Question 2

A 52-year-old man is evaluated in the office during a routine visit. Medical history is significant for type 2 diabetes mellitus, hypertension, hypercholesterolemia, and obesity. Medications are lisinopril, insulin glargine, insulin aspart, aspirin, and pravastatin (20 mg/d).

On physical examination, he is afebrile, blood pressure is 128/80 mm Hg, pulse rate is 73/min, and respiration rate is 18/min. BMI is 35. The lungs are clear to auscultation, and no murmurs are heard.

Laboratory studies:

Hemoglobin A1c

7.2%

Total cholesterol

168 mg/dL (4.35 mmol/L)

LDL cholesterol

109 mg/dL (2.82 mmol/L)

HDL cholesterol

40 mg/dL (1.04 mmol/L)

Triglycerides

95 mg/dL (1.07 mmol/L)

Which of the following is the most appropriate management?

AIncrease statin dose
BStart bile acid sequestrant
CStart fibrate
DStart niacin

The most appropriate modification of this patient's treatment regimen is to increase the statin dose. The National Cholesterol Education Program (NCEP) Adult Treatment Panel III LDL cholesterol treatment target for all patients at high risk is below 100 mg/dL (2.59 mmol/L). High risk is defined as the presence of coronary heart disease (CHD) or CHD risk equivalents, which include peripheral arterial disease, abdominal aortic aneurysm, carotid artery disease, transient ischemic attacks or stroke of carotid origin or 50% obstruction of a carotid artery, diabetes mellitus, and 10-year risk for cardiovascular disease of 20% or greater. For patients in the very-high-risk category, such as those with coronary artery disease and diabetes mellitus, as well as in the setting of an acute coronary syndrome, an LDL cholesterol level below 70 mg/dL (1.81 mmol/L) is a therapeutic option.

Patients with diabetes show similar relative risk reductions compared with those without diabetes, but as the absolute risk in these patients is higher, the number needed to treat (to prevent a cardiovascular event) is lower. Several studies have demonstrated the benefits of statin therapy. In ad hoc analyses involving patients with diabetes from the Scandinavian Simvastatin Survival Study, simvastatin therapy was associated with a 55% reduction in major coronary events. In analyses of the 8000 patients in the diabetic subgroup from the Heart Protection Study, there was a 22% reduction (20.2% vs. 25.1%) in major vascular events in the group receiving simvastatin.

Statins remain the first-line therapy for the treatment of hyperlipidemia and for the primary and secondary prevention of CHD. Trials of nonstatin drugs in the primary prevention of CHD have been associated with reductions in coronary events but not mortality. In this patient, an increase from a low dose (20 mg) of pravastatin to a moderate dose (40 mg) is the best approach, both in terms of tolerability and effectiveness.