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Defying Dangers of Diabetic Dyslipidemia

Apr 21 | 3:30 PM

Dyslipidemia is common in diabetes and there is substantial evidence that decreasing cholesterol improves cardiovascular outcomes, even in patients with seemingly normal lipid profiles. There is an association between atherosclerotic cardiovascular disease and serum cholesterol and triglyceride levels in both type 1 and type 2 diabetes. High triglyceride levels and low high-density lipoprotein (HDL) cholesterol are hallmarks of type 2 diabetic dyslipidemia. Join us LIVE on Medflix as we further explore this topic with renowned endocrinologist and diabetologist, Dr. Ganapathi Bantwal.

[Music] [Music] uh for this session on defying dangers of that diabetic dyslipidemia we have with us he's a proficient and expert endocrinologist uh practicing in bangalore uh sir completed his mbps and md uh from michael medical college in bangalore and then he went on to pursue his dm uh and dmv in endocrinology from pgi chandigarh uh sir has published many papers in both national and international um journals and he is currently the professor and head of endocrinology with st john's medical college and hospital bangalore thank you thank you thank you netflix for giving me this opportunity so in the next maybe say 30 minutes i will speak on [Music] the management of dyslipidemia why is it important that we should manage aggressively the dyslipidemia now as you know diabetes is associated with the market increase in the risk of coronary heart disease by around two to four fold and there is a three to seven fold increase in mortality from coronary heart disease and the strongest predictor of the risk so that is a link between cardiovascular events and dyslipidemia if you see the causes of death in people with diabetes ischemic heart disease contributes around 40 percent so people with diabetes die because of cardiovascular disease other heart disease is around 15 to 18 percent diabetes per se around 13 14 cancers around 14 percent stroke may be around 10 to 12 percent infections and other conditions now this was one of the famous study uh as early as in 1998 by stephen hafner he told patients with diabetes without mi have a worse outcome than a non-diabetic with an mi so you can see here the green one is non-diabetic the first one is non-diabetic no events the next one the green one here is actually is the one with the mi and the next one is the red one which is the one diabetes without an mi and you can see their mortality is actually worse than a non-diabetic with an mi and finally if you have a diabetic with an mi of course it has the burst outcomes so this was so that's the reason we should always tell diabetes is a coronary risk equivalent but then it has been criticized now they say yeah it becomes a coronary risk events maybe after seven to eight years of diabetes now what is the reason for this increased in [Music] even so one diabetes increases the risk of coronary plaque disruption and thrombosis there's an increase in platelet aggregation fibrinogen one milligram factor factor eight factor seven and there is you can also see there's an increase in pi one decrease in the tissue plasminogen activator decreases pgi too there's an increased sympathetic tone there's an increased black formation but then this has a uh what you call the plaque is more weak and it gets disrupted and can lead to equi-coronal syndromes what about diabetes and mortality rates in india see if you see overall mortality patients without diabetes versus patients with diabetes so naturally you can see it's around three and a half fold increase in mortality in patients with diabetes if you see the cardiovascular causes once again it is double in patients with diabetes and renal causes it's almost four times the reason coming to mortality from chd is in indians versus others so you can see we are the yellowish orange ones wherever you take you compare them in men or in women you compare with the other [Music] ethnic groups likes in canada we are almost double them similarly england singapore south africa so you compare with anybody whether it's men or women you continue to have a worse mortality in indians versus others now how is cd in diabetes different one it's more frequent it's more extensive it has a multi-vessel involvement and then it's distant disease it's more difficult to revascularize many of them present with silent ischemia or mi younger patients are involved there's an increased mortality and more importantly they have a worse outcomes despite revascularization and there is an increased risk stenosis after primary cutaneous angioplasties even with the stents so who estimates that dyslipidemia contributes to more than 50 percent of the cases of cst so lipids contribute more than 50 percent of coronary heart disease and then the next one is blood pressure and then others include the dietary factors physical inactivity smoking all these things all of them low hdl high ldl drag lasers all of them contribute to csd risk in fact