Test Your Knowledge

John S. is a 63-year-old white male with significant abdominal obesity, type 2 diabetes, hypertension, and dyslipidemia as well. On the basis of an exercise stress test, John was recently diagnosed with silent ischemia. John’s current medications include metformin, a DPP-4 inhibitor, an ACE inhibitor/HCTZ agent, a calcium channel blocker, a high-dose statin, and ezetimibe. John’s relevant physical exam and laboratory findings are as follows:

BMI: 34.8 kg/m2
Blood pressure: 140/86 mm Hg
HbA1C: 7.2%
Total cholesterol: 150 mg/dL
LDL-C: 79 mg/dL
HDL-C: 42 mg/dL
Triglycerides: 145 mg/dL
non-HDL-C: 118 mg/dL
eGFR: 65 mL/min/1.73 m2
ACR: 100 mg albumin/g creatinine

Question: In consideration of John’s overall risks and guideline recommendations, which of the following options would you recommend to manage his type 2 diabetes?

A. Stop the DPP-4 inhibitor due to risk of heart failure. It will not be necessary to add another antihyperglycemic agent as long as John’s HbA1C remains less than 8%.
B. Encourage John with practical advice for improving his lifestyle, and continue with the current regimen.
C. Add basal insulin to John’s regimen and titrate the dose until his HbA1C is less than 7%.
D. Recommend starting a GLP-1 receptor agonist or an SGLT2 inhibitor to improve John’s glucose control.

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John S. is a 63-year-old white man with significant abdominal obesity, type 2 diabetes, hypertension, and dyslipidemia as well. On the basis of an exercise stress test, John was recently diagnosed with silent ischemia. John’s current medications include metformin, a DPP-4 inhibitor, an ACE inhibitor/HCTZ agent, a calcium channel blocker, a high-dose statin, and ezetimibe. John’s relevant physical exam and laboratory findings are as follows:

BMI: 34.8 kg/m2
Blood pressure: 140/86 mm Hg
HbA1C: 7.2%
Total cholesterol: 150 mg/dL
LDL-C: 79 mg/dL
HDL-C: 42 mg/dL
Triglycerides: 145 mg/dL
non-HDL-C: 118 mg/dL
eGFR: 65 mL/min/1.73 m2
ACR: 100 mg albumin/g creatinine

Which statement best describes the evidence supporting cardiovascular benefits of the antihyperglycemic agents available to treat John’s type 2 diabetes?

A. Further glucose reduction using any available agent should have similar cardiovascular disease benefit.
B. Thiazolidinediones increase the risk of heart failure and myocardial infarction in patients with type 2 diabetes.
C. Two approved GLP-1 receptor agonists have been shown to reduce mortality in patients with type 2 diabetes and cardiovascular disease.
D. Both GLP-1 receptor agonists and SGLT2 inhibitors affect cardiovascular risk through the same physiologic mechanisms.

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Which of the following is a recognized strategy when considering diet and exercise in the management of hypertriglyceridemia?

A. Individuals should consume 45% of calories as fat, with saturated fat reduced to approximately 20% of calories.
B. Restricting simple carbohydrates and increasing dietary fiber are ineffective for lowering triglycerides.
C. Exercise has minimal impact on lowering triglyceride levels.
D. Progressive aerobic and toning exercise, weight loss, and dietary management can significantly lower triglyceride levels.

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Which of the following is accurate regarding the treatment and management of hypertriglyceridemia?

A. Pharmacologic therapy is typically initiated before lifestyle modifications in the treatment of primary and secondary dyslipidemia.
B. Patients can be treated before hypertriglyceridemia is confirmed.
C. Niacin raises LDL cholesterol levels.
D. High-potency statin monotherapy is recommended for severe or very severe hypertriglyceridemia.

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Which of the following is accurate regarding the diagnosis and workup of patients with hypertriglyceridemia?

A. The Endocrine Society recommends using nonfasting triglyceride levels over fasting triglyceride levels for the diagnosis of hypertriglyceridemia.
B. Type IV hyperlipidemia is characterized by abnormal elevations of VLDL, and triglyceride levels are almost always less than 1000 mg/dL; serum cholesterol levels are normal.
C. A standard lipid profile using the Friedewald equation to calculate the LDL cholesterol value is only useful if the triglyceride level is more than 400-500 mg/dL.
D. he Endocrine Society recommends routinely measuring lipoprotein particle heterogeneity in patients with hypertriglyceridemia.

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Which of the following is true regarding the presentation and diagnosis of hypertriglyceridemia?

A. Hypertriglyceridemia is usually asymptomatic until triglyceride levels are greater than 500-900 mg/dL.
B. When triglycerides are elevated, blood glucose and A1c should be checked to rule out uncontrolled diabetes.
C. Second-degree relatives should be screened for hyperlipidemia.
D. The use of oral contraceptives, beta-blockers, and thiazide diuretics have been linked to decreased plasma triglyceride and very low-density lipoprotein (VLDL) levels.

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Which of the following is an important consideration when giving a post-meal insulin bolus with the aid of CGM-based trend arrows dosing in order to avoid hypoglycemia in persons using multiple daily insulin therapy?

A. Always consider using the full dose suggested by calculations based on the correction factor and target glucose.
B. Give ~50% of the calculated insulin dose (using the correction factor and target glucose) to adjust for active insulin (insulin on board).
C. Use ~25% of the calculated insulin dose (using the correction factor and target glucose) to adjust for active insulin (insulin on board).
D. Use 75% of the calculated insulin dose (using the correction factor and target glucose) to adjust for active insulin (insulin on board).
E. Another insulin dose should never be given after eating.

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Which of the following is true regarding the epidemiology of hypertriglyceridemia?

A. Triglyceride levels increase gradually in women until about age 50 years and then decline slightly.
B. Triglyceride levels in men continue to increase with age.
C. Mild hypertriglyceridemia (triglyceride level greater than 150 mg/dL) is slightly more prevalent in women beginning at age 30 years and in men at the age of 60 years.
D. Non-Hispanic black persons often have lower triglyceride levels than white persons.

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Which of the following is true regarding the presentation and diagnosis of hypertriglyceridemia?

A. Hypertriglyceridemia is usually asymptomatic until triglyceride levels are greater than 500-900 mg/dL.
B. When triglycerides are elevated, blood glucose and A1c should be checked to rule out uncontrolled diabetes.
C. Second-degree relatives should be screened for hyperlipidemia.
D. The use of oral contraceptives, beta-blockers, and thiazide diuretics have been linked to decreased plasma triglyceride and very low-density lipoprotein (VLDL) levels.

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Hypertriglyceridemia, a condition in which triglyceride levels are elevated, is a common disorder in the United States. It is often caused or exacerbated by untreated diabetes mellitus, obesity, and sedentary habits, and is a risk factor for coronary artery disease. Additional risk factors for hypertriglyceridemia include diet, stress, physical inactivity, and smoking. More than 25% of US adults have elevated triglycerides.

Which of the following is true regarding the epidemiology of hypertriglyceridemia?

A. Triglyceride levels increase gradually in women until about age 50 years and then decline slightly.
B. Triglyceride levels in men continue to increase with age.
C. Mild hypertriglyceridemia (triglyceride level > 150 mg/dL) is slightly more prevalent in women beginning at age 30 years and in men starting at age 60 years.
D. People who are African American often have lower triglyceride levels than people who are Caucasian.

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