Unmet needs of diabetic patients.

Diabetes mellitus is a major risk factor for coronary heart disease. According to the National Cholesterol Education Program (NCEP) and Adult Treatment Panel III (ATPIII) recommendations, diabetes can be considered to be equivalent to coronary heart disease. In the United Kingdom Prospective Diabetes Study (UKPDS), low-density-lipoprotein cholesterol (LDL-C) is the most important risk factor for coronary heart disease in diabetes. A meta-analysis of 14 statin trials (which included 18,686 diabetic participants) showed that with an average 39 mg/dL reduction in LDL-C over 4.3 years, allcause mortality was decreased by 9% and major cardiovascular events by 21%. These results suggest that statins have become the most important medication for decreasing cardiovascular events in patients with diabetes, especially those who also suffer from coronary heart disease. The clinical practice recommendation from the American Diabetes Association suggests that statin therapy should be added to lifestyle therapy, regardless of baseline lipid levels, for diabetic patients with overt cardiovascular disease. The treatment target for LDL-C for such patients is <70 mg/dL. Clinical trial results indicate that patients with high triacylglycerol levels cannot be effectively treated with fibrates to reduce cardiovascular outcomes. In the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study, the use of fenofibrate did not significantly change the primary endpoint of nonfatal myocardial infarction or death related to coronary heart disease. Similarly, in the Action to Control CardiOvascular Risk in Diabetes (ACCORD) trial, the addition of fenofibrate to simvastatin vs. simvastatin plus placebo did not reduce the risk of cardiovascular events. Therefore, fibrate therapy was not strongly recommended as a clinical practice tool by the American Diabetes Association. Regarding antiplatelet therapy, the American Diabetes Association has recommended aspirin therapy (75e162 mg/d) as a primary strategy in those patients with type 1 or type 2 diabetes who are at increased cardiovascular risk (10-year risk >10%), and as a secondary prevention strategy in those with diabetes and a history of cardiovascular disease. Despite tremendous evidence supporting the efficacyof these evidence-based therapies, including statin and aspirin therapy, their utilization has been suboptimal in daily practice. For instance, in the recent CEPHEUS Pan-Asian survey (2012), the goal attainment for LDL-C was only 34.9% (70 mg/dL) in patients with a very high cardiovascular risk, which included