ldl the relative risk of a major recovery events is around 4.3 volts compared to that of a low hdl and a increase in triglycerides so what are the characteristic features this is a study done by gupta also what they found here was elevated triglycerides is one component seen in up to say 30 to 36 percent raised ldlc was seen in 56 to 65 percent low hdl women's a bit surprising normally estrogens increase the hdl but then you find here low hdl is seen more in women than in men 86.5 versus 79.2 percent and elevated triglycerides 50 and 47 percent respectively in women and men coming to the prevalence of dislipidum in the indian population so there have been various studies so telling that many of them have more triglycerides some having less than uh hdl so it's a mixture but then what is important is majority have high triglycerides low hdl and increase in small dense ldl coming to some studies this is a study done from beginner so what they found here was lipid abnormalities were very common in type 2 diabetes and it has a great influence on coronary artery disease and peripheral vascular disease another study from kerala glycemic status and prevalence of comorbid conditions among people with diabetes in kerala ldl more than 100 were seen in up to 90 percent and serum triglycerides more than 150 was seen in up to 38 percent in the study population another study so done in tamil nadu there's a high prevalence of diabetes and cardiovascular risk factors associated with urbanization so if you just see the marked ones cholesterol more than 200 so you can see in chennai it was around 25 percent kanchipuram it's semi urban so it's around 15.4 and panruth is a village so there you can see it's around 9.7 percent triglycerides more than 150 30 percent in chennai 28 in kanchipuram 21.7 in pandroti cholesterol less than 40 27 percent in chennai kanchipuram 31 and panruti 41.1 this is a little bit surprising because normally we think in villages and all they do more physical activity but then you can see here low hdl is actually lesser so what are the components of diabetic dyslipidemia so number one you have high triglycerides normal ldl cholesterol relatively normal earlier cholesterol but then they are elevated small dense particles and a low hdl so you have low hdl high triglycerides relatively normal ldl cholesterol levels but then these cholesterol actually have they are actually small dense which are more atherogenic and they have a risk of developing coronary heart disease so lipoprotein changes in type 2 diabetes so trigger rich lipoproteins there's an increased particle number increased postprandial concentration and triglycerides enriched and cholesterol increased particles ldl once again you have an increased particle number they are small and dense more arthritis these are all atrogenic hdl decreased particle number and now because of diabetes what's happening is the effectivity actually comes down so we always used to tell that hdl is good but then it can change its uh physiology quickly also if there is an inflammation they don't become that protective they in fact lose that what is the pathogenesis of dyslipidemia and type 2 diabetes so you have insulin resistance what is the action of insulin lipogenesis so when you have insulin resistance there is lipolysis so from the fat so you get a lot of free fatty acids because of lipolysis because of the insulin resistance what does it do it goes to the liver in the liver what happens so in the liver there is increased synthesis of bldl chylomicrons come from food the liver produces vldl chylomicrons contains increased triglycerides vidl also contains increased triglycerides so the increased free fatty acids will bind with the apob which is present in the liver and it produces what is known as vldl now vldl will get released from the liver into the circulation where it is acted upon by the lipoprotein lipase so what happens because of this action uh the trial is right from the vldl will go to the hdl and cholesterol ester from the hdl will go to the vldl now because of this so triglyceride enriched hdl is acted upon by hepatic lipase you require normal amount of hepatic lipase but here hepatic lipase is hyperactive so what happens because of this activity the apo a1 component which is present in hdl gets out in the goes out in front through the kidneys into the urine so and the hdl is lost so that's the reason you always find when you have a hydro exotics you have a low hdl so this is the mechanism of action hyperactivation of the hepatic lipase loss of foam gets lost in the urine hdl is gone now this can also the bl the triglycerides from the vldl can also go to the ldl this triglycerides enriched ldl is known as small dense ldl which is also known as the deadly uh lipid and the cholesterol ester from the ldl can go to the vldl and once again that is also a little bit anthrogenic so we call this as the deadly one which is small dense ldl the hdl which is a good and the ugly one is the tg how do you manage this so ldl lowering we have statins heterostatins