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Monday, September 08, 2003
Dumaguing: Zocor improves diabetes control
By Dr. Vic Dumaguing
THE 18th Federation Internationale du Diabete Congress held on August 22-29 in Paris came up with disturbing statistics. Presently, there are 194 million diabetics in the world and will rise to an estimated 333 million by 2025 representing an increase of 72 percent.
This epidemic rise in diabetes portends a rapid and fearsome increase also in cardiovascular disease (CVD) and coronary heart disease (CHD), which are the leading causes of morbidity (illness) and mortality (death) among diabetics. A more disturbing thought is that, the explosion of diabetes and its complications is occurring in both developed and developing Third World countries.
The precise link between diabetes and coronary heart disease is not yet fully understood but it is clearly multi-factorial. Thus, the approach to management of the diabetic state would also be multi-factorial.
Lifestyle changes lie at the heart of all cardiovascular prevention, with exercise and diet therapy contributing to a significant improvement in blood sugar control owing to increased sensitivity of the receptors to insulin.
However, it has been shown that although tight blood sugar control seems to mitigate or prevent microvascular complications of diabetes, the ravages of macrovascular diseases (as in atherosclerosis) appear to be refractory to treatment of blood sugar alone.
Overwhelming clinical experience argues for more vigorous lipid and blood pressure lowering therapy than is currently practiced. In other words, a more aggressive and comprehensive management of the diabetic state is in order.
Dr. Peter Libby, chief of Cardiology Division of the Brigham and Women's Hospital, in Boston, Massachusetts reiterated the US ATP-III guideline which consider diabetes a coronary risk equivalent in assessing need for lipid-modifying drug treatment.
The diabetic dyslipidemia encompasses hypertriglyceridemia (elevated trigylicerides), low HDL and increased small dense LDL particle size, but not necessarily grossly elevated LDL-cholesterol levels.
Trigylicerides, also called triacylglycerol or neutral fat are the body's major energy store, particularly inadipose tissues. TGs, for short, are produced by the esterification of glycerol with three fatty acids.
Hormone-sensitive lipase catalyzes the breakdown of TG, resulting to release of fatty acids into the blood. LDL is the major cholesterol-rich lipoprotein carrying approximately 70 percent of blood cholesterol. It is the "bad cholesterol" because it serves to carry cholesterol to peripheral cells, thus contribute significantly to their eventual deposition on the walls of blood vessels leading to atherosclerosis.
High-density lipoproteins (HDL) are the smallest of the lipoprotein series. HDL transport 20-30 percent of blood cholesterol. HDL is the "good cholesterol because of its role as a "scavenger," picking up droplets of cholesterol in the blood, bringing them to the liver, in the so-called reverse cholesterol transport.
Dr. Libby stated "statin therapy consistently reduces cardiovascular events, including myocardial infraction and stroke in diabetic patients in both primary prevention and secondary prevention in large-scale clinical trials."
The Heart protection Study is one of those landmark clinical trails. The HPS assessed the effects of Simvastatin (Zocor) and anti-oxidant vitamin supplementation in patients 40-80 years age range. Of the 20,536 patients enrolled in the study, 5,963 were diabetics. The participants were randomly allocated Zocor 40mg daily or matching placebo (inert pill) for 5 years.
Results showed a highly significant reduction of about one quarter in the first event or having first-time major coronary events, strokes and revascularizations in the Simvastatin group.
There was also further reduction in the rate of subsequent events during the scheduled treatment period. After making allowance for non-compliance, actual use of this regimen probably reduced these rates by about 33 percent.
Statins or vestatins are lipid-lowering medicines which exert their effects by inhibiting the enzyme Hydroxy methylglutaryl Coenzyme A reductase, a key enzyme in the rate-limiting and first committed step in cholesterol synthesis.
In the heart protection study, Zocor reduced LDL-C by 48 percent and increased the good cholesterol HDL by 13 percent. Controlling glucose and lowering lipids in patients with diabetes improves the overall cardiovascular risk of the patients.
Zocor is the Simvastatin used in the Heart Protection Study. It is available in 10, 20, 40 and 80 mg tablets. By the way, Zocor is now available at very popular prices.
(September 8, 2003 issue)
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