Mr. B is a 45 year old man
newly diagnosed with type 2 diabetes. He has a history of hypertension,
stopped smoking 3 months ago and a strong family history of coronary artery
disease. A lipid panel shows a HDL cholesterol of 31, triglycerides of 322 and
an LDL of 138mg/dl. While his glycemic control is less than optimal his HbA1c
is 7.8% he is adhering to a low fat diet and exercise plan. Which of the
following is the most appropriate intervention to manage his lipids:
As
LDL < 160mg/dl do nothing, and recheck in 1year.
Start
an HMG CoA reductase inhibitor.
Start
Niacin.
Start
Gemfibrozil.
Improve
his diabetes control.
Due
to the high prevalence of CAD in patients with diabetes the NCEP guidelines
recommend that patients with diabetes be screened annually and be treated
intensively like patients with known CAD. The target LDL should be less than
100mg/dl. The most appropriate agent to use in this scenario would be an HMG
CoA reductase inhibitor as it will lower the LDL increase the HDL slightly and
also slightly reduce the triglyceride level. Niacin can be considered however
it tends to worsen hyperglycemia. Gemfibrozil while having some beneficial
effect on the triglyceride and HDL levels will not exert sufficient reduction
in the LDL level and is usually used for an isolated hypertriglyceridemia.
Improving glycemic control may improve the triglyceride level but is unlikely
to bring his LDL into the target range.
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