suma statin rosuvastatin as it may be bile acid resins fish oils and then now we have the pcsk9 inhibitors which is allergy map and evaluate and the new one which has not had come to india shortly it will be coming which is known as bemidvionic acid how to increase hdl and triglyceride lowering fibroids can be given and nicotinic acid can be given now what are the recommendations in lipid management so in adults not taking statin a screening lipid profile is reasonable in patients with diabetes at the time of diagnosis add the initial medical evaluation and every five years or more frequently if indicated obtain a repeat profile at initiation of statin therapy and periodically thereafter so once you put them on a statin you must check after four to twelve weeks to know the adequacy of therapy to improve lipid profile in patients with diabetes i mean we recommend lifestyle modification focusing on weight loss reduction in saturated fat what does a saturated fat do it increases ldl cholesterol so you reduce that what does a trans fat do so you always find that it should be zero a trans fat increases such ldl and it reduces hdl also lower the cholesterol intake increase of omega-3 fatty acids fibers plants tanos and sterols increase physical activity the best way to increase physical i mean the the way to increase hdl is intense exercises improve hdl levels so coming to primary prevention for patients with diabetes is 40 to 75 years without atherosclerotic cardiovascular disease use moderate intensity statin therapy in addition to lifestyle therapy i'll tell you what is moderate what is high intensity later on for patients with diabetes age 20 to 39 with additional atherosclerotic cardiovascular disease risk factors it may be reasonable to initiate statin therapy in addition to lifestyle therapy so in patients with diabetes at high risk especially those with multiple atherosclerotic cardiovascular disease risk factors or age 50 to 70 years it is reasonable to use high intensity stacking in patients with diabetes and 10-year atherosclerotic cardiovascular disease risk of 20 or higher in addition to statins you can add acetaminophen to maximally tolerated statin therapy to reduce ldl cholesterol levels by 50 percent or more so this last thing addition of became actually from what is known as the improved trial that is improved reduction of outcomes vital inefficacy international trial this was an rct in 18 000 patients it compared the addition of acetaminophen to simmer starting therapy versus simmer starting alone these patients were more than 50 years of age had experienced a recent acute coronary syndrome and were treated for an average of six years so the addition of exeter mayweather led to a six point four percent relative risk reduction a two percent absolute reduction in major adverse cardiovascular events with the degree of benefit being directly proportional to the change in ldl cholesterol which was 70 in the statin group on an average and 54 in the combination group and in the subgroup analysis patients with diabetes twenty-seven percent of the participants the combination of moderate intensities semester in 40 milligram and as it may be 10 milligram showed a significant reduction of major adverse cardiovascular events with an absolute risk reduction of five percent so that it was two now it's absolute risk reduction of five percent and a relative risk reduction of fourteen percent over statin therapy alone so this is the ada recommendation less than 40 years no risk factors don't give anything risk factors are present you give either moderate or high intensity now what do you mean by risk factors ldl more than 100 high blood pressure smoking overweight obesity family history of premature as cbd if he already has an ac very high intensity starting 40 to 75 even though he has no risk factors moderate intensity statin is required for others you put them on high intensity and if he has had a recent acs and the ldl is more than 50 you add an energy maybe more than 75 years no risk factors none you could still give moderate intensity risk factors are there moderate or high intensity and the same thing conditions applied that is ac is an ldl cholesterol more than 50 who cannot tolerate high dose moderate degree statins plus as it may be so how do you assess that 20 percent risk or 10 percent risk all those things then you have this what is known as a pooled cohort risk assessment equation it predicts a 10-year risk for first atmospheric cardiovascular disease event so you have gender age race you just have to download it from google you get it and calculate the thing if it is more than 20 high risk what do you mean by high risk it lowers ldl cholesterol by more than 50 example at restaurant and 40 to 80 milligrams were standing 20 to 40 milligram moderate intensity started lowers ldl by 30 to 50 percent less than 50 percent like a total standard 10 to 20 milligram resolution 5 to 10 milligrams simmer starting 20 to 40 para stand in 40 to 80 lower standing 40 milligram petabyte in 2 4 fluorescent 80 milligram