Time to consider an Asian guideline for management of dyslipidemia?

Atherosclerotic vascular disease is the major cause of morbidity and mortality in patients with diabetes mellitus. It is well established that patients with diabetes tend to show atherogenic lipid profiles related to insufficient insulin action, including the appearance of small dense low-density lipoprotein (LDL), an increase in the amount of remnant lipoproteins, and a decrease in and functional disability of high-density lipoproteins (HDL). Indeed, patients with type 2 diabetes have been shown to benefit from lipid-lowering therapy in terms of prevention of cardiovascular events, as well as the decline in renal function. Cholesterol-lowering therapy reduces the relative risk ratio of cardiovascular events to a similar degree in diabetic and nondiabetic subjects. However, the actual benefit is expected to be greater in patients with diabetes, as they show a higher absolute risk, resulting in a lower number of patients that need to be treated. Therefore, it is important to properly manage not only blood sugar and blood pressure, but also lipids, from the earliest stage of disease as possible. Lipid treatment guidelines for both diabetic and non-diabetic subjects have been established in the USA and Europe, primarily based on results from epidemiological studies and clinical trials. In many Asian countries, management of dyslipidemia is carried out according to these guidelines in daily clinical practice. The Japan Atherosclerosis Society published original guidelines for the prevention of atherosclerotic cardiovascular diseases, including those for patients with diabetes as well, based on results from both Japanese and Western studies, taking into account that the risk for developing coronary artery disease is lower in Japanese compared with Western populations. The Western and Japanese guidelines are similar in their basic concepts. For example, both recommend lifestyle modification focusing on adequate diet, increased physical activity, smoking cessation and weight loss in obese patients as the first-line therapy. A reduction in excessive calorie and saturated fat intake, increase of omega-3 fatty acids and viscous fiber in the diet are recommended in every guideline. Pharmacological therapy, primarily with statins, is generally used when the lipid management goals cannot be achieved by lifestyle modification alone. In contrast, the idea of therapeutic targets, management goal level and the way to use lipid-lowering drugs are not identical between the Western and Japanese guidelines (Table 1). In the Western guidelines, diabetes is considered to indicate a high risk for cardiovascular disease (CVD) practically equivalent to that of patients with overt CVD. Therefore, it is recommended to reduce the LDL cholesterol (LDL-C) level below 100 mg ⁄dL (2.6 mmol ⁄L) in type 2 diabetes patients without evident CVD