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Between 2001 and 2007, treatments for type 2 diabetes have increased and therapeutic choices have improved. However glycemic control remains insufficient. Cardiovascular risk control has widely increased. Statins, hypertensive and antithrombotic treatments are more often prescribed. Blood pressure and LDL cholesterol levels have decreased whatever age. However, progress remains possible, especially regarding blood pressure control. Obesity has increased between 2001 and 2007 to reach 41% whereas the frequency of dietetic visits has decreased. Insulin therapy (more than obesity) determines the frequency of dietetic visits: dietetic care happens too late. Important improvements of the quality of follow-up are observed. However, fundus exams and more specifically albuminuria measurement remain insufficiently performed and their progression is too slow, as well as the podiatric examination. Only 10% of people with type 2 diabetes have an endocrinology visit, which has been stable between 2001 and 2007. Information expectations of people with type 2 diabetes are strong, especially for diet. Education demand is lower but more important for people who have already benefited. This improvement of medical care leads to an increase in the cost of reimbursements. The consequences of diabetes, more than the disease itself, alter the quality of life., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

International guidelines from the Task Force of European and other Societies on Coronary Prevention and national guidelines from the Belgian Lipid Club recently emphasized the potential interest of adequate management of patients with even moderate hypercholesterolaemia. However, current criteria for the reimbursement of lipid-lowering drugs in Belgium do not allow to follow these guidelines. A solution should be urgently found in order to bridge the gap and permit practitioners, after diet failure, to effectively prescribe lipid-lowering agents in patients who should benefit in priority of such a treatment. It is certainly the case in secondary prevention as well as, in high risk individuals, in primary prevention, i.e. in situations where these drugs have provided enough evidence of their efficacy with an acceptable cost-benefit ratio.

Atorvastatin is a second generation synthetic statin, introduced in Belgium in May 1998. Its mechanism of action is similar to that of the other statins, i.e. the inhibition of HMG Co-A reductase, the key enzyme in cholesterol synthesis, which leads to the increase of LDL receptors. The prolonged half-life (20-30 H) of atorvastatin and its active metabolites, induces a prolonged inhibition of HMG Co-A reductase and a reduction of hepatitic apo B production. The biological efficacy of atorvastatin is high: 41 to 61% lowering of LDL depending of the dose. Atorvastatin is indicated in primary hypercholesterolemia, mixed hyperlipidemia and homozygous familial hypercholesterolemia. If necessary, a resin or even a fibrate may be added. The safety profile is good. The most common adverse effects are gastro-intestinal and transient. Liver tests or muscle enzymes are rarely modified. If clinical proof of reduction of CV morbidity and mortality in primary and secondary prevention is obtained, atorvastatin shall represent a major step forward in the treatment of hypercholesterolemia.

There appears to be a continuum between the cardiovascular risk and the level of blood cholesterol, which hinders the definition of normal values, intervention threshold and therapeutic goals. The more and more convincing evidences provided by the "Evidence-Based Medicine" should be confronted to the pharmaco-economical constraints in order to first focus the essential of the efforts and resources on the target population with the highest risk. Unfortunately, the therapeutic strategy concerns a rather high percentage of the population of industrialized countries.

The demonstration that stains reduce the risk of cardiovascular diseases, in both secondary and primary prevention trials, led to the recent publication of sophisticated pharmaco-economical studies. A lot of factors may influence the cost-effectiveness ratio of the pharmacological intervention, especially the mode of calculation of various costs, the initial level of cardiovascular risk of the patients and the medico-economical particularities of each country. What so ever, available studies appear to justify the use of statins in secondary prevention, i.e. in coronary patients, even those with only a moderate hypercholesterolaemia, and, in primary prevention, i.e in hypercholesterolaemia individuals with obvious high risk of cardiovascular disease.