so normally statings are given once daily we normally give it in the night that's because cholesterol synthesis happens in the night so in clinical practice providers we need to adjust intensity of statin therapy based on individual patient response to medication that's side effect tolerability ldl cholesterol levels so statins are the initial pharmacological treatment for lowering ldl cholesterol in patients with type 2 diabetes the benefits are mediated predominantly by lowering ldl cholesterol it lowers non-hdl cholesterol more than apob more intensive therapy is required to achieve target fob so we have a target for fob also we want it less than 85 and less than 75 adverse events gi upset muscle x especially dose related hepatotoxicity and myotoxicity so you have a lot of evidence for starting from various trials so you can see hope trial the forest trial the app fcap text cap scale lipid ascot lla cards uranus so many trials are a lot of evidence for uh effect of statins but then in spite of so much evidence the statin prescription you see in patients with type 2 diabetes so statin prescription in patients with diabetes range from 18.5 for primary prevention to 38.1 percent for secondary prevention where you should have given in all the hundred percent so we talked about ldl reduction now what about triglycerides so how do you manage triglycerides intensify lifestyle therapy optimize glycemic control especially if you have a tg more than 150 milligram a hdl cholesterol less than 40 in men and less than 15 women for patients with their fasting tgm levels more than 500 milligrams per deciliter evaluate for secondary courses and consider medical therapy to reduce the risk of pancreatitis so number one alcohol intake or the patient is on some drug hyzers can increase steroids can increase so there are many drugs which can increase these triglycers estrogens can increase severe hypertrophy more than 1000 may vary immediate pharmacological therapy like fibric acid derivatives or fish oil to reduce the risk of acute pancreatitis so in adults with moderate hypertrophydemia that is fasting or non-fasting tg between 175 to 499 clinicians should address and treat lifestyle factors that is obesity and metabolic syndrome secondary factors like diabetes chronic liver or kidney disease nephrotic syndrome hypothyroidism and medications that raise triglycerides in patients with atherosclerotic cardiovascular disease or other cardiovascular risk factors on statin whose ldl is controlled but the tg is increased so there the addition of icosapent ethyl can be considered to reduce the cardiovascular risk what do you do for low hdl low hdl is associated as i told you with elevated triglycerides it's the most frequent pattern of disliking in individuals with type 2 diabetes but then the evidence for the use of drugs that target this lipid fraction is substantially less robust than that for statin therapy so there was a study known as uh aim high therapy where they used uh niacin but then they didn't get any benefit similarly there was hbs thrive here also they did not get any benefit and finally nowadays we are not using any drug to increase the hdl and then we also had what is known as the ctp inhibitors so you had the anastasia these type of drugs which are ctp inhibitors they also have failed to show any dosatropia and an acid rapid dial cetera so these are the three drugs at least anaestheti did show some benefit uh there was a relative risk reduction of around 15 percent with that but this benefit was seen not because of its increase in hdl the hdl increased by around 129 in these trials uh it was because it they also reduced ldl cholesterol by around 15 to 17 percent and that was a mechanism by which it brought an improvement what about combination therapy starting plus acetaminophen i told you you can use it from the improved trial so acetaminophen with moderate intensity starting provide additional cv benefit over moderate intensity statin therapy alone you should consider this for a patient with acs recent acs and ldl more than 50 or in patients who cannot tolerate high intensity statins so the new drug is the pcsk9 inhibitors you can combine statins and the pcsk9 inhibitors as an adjective therapy for high risk for activity events who require additional lowering of ldl cholesterol or who require but are internal into high intensity statins then you can use pcsk9 inhibitors allergy map and evolution map so the average reduction in ldl ranges from 36 to 59 percent so meta analysis so there are studies the four year trial then you have odyssey trial so the rate of adversity means no significant difference between anti-pc pcs k9 antibodies and placebo the dose used for ibalakimab was 420 milligram monthly or 140 milligram every two weeks reduced ldl by 54.6 percent versus placebo and by around thirty six point three percent versus acid maybe uh it also increased hdl by around seven point six percent versus placebo and six point four percent versus as it might be so evaluab and alloy rocky map are safe well tolerated