Patients with diabetes are often prescribed a combination of cholesterol medications. Different types of cholesterol drugs affect levels of fats in different ways:

• Statins. Considered a first line of treatment for most patients with high cholesterol (hypercholesterolemia), including those with diabetes. Statins block the production of specific enzymes used by the body to make cholesterol. Statins have been shown to reduce the risk of a first heart attack, as well as recurrent heart attacks in patients with known disease. They are particularly effective at lowering levels of LDL ("bad") cholesterol and, to a lesser degree, triglycerides. Though statins do increase levels of HDL ("good") cholesterol, they do not seem to increase those levels as well as other cholesterol drugs do.
  
  Routine use of statins in people with diabetes may provide an extra measure of defense against a first heart attack or stroke. People with diabetes have an increased risk of developing cardiovascular disease in general. The risk of stroke also might be decreased with use of statins. Some researchers have recommended statins to help prevent cardiovascular problems in diabetic patients who have normal levels of cholesterol.
  
  Some studies have shown that statins may benefit heart disease patients who also have mild kidney failure and that kidney transplant patients who receive statins have a lowered risk of heart-related death after the procedure. However, the U.S. Food and Drug Administration (FDA) reported in 2005 that kidney failure has been reported in patients taking statins, though it could not conclude that recommended doses of statins caused or worsened renal failure. Patients should ask their physician about the possible effects of statins on their risk of diabetic nephropathy and end-stage renal failure.
  
  

Contrary to earlier claims, statins do not offer protection against macular degeneration, an eye disease that can occur with advancing age. However, statins appear to help prevent cataracts, according to the Beaver Dam Eye Study, possibly because they may have antioxidant properties.

Research has suggested that statins have varying effects on different racial groups. Scientists have found that statins may be less effective for black Americans, perhaps because of genetic variations. The FDA has warned that Asian patients taking the statin rosuvastatin (Crestor) had twice the blood levels of the drug that white patients had, though the risk of rhabdomyolysis (a serious form of muscle damage) did not appear to be higher.

• Bile acid resins. Because the liver takes cholesterol out of the blood to make bile, bile acid resins (also known as bile acid sequestrants) prevent the recycling of bile acids in the intestine. As a result, the liver is forced to remove more cholesterol from the blood in order to manufacture more bile. Bile acid resins are usually taken in powder form or in a chewable bar. Many patients, however, have gastrointestinal discomfort with these drugs. Research has suggested that colesevelam might help lower glucose (blood sugar) in patients with type 2 diabetes.
  
  
• Nicotinic acid (niacin), a form of vitamin B3. In large doses, nicotinic acid is very effective in lowering triglyceride levels and raising levels of HDL (“good”) cholesterol. Nicotinic acid can also lower levels of LDL (“bad”) cholesterol, but not as effectively as other cholesterol drugs.

When taking niacin, patients are advised to slowly build up to the high doses needed to treat high cholesterol. Taking too much niacin too quickly can lead to intense side effects that include flushing, palpitations, nausea and, in extreme cases, liver toxicity (especially when taken in "rapid-release" form). Even with proper buildup, as many as 50 percent of patients find the side effects of this medication too difficult to tolerate. Nicotinic acid is available over the counter, but physicians prefer to prescribe the medication in time-release pills. Because of the potentially intense side effects, patients are advised not to begin taking niacin without the supervision of a physician.

• Fibrates (fibric acid derivatives). Fibric acid reduces the production of triglycerides and increases the rate at which they are removed from the bloodstream. Fibrates can significantly lower triglyceride levels and modestly increase HDL ("good") cholesterol levels in most patients, but they are less effective at reducing LDL ("bad") cholesterol levels. They are most commonly used in patients who have elevated triglycerides, usually in conjunction with low HDLs (many people with diabetes have this type of lipid profile). Simultaneous use of fibrates and statins should be carefully monitored.

Research reported by the American Heart Association has suggested that bezafibrate may prevent or delay the onset of diabetes in overweight patients with prediabetes and coronary artery disease.

• Cholesterol absorption inhibitors. Ezetimibe (Zetia) is the first of a newer class of drug that directly blocks cholesterol absorption in the small intestine (in contrast to bile acid resins, which bind with bile acid in the intestine). Ezetimibe is most commonly used in addition to statins, whereby up to an additional 25 percent reduction in LDLs is achieved. It can also be used as a single agent, but whether or not it will have the same protective effect as statins when used as a single agent is not yet known. Side effects have shown to be similar to that of placebo, and there is minimal increase in liver enzymes when used with statins.

Examples of these medications:

There are also combination drugs, such as Advicor (lovastatin and niacin), Vytorin (ezetimibe and simvastatin) and Caduet (atorvastatin and amlodipine, a calcium channel blocker used to lower high blood pressure).