Origin and therapy for hypertriglyceridaemia in type 2 diabetes

Table 1 Clinical categorisation of hypertriglyceridaemia according to guidelines based on fasting triglyceride concentrations

Ref.	Yearpublished	Triglyceride categories	Triglyceride concentration (mmol/L)
National institutes of Health[31]	2001	Normal	1.7
		Borderline high	1.7-2.3
		High	2.3-5.6
		Very high	> 5.6
Rydén et al[33]	2011	Desirable	< 1.7
		Elevated	1.7-5.5
		Very high	5.5-25.0
		Extremely high	> 25.0
Berglund et al[34]	2012	Normal	< 1.7
		Mild	1.7-2.3
		Moderately high	2.3-11.2
		Severely high	11.2-22.4
		Very severely high	> 22.4
Hegele et al[37]	2013	Normal	< 2.0
		Mild-to-moderate	2.0-10.0
		Severe	> 10.0

Table 2 Clinical guide for the assessment and treatment of hypertriglyceridaemia in type 2 diabetes

Steps
1	Obtain fasting lipid profile
2	Classify LDL-cholesterol concentration (primary target of therapy)
	< 2.60 mmol/L – optimal
	2.60-3.39 mmol/L – above optimal
	3.40-4.14 mmol/L – borderline high
	4.15-4.90 mmol/L – high
	> 4.90 mmol/L – very high
	Establish therapy:
	LDL-cholesterol > 2.60 mmol/L – initiate dietary and lifestyle modifications
	LDL-cholesterol > 3.40 mmol/L – consider pharmacotherapy simultaneously with dietary and lifestyle modifications
3	Identify presence of atherosclerotic disease
	Clinical coronary heart disease
	Symptomatic carotid artery disease
	Peripheral artery disease
4	Assess:
	Glycaemic control
	Obesity
	Dietary intake (e.g., Fructose, simple sugars, caloric intake)
	Physical activity
	Determine presence of other risk factors:
	Smoking
	Hypertension
	Family history of premature coronary heart disease (i.e,. in first- degree relative, male < 55 years, female < 65 years)
	Low HDL-cholesterol, < 1.0 mmol/L
5	Order of treatment considerations:
	Improve glycaemia (dietary and lifestyle modifications)
	Treat secondary risk factors
	Statins
	Fibrates
	n-3 fatty acids/niacin
6	Treat elevated triglyceride if triglyceride concentrations are > 2.30 mmol/L after LDL-cholesterol concentration target of < 2.60 mmol/L is reached Target non-HDL cholesterol (< 3.40 mmol/L) Triglyceride > 2.30 mmol/L – intensify LDL-lowering therapy or add fibrate Triglyceride > 5.60 mmol/L – very low-fat diet (< 15% of calories from fat), weight management, physical activity and add fibrate

Adapted from the NCEP ATP III guidelines[31]. LDL: Low density lipoprotein; HDL: High density lipoprotein.

Table 3 Recommended treatment targets for diabetic dyslipidaemia

		NCEP ATP III[31]	ADA[30]	NVDPA[128]	European Guidelines[33]
LDL-cholesterol (mmol/L)	Very high risk	< 1.8	< 1.8	< 2.0	< 1.8
	High risk	< 2.6	< 2.6	< 2.0	< 2.5
Triglycerides (mmol/L)			< 1.7	< 2.0	< 1.7
HDL-cholesterol (mmol/L)	Male		> 1.0	≥ 1.0	> 1.0
	Female		> 1.3	≥ 1.0	> 1.2
Non-HDL cholesterol (mmol/L)	Very high risk	< 2.6	< 2.6	< 2.5	< 2.6
	High risk	< 3.4	< 3.4	< 2.5	< 3.3
ApoB (g/L)	Very high risk		< 0.8		< 0.8
	High risk		< 0.9		< 1.0

NCEP ATP III: Third Report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation and treatment of high blood cholesterol in adults (Adult treatment panel III); ADA: American diabetes association; NVDPA: National vascular disease prevention alliance of australia; LDL: Low density lipoprotein; HDL: High density lipoprotein.