Interactive diabetes case 14: A 41-year-old patient with type 2 diabetes and hypertriglyceridemia – B1

ANSWER — 

Correct.

The patient's diabetes gradually comes into control on insulin as you advance the dose incrementally to 64 units a day. Over the next few visits, the glycated hemoglobin (A1C) value falls to the 6.3 to 7.8 percent range, depending in large part on variable adherence to the dietary regimen. Concomitantly, the triglyceride level falls into the 283 to 375 range. The total cholesterol is in the 180 to 206 range. The low-density lipoprotein (LDL) cholesterol, which can now be calculated, is in the 81 to 105 mg/dL range.

You advise the patient to stop the repaglinide, an insulin secretagogue, now that he is on insulin by injection and to continue the metformin. The patient gains 5 lbs over the next six months, although the food choices appear to be much healthier. You congratulate the patient on the success he has achieved and explain that you wish to reduce his lipid levels further to decrease the risk of cardiovascular disease.

What do you do now?

●You add omega-3 fatty acids 1 gram three times a day with meals to bring the triglyceride level consistently below 200 mg/dL, to reduce the risk of sudden cardiac death, and possibly to reduce the risk of atherosclerotic cardiovascular disease. (See "Interactive diabetes case 14: A 41-year-old patient with type 2 diabetes and hypertriglyceridemia – C1".)

●You add fenofibrate 145 mg a day to bring the triglyceride level consistently below 200 mg/dL and to achieve a reduction in the LDL cholesterol level and an increase in the high-density lipoprotein (HDL) cholesterol level. (See "Interactive diabetes case 14: A 41-year-old patient with type 2 diabetes and hypertriglyceridemia – C2".)

●You add atorvastatin 20 mg every evening to bring the LDL cholesterol consistently below 70 mg/dL in this patient with obesity, diabetes, hypertension, and hyperlipidemia in order to reduce the triglyceride level and to increase the HDL cholesterol level. (See "Interactive diabetes case 14: A 41-year-old patient with type 2 diabetes and hypertriglyceridemia – C3".)