Prevalence and treatment of low HDL cholesterol among primary care patients with type 2 diabetes: an unmet challenge for cardiovascular risk reduction.

OBJECTIVE Patients with diabetes remain at high risk for cardiovascular events despite aggressive blood pressure, LDL cholesterol, and blood glucose control. We identified prevalence and predictors of low HDL cholesterol, characterized current lipid therapy, and estimated the theoretical benefit of more effective HDL cholesterol-raising methods among patients with type 2 diabetes. RESEARCH DESIGN AND METHODS We analyzed a primary care-based population of patients with type 2 diabetes (n = 7,692) in 12 eastern Massachusetts outpatient practices. We grouped fibrates, niacins, and n-3 fatty acid preparations as nonstatin HDL cholesterol-raising medicines, and we used published studies to estimate the potential benefit of raising HDL cholesterol levels in this population. RESULTS Nearly half (49.5%) of patients had low HDL cholesterol (<40 mg/dl for men, <50 mg/dl for women). Low HDL cholesterol was independently associated with prevalent cardiovascular disease (CVD), younger age, and higher A1C levels. Nearly two-thirds of patients (63.0%) were prescribed a statin (67.6% of patients below the HDL cholesterol goal, 80.5% of patients with CVD). In contrast, only 7.9% of patients were prescribed a nonstatin HDL cholesterol-raising medication, including 16.4% of patients below the HDL cholesterol goal with CVD. Based on published studies, normalizing low HDL cholesterol in this primary care cohort would correspond to an estimated CVD mortality reduction of 42% in women and 23% in men. CONCLUSIONS Nearly half of the patients in this large primary care cohort had low HDL cholesterol levels. In contrast to frequent statin use, few patients were prescribed currently available medicines to raise HDL cholesterol. Low HDL cholesterol represents a highly prevalent and potentially modifiable risk factor for CVD prevention in type 2 diabetes.