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A 55-year-old woman with a history of type II diabetes mellitus (DM), hypertension, and obesity is seen in the clinic for general followup. Her current medications include metformin, lisinopril, aspirin, and citalopram. She reports well controlled fasting blood glucose values with AM fingersticks of approximately 100 mg/dL. Her blood pressure is controlled at 120/70 mm Hg. You order fasting lipids. Her laboratory studies show:
cholestrol210
ldl127
hdl 40
triglycerides250
Which of the following is the most appropriate medication at this time?
A. Garlic
B. Gemfibrozil
C. Niacin
D. No medications are necessary at this time
E. Simvastatin
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E..........
lol althoigh garlic cardioprotective!
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The correct answer is E. Current guidelines (ATP III) consider DM to be a coronary heart disease (CHD) equivalent. In a patient with diabetes, therefore, the goal LDL is
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The correct answer is E. Current guidelines (ATP III) consider DM to be a coronary heart disease (CHD) equivalent. In a patient with diabetes, therefore, the goal LDL is
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The correct answer is E. Current guidelines (ATP III) consider DM to be a coronary heart disease (CHD) equivalent. In a patient with diabetes, therefore, the goal LDL is less then100 mg/dL. The most appropriate medication to achieve this goal in patients with diabetes is an HMG-CoA reductase inhibitor (simvastatin), as evidenced by the CARE trial and Heart Protection Study. Prescribing no medications (choice D) is therefore incorrect.
Choice A is incorrect because there are presently no good data supporting the use of garlic in the treatment of dyslipidemia.
Although the patient does have elevated triglycerides, the first goal of therapy should be treatment of the patient™s LDL cholesterol. Statins do have some effect on lowering triglycerides. After normalization of LDL is achieved, one may consider a second agent such as gemfibrozil (choice B) for treatment of hypertriglyceridemia. Obesity, excessive consumption of simple sugars and saturation fats, inactivity, alcohol consumption, and insulin resistance are commonly associated with hypertriglyceridemia.
Niacin (choice C) can help to increase HDL levels but is not an optimal agent for LDL reduction. At high doses it can increase HDL up to 30% but will decrease LDL by only approximately 5-10%. Its use often is limited by side effects such as flushing. It is also associated with insulin resistance and hyperglycemia, which make it a suboptimal choice for this patient.
