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62 Year Old Male with High Cholesterol and Statin Intolerance

62 Year Old Male with High Cholesterol and Statin Intolerance. Case Category: Familial Combined Hyperlipidemia; Primary Prevention History of present illness: 62 year old male with high cholesterol, prior statin intolerance and family history of diabetes. Patient Information. Patient History.

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62 Year Old Male with High Cholesterol and Statin Intolerance

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  1. 62 Year Old Male with High Cholesterol and Statin Intolerance Case Category:Familial Combined Hyperlipidemia; Primary Prevention History of present illness: 62 year old male with high cholesterol, prior statin intolerance and family history of diabetes.

  2. Patient Information

  3. Patient History

  4. Current Medications

  5. Labs Worth Noting

  6. Questions to Consider • Question 1: Very abnormal lipids and several secondary causes. New hypothyroidism and diabetes. What is his willingness to accept pharmacologic therapy? Address any barriers to treatment. • Question 2: Diet, salt, alcohol, carb, sugar intake? • Question 3: Previous statin trials? Which statin and what dose? • Has vitamin D deficiency been ruled out as cause of myalgias and previous statin intolerance?

  7. Labs

  8. Labs

  9. Labs On no medications currently, oversynthesizing cholesterol in liver and candidate for statin, no evidence of hyperabsorption, previous intolerance to lipophilic statins (Simvastatin, Atorvastatin).

  10. Labs

  11. Labs

  12. NMR LipoProfile • Insert NMR LipoProfile 10122011 JB49 Insert

  13. Other Labs

  14. Initial Treatment & Management • Start Crestor 20 mg/day • Start Lovaza 1 g 1-4/day • Advise home blood pressure meter • Start Synthroid 50 mcg/day • Start Metformin ER 500 mg 2-3 tablets daily with slow titration as tolerated over the next few weeks • Start once daily injectable Liraglutide (Victoza) 6 mg/ml soln daily with gradual titration to 1.8 mg/ml • Advised low salt, low carb diet and daily exercise • Start Vitamin D3 5000 IU daily • Preventive care reminders with new diabetes diagnosis, ophthalmology, foot care, immunizations etc.

  15. Discussion

  16. Discussion

  17. Follow Up • Familial Combined Hyperlipidemia – Improved; Started Crestor 20 mg, Metformin 2000 mg/day, Victoza 1.2 and Lovaza 4/day; LDL-P dropped from 2732 to 1433; Apo B normalized from 152 to 59; Total cholesterol dropped from 248 to 110, LDL-C from 157 to 53, triglycerides from 170 to 84 and non-HDL from 207 to 80. HDL is still low. • Diabetes – Improved; HbA1c lowered to 7.5 from 9.0; weight loss of 16 lbs; Continue therapy. • Hypothyroidism – Improved; Increase Synthroid to 75 mg/day. • Vitamin D Deficiency – Improved; Vitamin D level has increased from 26 to 52; Consider increasing if low energy.

  18. Follow-Up Labs

  19. Follow-Up Labs

  20. Follow-Up Labs

  21. Follow-Up Labs

  22. Case Summary

  23. Clinical Pearls Untreated diabetes will significantly impact LDL–P, Apo B and other lipids. Most diabetes therapies with the exception of Pioglitazone do not have published data on effect on lowering LDL-P/Apo B. Triglyceride reductions have been seen with Metformin, Pioglitazone, Cycloset, Exenatide, Liraglutide. In our clinical experience above therapies also improve small dense LDL-P.

  24. References • Diagnosis and classification of diabetes mellitus. Diabetes Care. Jan 2010;33 Suppl 1:S62-9 • Standards of medical care in diabetes. Diabetes Care. Jan 2012;35 Suppl S20. • Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). UK Prospective Diabetes Study (UKPDS) Group. Lancet. Sep 12 1998;352(9131):854-65. • KnowlerWC,Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, Nathan DM. Reduction in the incident of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393-403. • Gerstein HC, Yusuf S, Bosch J, Pogue J, Sheridan P, Dinccag N, Hanefeld M, Hoogwerf B, Laakso M, Mohan V, Shaw J, Zinman B, Holman RR. Effect of rosiglitazone on the frequency of diabetes in patients with impaired glucose tolerance or impaired fasting glucose: a randomized controlled trial. Lancet 2006;368:1096-1105. • Orchard TJ, Temprosa M, Goldberg R, Haffner S, Ratner R, Marcovina S, Fowler S: The effect of metformin and intensive lifestyle intervention on the metabolic syndrome: the Diabetes Prevention Program randomized trial. Ann Intern Med 2005; 142:611-619. • Zhao-Wei Ting R, Chun Szeto C, Ho-Ming Chan, M, et al. Risk factors of vitamin B12 in patients receiving Metformin. 2006; Arch Intern Med; 166:1975-1979

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