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A 49-year-old woman comes to the clinic for a routine healthcare checkup. She has a past medical history that includes diabetes and hypertension. Her diabetes and hypertension have been well controlled, requiring metformin, lisinopril, and hydrochlorothiazide, in addition to the baby aspirin and potassium supplementation she takes daily. She was discovered to have dyslipidemia 1 year earlier, however. Despite following a strict diabetic diet, exercising regularly, and taking a high-dose statin, her LDL-cholesterol remains at greater than goal. Additionally, her HDL-cholesterol is mildly less than normal. Which of the following is an appropriate medication to start at this time?
A. Additional statin
B. Bile acid sequestrant
C. Fish oil supplements
D. Probucol
E. Short-acting nicotinic acid
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Posts: 3,675,937
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Posts: 3,675,937
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monia, I want to say yes, dear. But my patient say:" please don't do that I aslo have DM, help me out, doc!"
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Sammy, the patient will say thank you if you don't say sorry.
The correct answer is B. Bile acid sequestrants, such as cholestyramine, colestipol, or colesevelam, can be added to a statin when target goals have not been met. The addition of a sequestrant synergistically decreases LDL-cholesterol levels (up to a 50% decline compared with no therapy), and modestly increases HDL-cholesterol levels. Choices other than a bile acid sequestrant include a fibrate or a nicotinic acid derivative, though each is appropriate only in certain clinical situations.
An additional statin (choice A) is unlikely to provide increased benefit. The statin treatments differ in potency, and sometimes a patient responds to a change in statin. Many patients with persistent dyslipidemia on treatment, however, require an additional medication.
Fish oil supplements (choice C) help mainly with triglyceride levels and only modestly diminish LDL levels. Further, they can potentiate hyperglycemia and need to be used cautiously (if at all) in patients with diabetes.
Probucol (choice D) is no longer available in the United States. It has been found to cause a decline in HDL-cholesterol levels believed to more than offset the cardioprotective benefits of its moderate reduction in LDL-cholesterol.
Nicotinic acid (choice E) can be added to a statin to help reduce LDL-cholesterol levels. In patients with diabetes, however, it can worsen glycemic control, as the drug promotes insulin resistance. The short-acting versions are particularly difficult to use in patients with diabetes, whereas the long-acting crystalline versions are usually manageable.
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