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64 Year Old Female with Familial Combined Hyperlipidemia and Diabetes

64 Year Old Female with Familial Combined Hyperlipidemia and Diabetes. Case category: Familial Combined Hyperlipidemia, Diabetes

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64 Year Old Female with Familial Combined Hyperlipidemia and Diabetes

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  1. 64 Year Old Female with Familial Combined Hyperlipidemia and Diabetes Case category: Familial Combined Hyperlipidemia, Diabetes History of present illness: 64 year old female with familial combined hyperlipidemia and diabetes. Prior to this visit she was well controlled on Crestor 20, metformin 2250, and Lovaza 4, but has been non-compliant with her medications for 6 months. She is here for follow-up. She was hoping that weight loss and an attention to diet and exercise would control her conditions. 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

  2. Patient Information

  3. Patient History

  4. Current Medications She has not taken Crestor, metformin or Lovaza for 6 months. She wanted to try lifestyle modifications only.

  5. Labs Worth Noting off Medications for 6 months

  6. Questions to Consider • Question 1: Address noncompliance concerns, fears of side effects, etc. Willingness to resume therapy? • Question 2: Any symptoms of hypothyroidism? TSH was high normal. • Question 3: Address diet. What type of diet is she following? Room for more exercise?

  7. Labs off Medications for 6 Months (1 of 5) Familial combined hyperlipidemia

  8. Labs off Medications for 6 Months (2 of 5)

  9. Labs off Medications for 6 Months (3 of 5)

  10. Labs off Medications for 6 Months (4 of 5)

  11. Labs off Medications for 6 Months (5 of 5)

  12. NMR LipoProfile • Insert NMR Lipoprofile 06012011 PW46 Insert

  13. Other Labs off Medications for 6 Months

  14. Initial Treatment & Management • Restart Crestor 20 mg/day to lower LDL-P. Goal is <700 with risk factors. Restart Lovaza 4 g/day to lower triglycerides. • Restart metformin ER 500 mg 3-4 tablets daily with slow titration as tolerated over the next few weeks. • Restart vitamin D3 5000 IU/day for vitamin D deficiency.

  15. Discussion

  16. Discussion

  17. Follow Up on Crestor 20, Metformin 2250 and Lovaza 4 (1 of 2) • Familial Combined Hyperlipidemia – Improved. • Currently on Crestor 20 and Lovaza 4. Excellent response. • LDL-P lowered from 2146 to 682. LDL-C dropped from 139 to 46. Total cholesterol lowered from 273 to 132. Triglycerides reduced to 120 from 325. • Consider adding Co Q 10 ubiquinol 300-600/day to help prevent/address myalgias with use of statin. • Continue therapy. • Diabetes Type 2 –Improved. • Currently on metformin 2000. • HbA1c lowered from 5.9 to 5.5. IR Score improved from 66 to 34. • Continue therapy. • Vitamin D Deficiency – Improved. • Currently on vitamin D3 5000. • Levels increased from 36 to 78. • Continue supplements.

  18. Follow Up on Crestor 20, Metformin 2250 and Lovaza 4 (2 of 2) • Vitamin B12 Deficiency • Vitamin B12 is low at 354. Optimal is >400. Causes of B12 deficiency include use of certain drugs such as metformin, methotrexate and antacids, bacterial flora changes that may induce food cobalamin malabsorption, poor dietary intake of foods high in B12 and some chronic diseases. Treatment of B12 deficiency is important to avoid health changes. • Foods high in B12 that are also heart healthy include Sockeye salmon, plain yogurt, milk and roasted chicken. • Start sublingal tablets 1000 mcg/day.

  19. Follow Up Labs on Crestor 20, Metformin 2000 and Lovaza 4 g (1 of 5)

  20. Follow Up Labs on Crestor 20, Metformin 2000 and Lovaza 4 (2 of 5)

  21. Follow Up Labs on Crestor 20, Metformin 2000 and Lovaza 4 (3 of 5)

  22. Follow Up Labs on Crestor 20, Metformin 2000 and Lovaza 4 (4 of 5)

  23. Follow Up Labs on Crestor 20, Metformin 2000 and Lovaza 4 (5 of 5)

  24. NMR LipoProfile • Insert NMR Lipoprofile 09062011 PW46 Insert

  25. Clinical PearlsLab Results Prior to Going Off Medications 6 months ago It is at times reasonable to let patients stop medications so they see what diet and exercise alone can do. Clearly when genetic dyslipidemia is present medications in addition to lifestyle are very important. She is more comfortable being on medications after seeing these results both on and off therapy. Also very helpful to address patients fear of side effects. Statins are very safe overall and it’s important to help patients understand risk vs benefit. Benefit far outweighs risk in most cases.

  26. Case Summary

  27. References (1 of 2) Familial Combined Hyperlipidemia • Cromwell WC, Otvos JD, Keyes MJ, et al. LDL particle number and risk of future cardiovascular disease in the Framingham offspring study – implications for LDL management. J Clin Lipidol. 2007 Dec;1(6):583-92. • Brunzell JD, Davidson M, Furberg CD, et al. Lipoprotein management in patients with cardiometabolic risk: consensus statement from the American Diabetes Association and the American College of Cardiology Foundation. Diabetes Care. 2008 Apr;31(4):811-22. • Nicholls SJ, Ballantyne CM, Barter PJ, et al. Effect of two intensive statin regimens on progression of coronary disease. N Engl J Med. 2011 Dec 1;365(22):2078-87. Diabetes • ADA Standards of Medical Care in Diabetes - 2012. Diabetes Care. Jan 2012 35(1)11-63. • Schwartz S, Fonseca V, Berner B, et al. Efficacy, tolerability, and safety of a novel once-daily extended release metformin in patients with type 2 diabetes. Diabetes Care. 2006 Apr;29(4):759-64. • 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. 1998 Sep 12;352(9131):854-65.

  28. References (2 of 2) Vitamin D Deficiency • Dobnig H, Pilz S, Scharnagl H, et al. Independent association of low serum 25-hydroxyvitamin d and 1,25-dihydroxyvitamin d levels with all-cause and cardiovascular mortality. Arch Intern Med. 2008;168(12):1340-1349. • Giovannucci E, Liu Y, Hollis B, Rimm E. 25-hydroxyvitamin d and risk of myocardial infarction in men. Arch Intern Med. 2008;168(11):1174-1180. • Michos E and Blumenthal R. Vitamin D Supplementation and Cardiovascular Disease Risk. Circulation. 2007;115(7):827-828. • Hathcock J, Shao A, Vieth R, et al. Risk assessment for vitamin D. Am J ClinNutr. 2007;85:6-18. • Holick M. Vitamin D Deficiency. N Engl J Med. 2007;357:266-81.

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