MKSAP Quiz: Diabetes and hyperlipidemia
This month's quiz asks readers to treat hyperlipidemia in a 67-year-old man with a recent diagnosis of type 2 diabetes mellitus.
A 67-year-old man is evaluated following a recent diagnosis of type 2 diabetes mellitus. He is sedentary but is without cardiopulmonary symptoms. Family history is significant for myocardial infarction in his father at age 50 years and stroke in his mother at age 54 years. He takes no medications.
On physical examination, the patient is afebrile, and blood pressure is 144/96 mm Hg. BMI is 40.
Other than obesity, his physical examination is normal.
Laboratory studies show alanine aminotransferase 31 U/L, total cholesterol 203 mg/dL (5.26 mmol/L), LDL cholesterol 123 mg/dL (3.19 mmol/L), HDL cholesterol 40 mg/dL (1.04 mmol/L), serum creatinine 0.75 mg/dL (66.3 µmol/L), glucose 194 mg/dL (10.8 mmol/L), triglycerides 201 mg/dL (2.27 mmol/L), and HbA1c 6.7%. Electrocardiogram is normal. His 10-year atherosclerotic cardiovascular disease risk based on the Pooled Cohort Equations is 25%.
The patient is counseled on lifestyle changes to reduce cardiovascular risk, and management of his diabetes and hypertension is initiated with metformin and ramipril.
Which of the following is the most appropriate treatment of this patient's hyperlipidemia?
A. Gemfibrozil
B. High-intensity atorvastatin
C. Moderate-intensity simvastatin
D. No additional treatment
MKSAP Answer and Critique
The correct answer is B. High-intensity atorvastatin. This item is available to MKSAP 17 subscribers as item 45 in General Internal Medicine section. More information about MKSAP 17 is available online.
The most appropriate treatment for this patient is high-intensity statin therapy, such as with atorvastatin. Strong evidence indicates that statins are effective in both primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD). According to the American College of Cardiology/American Heart Association guidelines, this patient with diabetes and no clinical ASCVD meets the criteria for one of four patient groups that have been shown to benefit from the treatment of hyperlipidemia with statin therapy. For patients 40 to 75 years of age with diabetes mellitus and an LDL cholesterol level of 70 to 189 mg/dL (1.8-4.90 mmol/L), intensity of statin therapy is dictated by the estimated 10-year risk for ASCVD as determined by the Pooled Cohort Equations. High-intensity statin therapy (for example, atorvastatin, 40-80 mg/d, or rosuvastatin, 20-40 mg/d) is recommended for all patients with a 10-year ASCVD risk of 7.5% or higher, and moderate-intensity therapy is indicated for patients with a risk of less than 7.5%. This patient's 10-year ASCVD risk exceeds 7.5%; therefore, high-intensity therapy is recommended.
Significant reductions in cardiovascular events have not been clearly demonstrated with fibrate monotherapy, rendering gemfibrozil an inferior choice for this patient with elevated risk for clinical ASCVD. Fibrates are indicated for patients with triglyceride levels greater than 500 mg/dL (5.65 mmol/L), patients with hypertriglyceridemia-induced pancreatitis, and patients who have an inadequate response to statin therapy.
Moderate-intensity statin therapy (for example, simvastatin, 20-40 mg/d; atorvastatin, 10-20 mg/d; or rosuvastatin, 5-10 mg/d) is not appropriate for this patient with diabetes, elevated 10-year risk for ASCVD, other cardiovascular risk factors (family history of premature cardiovascular disease), and no contraindications to high-intensity therapy. Moderate-intensity statin therapy is an acceptable alternative to high-intensity therapy in patients who tolerate statins poorly or have risk factors for statin-associated adverse effects (impaired kidney or liver function, history of muscle disorders, use of drugs affecting statin metabolism [calcium channel blockers, fibrates, protease inhibitors, amiodarone, macrolide antibiotics], and age greater than 75 years). Because none of these factors are present in this patient, high-intensity statin therapy would be the optimal therapeutic approach given his risk profile.
Therapeutic lifestyle changes are a cornerstone of treatment for hyperlipidemia and should be encouraged in all patients; however, additional treatment with statins is indicated in this patient with an elevated 10-year risk of ASCVD and diabetes.
Key Point
- In adults 40 to 75 years of age with diabetes mellitus, an LDL cholesterol level of 70 to 189 mg/dL (1.8-4.90 mmol/L), and an estimated 10-year atherosclerotic cardiovascular disease risk of 7.5% or higher, high-intensity statin therapy is recommended.