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38 Year Old Female With Familial Combined Hyperlipidemia / Combination Therapy

38 Year Old Female With Familial Combined Hyperlipidemia / Combination Therapy. Case Categories Primary Prevention Secondary Prevention Pediatric Case Familial Hypertriglyceridemia Diabetes Metabolic Syndrome Low HDL Familial Combined Hyperlipidemia Familial Hypercholesterolemia

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38 Year Old Female With Familial Combined Hyperlipidemia / Combination Therapy

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  1. 38 Year Old Female With Familial Combined Hyperlipidemia / Combination Therapy 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, Low HDL, Metabolic Syndrome, Combination Therapy History of present illness: 38 year old female with familial combined hyperlipidemia with low HDL. She also has a history of insulin resistance syndrome, hypothyroidism and elevated CRP. Doing well on combination therapy. Here for follow-up.

  2. Patient Information

  3. Patient History

  4. Current Medications

  5. Lipid Profile on Crestor 20, Zetia 10 and Metformin 1500 Fasting: NF NT = Not Tested

  6. Other Labs Worth Noting on Crestor 20, Zetia 10 and Metformin 1500 Fasting: NF NT = Not Tested

  7. Labs on Crestor 20, Zetia 10 and Metformin 1500

  8. NMR LipoProfile Insert NMR Lipoprofile 033010 SB72 Insert Page 1 Insert NMR Lipoprofile 033010 SB72 Insert Page 2

  9. NMR Interpretation

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

  11. Initial Treatment & Management Continue Crestor 20 mg/day for familial combined hyperlipidemia. Trial off Zetia as NMR and lipid profile are stable. Continue metformin 1500 mg/day for insulin resistance syndrome. Crestor 20 and metformin 1500 will help lower elevated CRP. Continue Synthroid 112 mcg/day for hypothyroidism.

  12. Discussion (1 of 4) Risk Factors: Hyperlipidemia, Low HDL, Metabolic Syndrome, Elevated CRP Assessment: Familial Combined Hyperlipidemia

  13. Discussion (2 of 4) Risk Factors: Insulin Resistance Syndrome

  14. Discussion (3 of 4) Assessment: Elevated CRP

  15. Discussion (4 of 4) Assessment: Hypothyroidism

  16. 4 Month Follow Up on Crestor 20 and Metformin 1500 / Off Zetia 10 (1 of 2) • Familial Combined Hyperlipidemia – Deteriorated. • Currently taking Crestor 20 mg/day and metformin 1500 mg/day. Stopped Zetia last visit. • LDL-P increased from 987 to 1443. Goal is <1000. Small dense LDL-P increased from 712 to 823. Optimal is <850. • Total cholesterol, LDL-C and triglycerides all increased but remain normal. HDL lowered to 50. • Start Welchol 625 mg tablets. Take 6 tablets daily with meal. • Continue Crestor 20 mg/day and metformin 1500 mg/day. • Insulin Resistance Syndrome – Unchanged. • IR score increased from 42 to 58. Optimal is <45. • HbA1c lowered from 5.5 to 5.1. • Continue metformin 1500 mg/day. • Recommend low glycemic diet and increased exercise.

  17. 4 Month Follow Up on Crestor 20 and Metformin 1500 / Off Zetia 10 (2 of 2) • Elevated CRP – Unchanged. • CPR level is 1.4. Optimal is <1.0. • Crestor and metformin will help lower CRP. • Hypothyroidism – Unchanged. • Currently taking Synthroid 112 mcg/day. • TSH is 0.42. • Will recheck TSH if she begins to experience any symptoms.

  18. 4 Month Follow Up Labs on Crestor 20 and Metformin 1500 / Off Zetia 10

  19. NMR LipoProfile Insert NMR Lipoprofile 081710 SB72 Insert Page 1 Insert NMR Lipoprofile 081710 SB72 Insert Page 2

  20. 18 Month Follow Up on Crestor 20, Metformin 2000 and Welchol 625 (1 of 5) • Familial Combined Hyperlipidemia – Improved. • Currently taking Crestor 20 mg/day, metformin 2000 mg/day and Welchol 625 6 tablets/day. Metformin was increased from 1500 to 2000 between visits. • LDL-P lowered from 1443 to 1293. Small dense LDL-P increased from 823 to 990. • Total cholesterol, LDL-C and triglycerides all decreased and remain normal. HDL increased from 50 to 64. • Started OTC omega 3 fish oil 1000 IU between visits. Omega 3 index is borderline low at 7.5%. Increase to 2000 IU/day. • Continue therapy.

