Lipids in Diabetes
My name is William Conway, M.D What matters to me is caring for you, listening to your successes and comforting you during difficulty. I am pleased when my patient stays with me for years, allowing us to share.
I am a general internist with as specialty in addiction medicine. I have been practicing in Tennessee since 2002, and in Nashville for a decade. . Through Nashville Concierge Medicine and Suboxone+PrimaryCare™, I care for patients who want medicine that feels personal — where we combine the science of prevention with the art of partnership.
I have cared for patients with diabetes for years. They are thoughtful people who make sensible choices for eating, checking their blood sugar four times a day, using their basal bolus insulin with sophistication. Yet, their cholesterol is still “too high.” I sense their frustration. I hear the question about “why does Dr, Conway pay so much attention to a LDL cholesterol?” For them, and for you, I hope this article provides understanding and hope.
Executive Summary of Treatment at Nashville Concierge Medicine.
- High LDL (“bad’) cholesterol raises the risk of heart attacks
- Having diabetes increases your risk of heart in comparison to a person without diabetes
- Statins are “gold” in treatment.
- We now have additional medications if statins are not enough
- Inflammation is the “fire in the vessels” which needs to be tamed
- Modern medicine is producing truly remarkable advances.
A Patient Speaks in Nashville
Yesterday, I was reviewing the lab of Susan, a charming, articulate, professional woman who works in a law firm. I have been her companion in struggle for ten years, diagnosing her diabetes, and beginning her on insulin. As we worked through the intricacies of insulin, I leaned her web. To dose her insulin, we had to discuss what she ate daily, what her daily stresses were like, and the often-inscrutable nature of her blood sugars. With such sophistication, I was surprised her frustration over her LDL cholesterol.
With my medical assistant present in the room, I touched her hand to reassure her, as I had done so often over the past years. “Susan, this is part of your biology. Your diabetes changes not only the way your body handles sugar, but also the way your body handles cholesterol. Do not blame yourself. This is not your fault. We want our treatments to protect you, not punish you.” Susan looked relieved. My medical assistant smiled.
Why Treating LDL is important for you
The silent threat that invisibly builds
In speaking with Susan, I reflect by thinking of all the patients who are ambivalent about their cholesterol. They have all thought that “ this is another pill Dr. Conway wants me to take every day. Is there no end to the medicine that she requests me to take?” I reply to her unspoken, but very real desire not to take another medicine every day. I reply to her unspoken, but very real fear that her body is not adequate. Susan, “ I understand your ambivalence. So much medicine, for so long, for no real discomfort. Please understand that the decisions we make today will help create your future. We want you to avoid a heart attack. Please stay with your statin. Most of my patients do beautifully, and if your muscles ever ache, we will find a gentler one together.”
Helping Susan is like all the rest of my patients I treat at Nashville Concierge Medicine. As her physician, I, Dr. Conway, wish to create a vibrant and alive future for her.
Statins remain the Foundation of Treatment
I love to discuss statins. Statins have been very well researched. Now, all of the powerful statins have become generic, making this truly remarkable medicine affordable to all. Statins have contributed to saving lives and reducing suffering
In diabetes, the benefit of Statins is profound. Multiple trials over many years in many different countries with literally thousands of patients have shown that lowering LDL cholesterol reduces major cardiovascular events by 25-50%.
Target LDL cholesterol <70 mg/dl in most patients
Target LDL cholesterol < 55 mg/dl in higher risk patients
The Lower the LDL cholesterol, the better.
So, to Susan I say, “ please take your statin. My patients rarely get muscle aches. If you do, then we will change your medicine”
If You Need more than a Statin
If Susan gets persistent muscle aches which last, then I have to consider other alternatives.
Ezetimide, or Xetia, is my first choice. It is well established. In my patients, it has been well tolerated. It is inexpensive. Ezetimide is my first choice if a statin does not do the job, or if a statin is not tolerated for any reason.
We have other choices if statins are not enough.
- PCSK9 inhibitors – injectable biologics, LDL ↓ 50–60 %, strong outcome data.
- Bempedoic acid – oral, LDL ↓ 20 %, benefit for statin-intolerant (CLEAR Outcomes).
- Icosapent ethyl (Vascepa) – targets triglycerides and inflammation (REDUCE-IT).
In my practice of Nashville Concierge Medicine, everyone is special. Everyone has a special biology, which is usually unpredictable. If Susan requires a medication beyond a statin, requiring the “high priced stuff”, then we carefully evaluate the benefits and cost, and the approach to getting the treatment
Understanding Inflammation
Inflammation is the fundamental way that the body heals itself from injury or disease. However, while inflammation fundamentally heals, inflammation which “goes wrong” can fundamentally hurt. We have a whole category of diseases, known as autoimmune diseases, in which inflammation “goes wrong” producing disease.
In some patients with diabetes, inflamation is a quiet fire driving the clogging of arteries, and abrupt presentation of heart attacks. In diabetes, calming inflammation means calming the fire before it harms
- Balancing sugar,
- Improving rest,
- Supporting the vessel wall with medicines like icosapent ethyl or GLP-1 receptor agonists.
Susan has an inquisitive mind. It is a joy for me to explain inflammation to Susan
Everything Matters in Diabetes
Susan is an inspiration to me. Compulsive, consistent, and always in control, Susan shows a quiet strength from a life lived in rhythm.
Susan protects her heart through quiet diligence- tiny choices, repeated faithfully every day.
- Blood sugar control. Every 1% drop in HgA1C reduces heart events by 15-20%
- Maintaining her blood pressure below 120/80 with medication and exercise protects the heart
- Taking her SGLT2 inhibitor and her GLP1-agonist protects her heart
- Living well with exercise, healthy eating and rest protect her heart.
Reflective Closing — The Future Is Bright
Healing begins with understanding, and understanding begins with listening. It is a joy to have Susan as a patient. I expect her to prosper. I hope she will live to 100 years strong, curious, and loved.
Susan has a potentially fatal disease. If she ignored her diabetes, her risk of premature suffering is high. If she has complications, her risk of shortened life is higher.
Susan has learned her lessons well. She mastered basal bolus insulin early, and continued its daily discipline. She began her statin, and continued it until muscle aches. We began an alternative to her statin. When the GLP1-agonists arrived, Susan begin
That’s the promise of modern concierge medicine in Nashville: partnership, prevention, and personal attention. I, Dr. Conway, am honored to have Susan as a patient.
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