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49 Year Old Female with Familial Combined Hyperlipidemia, Diabetes and Statin Intolerance

49 Year Old Female with Familial Combined Hyperlipidemia, Diabetes and Statin Intolerance. Case Categories Primary Prevention Secondary Prevention Pediatric Case Familial Hypertriglyceridemia Diabetes Metabolic Syndrome Low HDL Familial Combined Hyperlipidemia

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49 Year Old Female with Familial Combined Hyperlipidemia, Diabetes and Statin Intolerance

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  1. 49 Year Old Female with Familial Combined Hyperlipidemia, Diabetes and Statin Intolerance Case Categories Primary Prevention Secondary Prevention Pediatric Case Familial Hypertriglyceridemia Diabetes Metabolic Syndrome Low HDL Familial Combined Hyperlipidemia Familial Hypercholesterolemia Elevated Lipoprotein (a) Statin Intolerance Case category: Familial Combined Hyperlipidemia, Diabetes, Statin Intolerance History of present illness: 49 year old female with familial combined hyperlipidemia and diabetes. One month ago stopped Simvastatin due to muscle aches. She has also tried Niaspan and experienced flushing. Currently on metformin and insulin. She is here for advanced testing and treatment recommendations.

  2. Patient Information

  3. Patient History

  4. Current Medications

  5. Lipid Profile on Metformin 1000 and Insulin Fasting: NF NT = Not Tested

  6. Other Labs Worth Noting on Metformin 1000 and Insulin Fasting: NF NT = Not Tested

  7. Labs on Metformin and Insulin(1 of 5)

  8. Labs on Metformin and Insulin(2 of 5)

  9. Labs on Metformin and Insulin(3 of 5)

  10. Labs on Metformin and Insulin(4 of 5)

  11. Labs on Metformin and Insulin(5 of 5)

  12. NMR LipoProfile Insert NMR Lipoprofile 041211 SG62 Insert

  13. NMR Interpretation

  14. Questions to Consider Question 1 Question 2 Question 3 Question 4

  15. Initial Treatment & Management Start low dose Crestor 5 mg for familial combined hyperlipidemia. Due to previous statin intolerance, take ½ tablet every other day. Increase metformin to 2250 mg/day for diabetes and to reduce LDL-P and lower triglycerides. Continue insulin. Start Lovaza 4 g/day to lower triglycerides and raise HDL. Start vitamin D2 50,000 IU/week and D3 5000 IU/day for vitamin D deficiency. Start CO Q 10 300-600 mg/day capsules with oil for muscle aching.

  16. Discussion (1 of 5) Continued Next Slide Risk Factors: Hyperlipidemia, Diabetes, Low HDL Assessment: Familial Combined Hyperlipidemia

  17. Discussion (2 of 5) Assessment: Familial Combined Hyperlipidemia - Continued

  18. Discussion (3 of 5) Assessment: Diabetes Type II

  19. Discussion (4 of 5) Assessment: Vitamin D Deficiency

  20. Discussion (5 of 5) Assessment: Myalgia

  21. 4 Month Follow Up on Crestor 2.5, Metformin 1500, Insulin, Lovaza 4 and Vitamin D3 5000 / D2 50,000 (1 of 2) • Familial Combined Hyperlipidemia – Improved. • Currently taking Crestor 2.5 mg every other day, Lovaza 4 g/day, metformin 1500 mg/day and insulin. • LDL-P lowered from 2245 to 1245. Excellent response. Total cholesterol lowered from 193 to 104. LDL-C reduced to 60 from 98. Triglycerides lowered from 637 to 55 and are now normal. HDL increased from 29 to 33. Still too low. • Risk for pancreatitis is much reduced. • Try to increase Crestor to every day. • Diabetes Type 2 – Improved. • Currently taking metformin 1500 mg/day and insulin. Recommended to take 2250 mg/day last visit. • IR Score lowered from 100 to 46. HbA1c is 6.2. • Continue therapy.

  22. 4 Month Follow Up on Crestor 2.5, Metformin 1500, Insulin, Lovaza 4 and Vitamin D3 5000 / D2 50,000 (2 of 2) • Vitamin D Deficiency – Improved. • Currently taking vitamin D3 5000 IU/day and D2 50,000 IU/week. • Levels increased from 7 to 67. Excellent response. • Continue supplements. • Myalgia – Improved. • Muscle aching has improved on vitamin D3 and D2.

  23. 4 Month Follow Up Labs on Crestor 2.5, Metformin 1500, Insulin, Lovaza 4 and Vitamin D3 5000 / D2 50,000

  24. NMR LipoProfile Insert NMR Lipoprofile 080211 SG62 Insert Page 1 Insert NMR Lipoprofile 080211 SG62 Insert Page 2

  25. 10 Month Follow Up on Crestor 2.5, Metformin 1500, Insulin, Lovaza 4 and Vitamin D3 5000 / D2 50,000 (1 of 2) • Familial Combined Hyperlipidemia – Improved. • Currently taking Crestor 2.5 mg every other day, Lovaza 4 g/day, metformin 1500 mg/day and insulin. • LDL-P lowered from 1245 to 1113. Total cholesterol is normal at 114. LDL-C is normal at 70. Triglycerides are normal at 71. HDL remains low at 30. • Continue therapy. • Diabetes – Improved. • Currently taking metformin 1500 mg/day and insulin. • IR Score is 44 down from 46. HbA1c lowered from 6.2 to 5.8. • Discussed other options other than insulin including Cycloset, Victoza and Byetta. • Continue therapy.

  26. 10 Month Follow Up on Crestor 2.5, Metformin 1500, Insulin, Lovaza 4 and Vitamin D3 5000 / D2 50,000 (2 of 2) • Vitamin D3 Deficiency – Improved. • Currently taking vitamin D3 5000 IU/day and D2 50,000 IU/week. • Levels remain stable at 67. • Continue supplements. • Myalgia – Improved. • Muscle aching has improved on vitamin D3 and D2.

  27. 10 Month Follow Up Labs on Crestor 2.5, Metformin 1500, Insulin, Lovaza 4 and Vitamin D3 5000 / D2 50,000

  28. NMR LipoProfile Insert NMR Lipoprofile 011612 SG62 Insert Page 1 Insert NMR Lipoprofile 011612 SG62 Insert Page 2

  29. Clinical Pearls

  30. Case Summary

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