0.007 for triglycerides [TGs]) with the exception of highdensity lipoprotein cholesterol (HDL-C), which declined from 40.0 mg/dL to 36.3 mg/dL (P <0.001). A total of 50 patients (43.5%) were on lipid-lowering pharmacotherapy at baseline versus 108 patients (93.9%) at follow-up. Compared with UC, LC patients were more likely to have achieved goal LDL-C (64.3% vs. 15.7% for UC, P <0.001) and TC (82.6% vs. 40.9%, P <0.001), but there was no difference in the proportion of patients at TG goal for LC (65.2%) compared with UC (52.2%, P = 0.061) or at HDL-C goal (23.5% for LC vs. 33.0% for UC, P = 0.143). A higher proportion of LC patients (93.9%) used lipid-lowering agents compared with UC patients (24.3%, P <0.001). Subanalysis of patients on a lipid-lowering agent found that a significantly higher proportion (85.2%) in the LC group were at goal total cholesterol compared with 60.7% for UC (P = 0.012) and at goal LDL-C (66.7% for LC vs. 39.3% for UC, P = 0.016). However, a lower proportion were at goal HDL-C for LC (21.3%) versus 42.9% for UC (P = 0.043). Overall, only 11 LC patients (9.6%) attained goal levels for all 4 serum lipid values by the end of follow-up versus 2 UC patients (1.7%, P = 0.019). CONCLUSIONS: Nearly two thirds of patients diagnosed with dyslipidemia and enrolled in a pharmacist-managed LC had LDL-C levels at or below NCEP ATP III target goal compared with 16% of dyslipidemia patients who received UC from their primary care provider. The pharmacist-managed LC patients were also twice as likely (83 vs. 41%) to have attained the TC target goal, but there was no difference between the 2 groups in the proportion of patients who attained either TG or HDL-C target goals. Only 9.6% of LC patients were at goal for all 4 individual lipid measures at the end of follow-up.

Delaying the onset of type 2 diabetes mellitus in patients with prediabetes.

The frequency of type 2 diabetes mellitus is increasing at an alarming rate. Prediabetes, also referred to as impaired glucose tolerance (IGT) and/or impaired fasting glucose, is a major risk factor for development of type 2 diabetes mellitus. In addition, IGT has been associated with an increased risk of cardiovascular disease and mortality. Several studies have measured the effects of various interventions in patients with IGT on the development of type 2 diabetes mellitus. Intensive lifestyle modifications through alterations in diet and improvement in exercise have delayed the development of type 2 diabetes mellitus by 58% in patients with IGT. Therapy with metformin, troglitazone, or acarbose also has reduced the progression of IGT to diabetes mellitus by 31%, 49% and 25%, respectively. The mechanisms by which lifestyle interventions and drugs reduce the progression may be through alterations in insulin sensitivity. The American Diabetes Association recommends screening for prediabetes in patients who are 45 years or older and those with a body mass index of 25 kg/m2 or greater who have additional diabetes mellitus risk factors. Pharmacists can promote awareness, counsel patients on intervention strategies to delay the onset of diabetes mellitus, and screen high-risk patients.