combination therapy starting in fibroids does not improve ascbd outcomes and generally not recommend it but then we do use sometimes when you want to use it consider it in patients with for men with both triglycerides more than 204 and hdl less than 34 so this group they found it was beneficial this is actually from the accord trial where they found in the subgroup analysis this group benefited so combination therapy statin in niacin hasn't demonstrated additional cv benefit over statin alone may raise the risk of stroke and is not recommended so summary of the recently published guidelines for dyslipidemia so aha acc establish a cvd use high intensity statin goal is 50 ldl reduction or ldl less than 70. second line consider hdmi and or replace with pcsk9 inhibitor uh so in the group where you have diabetes 40 to 75 and estimated a cvd more than 7.5 percent with cardiovascular risk with cardiovascular risk calculator or high risk features that is retinopathy ckd album urea increased lipoprotein use high intensity statin goal is the same in addition so that is you require a ldl reduction of more than 50 percent especially those have an ldl between 70 to 189 or a non hdl less than 130. you could add hdmi or bile acid sequence strength as a second line uh diabetes 40 to 75 ac video risk less than 7.5 percent with the cardiovascular risk calculator and no high risk features that is retinopathy ckd albuminuria elevated lipoprotein little a so in them you use moderate intensity statin that is ldl reduction 32 less than 50 percent for ldl less than 100 or non hdl less than 130 consider if they don't respond second line is use high intensity status diabetes less than 40 or more than 75 or ldl less than 70 consider statin therapy based on risk benefit ratio so to conclude dyslipidemia and diabetes used to be treated with statins with either moderate or high intensity statins depending on the associated a civilian risk factors hypertriglycemia used to be treated with aggressive glycemic control fish oils and if more than thousand milligrams per deciliter with fiber it's combination therapy with statins with as it may be used if the patient has recent ac and ldl more than 50 so also you could add a pcsk9 thank you for patient hearing for that wonderful session uh so we have a few questions so we start with the q a yeah sure uh so the recommendation is you must start actually aspirin if the patient cannot tolerate aspirin then you have to start clopidogrel we do start combination if the patient had a recent mi is say post pdca etc or a recent mi then you can actually use this combination therapy for at least two years let's go on to the next question okay so there is one question by sajak do you prefer pcsk9 inhibitors or conventional statin therapy clinic see now pcsk9 inhibitors are very expensive so we will actually prefer to use starting therapy we will use a high intensity startings now in spite of this high intensity stat in the patient continues to get another attack then we must bring down the ldl as low as possible which could be less than 150 or even 30 you can bring it down so that's a rational of using then we want to use it or if the patient is intolerant to a statin then we would like to use a pcsk9 inhibitor go ahead with your question yeah putting sir excellent discussion and practically accord everything uh my one point is uh is there any specific anti-diabetic drug which we can prepare keeping in mind that this slipping by apart like glitter zones have a favorable effect on the lipid profile uh that was one and second about this sarah glitters for the triglycerides yes so they do help even for that matter pyrolytism also because it has an action on the p bar alpha so something which is acting on the p power alpha can reduce triglycerides so you could use that but then the only drawback is that weight gain which can happen some people are not very comfortable with that so that's the problem star regulators are yes you could use it our gastroenterologist right left and right for uh non-alcoholic fatty liver disease uh so that's another benefit also with some effect on glycemia also marginal compared to that of paralytic zone where it is robust for glycemia because the moment you control glucose the triglycerides comes down so the most important factor for triglyceride control is glucose control and spite of that if it is not coming down yes then we use the fish oils then also we can use the fibroids also we can use it fibroids have another benefit that is in the long run it's going to help for the eye disease so in fact in australia it's been marketed only to prevent eye disease suppose you find somebody's having an eye problem whatever you do control is good is still getting some bleeding etc you put them on a vibrate but you must tell him it's not going to act today after an year or two he'll start to get the benefits of that so five bits are useful in that aspect first it was found in the field trial and then in the echo trial also they found this and one more thing is when you come combine a vibrate