Interactive diabetes case 14: A 41-year-old patient with type 2 diabetes and hypertriglyceridemia

CASE — You are asked to evaluate and manage a 41-year-old man with type 2 diabetes who was recently noted to have a triglyceride level of 1118 mg/dL on routine lipid evaluation.

Three years ago, the patient had the following fasting laboratory values, obtained on a routine basis because of obesity: glucose 102 mg/dL (5.66 mmol/L), total cholesterol 209 mg/dL, triglycerides 394 mg/dL, high-density lipoprotein (HDL) cholesterol 33 mg/dL, low-density lipoprotein (LDL) cholesterol 116 mg/dL.

Two and a half years ago, the patient had a fasting blood glucose level of 138 mg/dL (7.66 mmol/L). A glycated hemoglobin (A1C) value a few days later was 7.1 percent. The patient was told that he has type 2 diabetes and met with a registered dietitian for medical nutrition therapy.

His efforts to reduce weight were unsuccessful despite regular visits to his clinician. Two years ago, he was started on metformin with doses titrated to 1000 mg twice a day. Repaglinide was added soon thereafter, with doses titrated to 4 mg three times daily before meals. One month before his visit to you, his fasting laboratory values were as follows: glucose 173 mg/dL (9.6 mmol/L), A1C 8.9 percent, total cholesterol 231 mg/dL, triglycerides 1118 mg/dL, and HDL cholesterol 36 mg/dL. The LDL cholesterol was not calculated by the laboratory, because these calculations are inaccurate when the triglyceride level exceeds approximately 400 mg/dL.

The patient eats out in restaurants three times a week, where he has 16-ounce portions of untrimmed red meat with a baked potato. He has two eggs with two sausages for breakfast three times a week, does not drink milk, and consumes approximately one-quarter of a pound of cheese once a week. He states that he knows he can do better with his diet and is determined to do so.

He does not drink alcoholic beverages currently, although he acknowledges "a drinking problem" when he was younger, and does not smoke. He is sedentary at work and does not exercise. He has hypertension treated with ramipril 20 mg a day. His other medications include calcium 600 mg with vitamin D 400 international units twice daily. He has no known heart disease.

On examination, he weighs 217 lbs and is 5 feet 5 inches tall, with a body mass index (BMI) of 36.1 kg/m². The blood pressure is 120/80 mmHg right arm supine, 130/90 mmHg right arm upright. On physical examination, there is no evidence of retinopathy, neuropathy, or peripheral artery disease. The blood urea nitrogen (BUN) is 18 mg/dL, the serum creatinine is 1.2 mg/dL, and the urine microalbumin/creatinine ratio is 6.4 mg/g. The thyroid-stimulating hormone (TSH) level is 1.8 microunits/dL.

You confirm in an individual discussion with the patient's spouse that he no longer consumes alcoholic beverages in any amount.

What is your assessment and plan?

●You conclude that the patient has mixed hyperlipidemia based on the total cholesterol and triglyceride levels and that the HDL level is below recommended values for a male patient. You conclude that he is at high risk for cardiovascular disease because of his lipid levels, diabetes, and hypertension.

You advise him to limit his red meat intake to smaller portions (eg, 4 or 5 ounces), trimmed to remove the fat and consumed less frequently; to use a low-fat sausage substitute and an egg substitute instead of eggs; to reduce portions at meals including those of carbohydrates; and to eliminate drinks with concentrated carbohydrates such as regular sodas and fruit juices. You encourage him to eat fish at least twice a week.

You refer him to a registered dietitian to review his diet. You advise him to begin walking at least five days a week, gradually increasing the duration to at least 35 minutes a day. You start him on a statin for cardiovascular risk prevention, using atorvastatin 10 mg in the evening. You advise him to take aspirin 81 mg a day. You consider adding a fibric acid derivative at a later time. (See "Interactive diabetes case 14: A 41-year-old patient with type 2 diabetes and hypertriglyceridemia – A1".)

●You conclude that the patient probably has acute pancreatitis based on his triglyceride level. You order stat levels of amylase and lipase and a white blood count and differential count. You obtain abdominal radiographs. You ask the patient to remain in your office, anticipating admission to the hospital. (See "Interactive diabetes case 14: A 41-year-old patient with type 2 diabetes and hypertriglyceridemia – A2".)

●You conclude that the patient has uncontrolled diabetes and that this may be the reason for the rise in his triglyceride level over the last three years. You note that the diabetes is uncontrolled despite a prolonged trial of medical nutrition therapy and full doses of two oral agents for diabetes.

You are concerned that he may have an elevation of the LDL cholesterol above recommended levels but conclude that this cannot be assessed satisfactorily until the triglyceride level has been reduced markedly.

You are also concerned that the patient is at high risk for pancreatitis. You order a white blood count, differential count, and levels of amylase and lipase.

You advise him to limit his red meat intake to smaller portions (eg, 4 or 5 oz), trimmed to remove the fat and consumed less frequently; to use a low-fat sausage substitute and an egg substitute instead of eggs; to reduce portions at meals including those of carbohydrates; and to eliminate drinks with concentrated carbohydrates such as regular sodas and fruit juices. You encourage him to eat fish at least twice a week. You refer him to a registered dietitian to review his diet.

You advise him to begin walking at least five days a week, gradually increasing the duration to at least 35 minutes a day. You advise him to take aspirin 81 mg a day. You inform him of the risk of acute pancreatitis, a painful and life-threatening condition, if he does not reduce his triglyceride levels, and you advise him of the need for close medical follow-up in the near future. (See "Interactive diabetes case 14: A 41-year-old patient with type 2 diabetes and hypertriglyceridemia – A3".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Type 2 diabetes (The Basics)" and "Patient education: High cholesterol (The Basics)")

●Beyond the Basics topics (see "Patient education: Type 2 diabetes: Overview (Beyond the Basics)" and "Patient education: Preventing complications from diabetes (Beyond the Basics)" and "Patient education: High cholesterol and lipids (Beyond the Basics)")