MKSAP Quiz: Treating hyperlipidemia and type 2 diabetes
This month's quiz asks readers to evaluate a 56-year-old man who received a diagnosis of type 2 diabetes mellitus 6 months ago and is returning for follow up.
A 56-year-old man comes to the office for a follow-up evaluation. Since receiving a diagnosis of type 2 diabetes mellitus 6 months ago, he has been eating a low-fat, high-fiber, high-carbohydrate diet and walking for 20 minutes at night. The patient has never smoked and drinks no alcohol. He originally took metformin to treat his diabetes but stopped because of persistent diarrhea. Current medications are glyburide and ramipril.
On physical examination, temperature is 36.8 °C (98.2 °F), blood pressure is 129/76 mm Hg, pulse rate is 76/min, and respiration rate is 15/min; BMI is 22. Other physical examination findings are normal.
Laboratory studies show: alanine aminotransferase 102 units/L; aspartate aminotransferase 96 units/L; cholesterol: total 264 mg/dL (6.83 mmol/L), LDL 157 mg/dL (4.07 mmol/L), HDL 42 mg/dL (1.09 mmol/L); fasting glucose 196 mg/dL (10.9 mmol/L); hemoglobin A1c 9.8%; iron studies normal; triglycerides 437 mg/dL (4.94 mmol/L); hepatitis virus negative.
Bedtime neutral protamine Hagedorn (NPH) insulin is initiated.
Which of the following is the most appropriate treatment of his hyperlipidemia?
A. Begin a fibrate now
B. Begin a statin now
C. Begin a statin after results of liver chemistry studies normalize
D. Begin nicotinic acid (niacin) now
E. Begin either a fibrate or nicotinic acid after results of liver chemistry studies
normalize
MKSAP Answer and Critique
The correct answer is B. Begin a statin now. This item is available to MKSAP 16 subscribers as item 45 in the Endocrinology section. Information about MKSAP 16 is available online.
In addition to neutral protamine Hagedorn (NPH) insulin at bedtime, a statin should be added now to this patient's diabetes regimen. He has poorly controlled type 2 diabetes mellitus, and thus adding a bedtime basal insulin to his sulfonylurea is a reasonable step to improve his fasting plasma glucose level and hemoglobin A1c value. His liver chemistry studies show moderately elevated aminotransferase levels, but he has no other evidence of liver disease. This makes the diagnosis of nonalcoholic fatty liver disease most likely. In light of his diabetes and significant hypercholesterolemia, the addition of a statin is likely to be beneficial. Patients with nonalcoholic fatty liver disease are not necessarily at a higher risk of adverse outcomes from statin therapy than patients without the disease, and thus statins are a treatment option in these patients. In a study of 437 patients whose liver chemistry levels were up to three times the upper limit of normal, treatment with atorvastatin resulted in a threefold reduction in cardiovascular events (10% versus 30% in the nontreatment group) and a greater reduction in liver chemistry levels compared with patients not receiving a statin during 3 years of follow-up evaluation.
Fibrates are most effective for reducing the triglyceride level and have little impact on the LDL cholesterol level, the primary lipid target in this patient.
Starting the statin should not be delayed until after his glycemic control has improved or his liver chemistry tests normalize.
Nicotinic acid can lower the LDL cholesterol level and increase the HDL cholesterol level. Its use is typically limited by its adverse effects. Nicotinic acid can cause elevation of glucose and liver chemistry levels and may cause severe hepatocellular damage. Nicotinic acid would be relatively contraindicated in this patient with probable nonalcoholic fatty liver disease.
Key Point
- Statins are a viable treatment option in patients with diabetes mellitus, hyperlipidemia, and nonalcoholic fatty liver disease.