  21. 18 Month Follow Up on Crestor 20, Metformin 2000 and Welchol 625 (2 of 5) • Insulin Resistance Syndrome – Improved. • Currently taking metformin 2000 mg/day. • IR score decreased from 58 to 48. Optimal is <45. HbA1c lowered from 5.1 to 4.9. • Continue therapy. • Elevated CRP – Deteriorated. • CRP level is 2.3. Optimal is <1.0 • Crestor and metformin will help lower CRP. • Started OTC omega 3 fish oil 1000 IU between visits. Omega 3 fish oil will help lower CRP. Increasing this visit to 2000 IU/day. • Hypothyroidism – Unchanged. • Currently taking Synthroid 112 mcg/day. • TSH is 0.42. • Will recheck TSH if she begins to experience any symptoms.

  22. 18 Month Follow Up on Crestor 20, Metformin 2000 and Welchol 625 (3 of 5) • APO E3E4 Genotype • Individuals with the Apo E3E4 genotype have an increased risk for CVD (25% for E3/E4). • This genotype is associated with lower HDL-C and increased triglycerides, LDL-C and total cholesterol. • Statin therapy may not be as effective for those with this gene due to less LDL decrease. • A very low-fat diet will decrease LDL-C. Alcohol cessation is recommended as alcohol decreases HDL. • Increase exercise. • Plant sterols may decrease LDL and Apo B but is not recommended unless the individual does NOT absorb sterols, which would be more atherogenic than abnormal cholesterol. Soy protein and soluble fiber may help increase HDL. Fish oil and plant stanols (Benecol) are an option.

  23. 18 Month Follow Up on Crestor 20, Metformin 2000 and Welchol 625 (4 of 5) • Vitamin D Deficiency – New. • Vitamin D levels were low between visits. Vitamin D deficiency is defined at < 20. Vitamin D insufficiency is 20-30. Optimal is >60-90. Vitamin D deficiency is associated with increased risk for CVD if < 10. Deficiency is associated with increased incidence of CVD events, atherosclerosis, hypertension, insulin resistance, cancer, osteoporosis, diabetes, metabolic syndrome and all cause mortality. Vitamin D deficiency can cause worsening muscle aches and make statin treatment more difficult. • Started vitamin D3 2000 IU/day. • Levels are now 51 with supplements. • Continue therapy.

  24. 18 Month Follow Up on Crestor 20, Metformin 2000 and Welchol 625 (5 of 5) • Vitamin B12 Deficiency – New. • Vitamin B12 levels were low between visits. Causes of B12 deficiency include use of certain drugs such as metformin, methotrexate and antacids. Bacterial flora changes may induce food cobalamin malabsorption. Poor dietary intake of foods high in B12 and some chronic diseases can affect the absorption of B12. • Started vitamin B12 500 mcg/day. • Levels are now at 987 on supplements. • Continue therapy.

  25. 18 Month Follow Up Labs on Crestor 20, Metformin 2000 and Welchol 625 (1 of 6)

  26. 18 Month Follow Up Labs on Crestor 20, Metformin 2000 and Welchol 625(2 of 6)

  27. 18 Month Follow Up Labs on Crestor 20, Metformin 2000 and Welchol 625 (3 of 6)

  28. 18 Month Follow Up Labs on Crestor 20, Metformin 2000 and Welchol 625 (4 of 6)

  29. 18 Month Follow Up Labs on Crestor 20, Metformin 2000 and Welchol 625 (5 of 6)

  30. 18 Month Follow Up Labs on Crestor 20, Metformin 2000 and Welchol 625(6 of 6)

  31. NMR LipoProfile Insert NMR Lipoprofile 103111 SB72 Insert

  32. Clinical Pearls

  33. Case Summary

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