with a pheno with the paralytic zone you get what is known as a disappearing hdl syndrome you find that suddenly the hdls are becoming lower and lower and that's actually a idiosyncratic reaction and that's the reason this happens so disappearing hdl syndromes can happen very rarely we find i have had patients also hdl 11 12 and all we just stopped the vibrate and next time it's fine sir since you mentioned about the nafld and the use uh that's which is a frequent occurrence with the diabetes and which can ultimately also help contribute to the cardiovascular risk should we add vitamin e at what stage we should add vitamin e for the management of see vitamin e in the trials uh whenever you find an increase in ast alt so then you could actually add vitamin e but then long-term benefits we don't know but for pioneering we have histological benefit biopsy benefits are there so partly the zone we do have that benefit so given the choice between these two yeah we'll write left and right vitamin e whenever we find an increase in asd 80 so i do keep writing it foreign milligram twice sale we do write it but then how long that's a question uh of course it's vitamin e there's no harm in continuing so we do continuity so we can but the therapy for that is weight reduction of at least 10 percent right so one last question before i step off about the routine use of antioxidants by most of the practitioners does it really help or is there any evidence one of the pharma company told i see that you never write a tablet like these things you are the only guy who don't write that they told because i don't see any benefit as of now sir thank you so much thanks welcome thank you we have another question um yeah one is uh cholesterol over statins in lowering lipid statins are very powerful agents the reduction in ldl cholesterol is significant with statins compared to that of cholestyramine now cholesterol and one of the side effect is it can increase triglyceride levels so somebody has a combined disease there is dyslipidemia increase in ldl less than increase in triglycerides don't use a cholesterol so that's one drawback of cholestyramine and the reduction in ldl is around 17 percent whereas with statins it is around 40 percent also so that's another thing and secondly the preparations of cholesterol they're not very nice to eat so you'll have to make up how to make it more compatible or palatable you can say is you make it as a paste with you can add some orange i mean some flavor to that keep it in the fridge and use it the next day so overnight you have prepared it for the morning one and for the night one you prepare it in the morning so then it becomes more palatable and then when you're using that you have to be careful because it interferes with the absorption of other drugs and also that's another thing suppose somebody's on thyroxine there's an entero hepatic circulation which happens so it gets binded with that and so these things don't happen with that though it has other advantages somebody has taken excess doses of uh say thyroxine it'll help or the patient has hyperthyroidism the anti-hepatic circulation contributes to around 30 35 that's also helping them so you can slightly bring down the thyroid hormone levels sarah glitters are with statin and as it may be combination in a patient with high tg and ldl yeah you could use it not an issue you can use that combination uh with c rho so starting and as it may be predominantly brings down ldl cholesterol and for the high tg and in fact statin also have around thirty percent they can bring down reduction in privacy also plus the addition of uh sarah glitters will further help that so you could use there's no harm in using that which statin is very useful with less toxic effect see the hydrophilic statins have the less toxic compared with the hydrophobic ones like for example heterostatisostatin they are all hydrophilic so they produce less of this myocytis etc so how do you prevent these myocytis number one you can give them vitamin d because they have found that whenever you have had the vitamin d deficiency the pain increases hypothyroidism is another one if they have even subclinical hypothyroidism control it properly so that's another group where you get it so you see that these things are taken care and if you still gets pain then you actually reduce the dose try to give alternative therapy people have even tried what is known as a pulse therapy and they can't tolerate it at all so the pulse therapy is giving statin for around one month then give a break because it's usually after four to five weeks the pain starts they stop it after that it gets washed away restart once again so this is known as a pulse therapy for a starting and people have even tried what is known as tonic water or red yeast rice so reddish rice contains lower satin but when you eat with that you don't get the pain when you eat it separately you get it so for reasons not no okay so that's another way by which actually you can prevent the pains with that and finally many times we take azithromycin tablet they are the ones which can actually worsen the pains and all your patient is on the fluconazole so because of fungal infection we put them on that that can all precipitate these pains so there are a lot of drugs which can precipitate which we don't know and you must be aware of that we're starting to prefer are there any advantages of one starting over other ah see now simmer starting 80 milligram produces lot of myositis so it's not recommended so use it at 40 milligram if at all if you want to use it it's hydrophobic i told you side effects are more so nowadays we prefer at our statin or for that matter resource starting 40 milligram people have found that some renal things very rarely can happen so if you have a real problem etc don't use that much often okay what side effects do you frequently see with statins in your clinic i told you how to manage that lipoprotein literally if it is high what do you do normal circumstances we don't give anything because if we control ldl cholesterol that is enough but then in a patient you control this ldl it's low and still is getting a mi or he's getting an unstable angina once again in spite of all these things then we must give importance to lipoprotein little a so which are the drugs which can bring down one is niacin can bring it down pcsk9 inhibitors can bring it down what is the other importance of lipoprotein delay they contribute to 0.3 percent of the ldl for example somebody has a lipoprotein literally of around 100 0.3 is 30 milligrams is contributed so you are not only bringing say his ldl was 70 but actually his ldl is now 100 because lipoprotein little a is 100 so it contributes 0.3 percent to that so that means you have to be more aggressive in bringing down the statin to less than 70. so that's how it is alone when you want to suspect that you have to give importance to that is somebody is developing an iot disease so in them you start suspecting a lipoprotein lately disease is contributing so that's another place gem fibrozil for triglycerides should be started if triglycerides more than 1000 see now what happens is yeah you can either use gem fibrosis or you can use pheno fibrate phenothyroid is less toxic so that's the reason we prefer to use you know vibrant 145 milligrams we use it advantage of gem fibrozil is you can go higher dose you can go 1200 milligram also 300 milligram you can go up to 1012 200 milligram another advantage of gem fibrozil is in pregnancy with hypertriglycemia that is the patient is at risk of pancreatitis people have used stem fibrosis of course we start with fish oils up to four grams still no response then we add people have used gem fibrozil in this group of patients but then the risk of rhabdomyolysis along with the starting is more when you use gem fibrosis compared to that of phenol vibrate so okay there's a question on silent ischemia silent skin is diabetes don't get the pain no so that's the reason they develop an mi without the chest pain that's because of the autonomic neuropathy so not that all will have maybe around 15 to 20 percent can develop what is known as a silent m yeah could be genetic pre-boundaries could be there if anybody wants to come up on stage you can use the raised hand option on the right hand side and you can come up on stage to have a discussion with sir another question on a recommended diet for diabetic dyslexia okay so number one is if you if you have high triglycerides don't eat refined carbs refined carbs are food which are digested quickly white rice juices all these things avoid the most common cause of high triglycerides are orange juices we think it's all non-waste always non-veg and this that oil the soil know the most commonest cause of high triglycerides are juices so avoid that so that you must remember yeah the other diet is for ldl cholesterol what do you do i told you red meat so that is one which increases the total cholesterol dietary the red meat should be avoided and then trans fat i told you that is cookies the deep fried ones they increased ldl reduce hdl also so that's it so this is how you do and then physical activity now if you do a glycemic control ldl can come down by around 15 to 25 dry lizards can come down huge stop smoking the hdl can increase increase physical activity if you walk for around uh four miles that is 6.4 kilometers in 60 to 70 minutes the hdl increases by around 2 milligrams weight reduction also the hdl increases okay so ldl is 147 but hdl 36 yeah you can use a statin if the patient is diabetic but you must use it because that's high i told you know moderate intensity statin even without any risk factors you must but then this patient's ldl is high so you must use actually you do i told you that i put the guidelines thing so what does the recommendation say 42 75 no risk factors still you require a moderate intensity starting yes so uh so rightly told mahadev use of corn based toppings are that's actually fructose but then that's not good but the fruits which contain fructose they are good so the corn based syrups are not good okay side effects taking combination therapy of uh atonostatin pica granola and pheno fibrate uh [Music] same thing if you use a gem fibrozil risk of rhabdomyolysis is more but otherwise not so much with the pheno fibrillate as being diabetes inside of it the most important side effect for which we are worried is the gi erosions which happen so bleeding so that's the most important thing any precautions while giving starting in diabetic patients with alcohol intake not really but then alcohol can increase the triglyceride level so you must remember that say you may find that his triglyceride may be thousand that's because it's taken alcohol yeah there is one question uh oil recommended for cooking food so we say which is the best oil it's nothing like a single best oil we want the ratios to be good say sunflower with a groundnut oil [Music] sunflower with a mustard oil a vegetable oil so this combination is good rather than one because the mufa pufa ratios are not that we want it to be around four to six is to one if you take only say sunflower safflower oil it's around twenty is to one so that ratios are not built so that's why we take a combination missile uh hyperliberty big drug no we normally say continue to use it yeah drugs like pheno fibroids etc because the triglycerides were high yeah we can actually stop it because maybe he took some medication which increased it or he took a diet which increased the triglycerides now he's on a very good diet you can actually stop the hypo epidemic drug like not starting the fibroids statins the first thing before we start starting we tell them one statin always starting the dose may come down a little bit but you will always require that so the first question people ask is sir how long you must tell for a long time okay fish oil capsules really help yeah they do help actually you must use the proper dose at least 2 grams you have to use at four grams you can't sit near that person because they'll be burping fish oil smell okay i think you answered most of the questions if uh there are any more questions you can put it up in the comment section or you can use the raven feature to come up on stage omega-3 fatty acids effects here they reduce the triglycerides but then the uh the response to the what you call the cardiovascular risk factor benefits were seen only in that reduced trial where they use icosa and ethyl four grams was used so only in that trial they found the benefit of 25 percent risk reduction in the three-point maze mortality was c but there was one question made of russian familial okay so here the what's important is they do not produce cardiovascular risk because the triglyceride particles are bigger they don't stick to the vessel wall what we are considering them is pancreatitis risk of pancreatitis if they don't follow a proper diet so and they can also have a low hdl what it does is it further helps in plaque stabilization so these things will help when you use a height of statins 80 milligrams and then we want the ldl to be the as low as possible and when we say as low as possible even maybe though we say less than 70 it could be even lesser than that because they found that you can even bring it down below 50 also so that's also better and they have even found benefits up to even 30. many of my patients ask if it becomes 0 what will happen so at least up to 40 is really okay because when you're newborn the ldl level is around 40 so it is that what is the minimal amount of statin i mean ldl required is around 25 milligrams they did cultural studies in fibroblast put it at 25 they stopped taking the cholesterol so that's required for the cell membrane synthesis etc so after that it is not required software 25 is minimally required at dg500 vldl100 yeah you can actually use a statin because it will reduce the triglycer by around 35 percent you could use especially the patient as a family history of iot uh disease you could use it okay global is better than asking your thoughts on that the recommendation is aspirin first choice do not tolerate aspirin then you scrub adopted yeah there has been studies where they showed benefit like the kp trial etc but then the ada recommendation is use aspirin first aspen resistance yes then you go it okay i use copy doggle especially when they have gastritis etc with an aspirin that's a time i use a cloaked i think most of the questions have been answered um so thank you so much for this wonderful session and i'm sure our audience taken back a lot uh with them we hope to see you again on netflix soon and thank you once again sir

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Dr. Dr Venkatachalapathy Anur & 1445 others

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dr. Ganapathi Bantwal

Dr. Ganapathi Bantwal

Professor & Head, Endocrinology | St. John's Medical College & Hospital, Bangalore.

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dr. Ganapathi Bantwal

Dr. Ganapathi Bantwal

Professor & Head, Endocrinology | St. John's ...

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