A 56-year-old Hispanic male is referred to the clinic for dyslipidemia management.
His past medical history is significant for type 2 diabetes mellitus (T2D) (diagnosed 12 years prior), diabetic neuropathy, and hypertension (HTN). He does not have a history of clinical atherosclerotic cardiovascular disease (ASCVD).
Family history: father with HTN (deceased at age 72 due to myocardial infarction); mother with T2D (alive, diagnosed 25 years prior) and transient ischemic attack (age 64); siblings with HTN (alive).
Social history: drinks 2-3 glasses of alcohol weekly; denies tobacco or illicit drug use.
Current medications:
- lisinopril 20 mg PO daily
- metformin 500 mg PO bid
- glipizide 5 mg PO daily
- hydrochlorothiazide 25 mg PO daily
- pregabalin 75 mg PO bid
Physical examination:
Height: 5'10'; weight 202 lbs; body mass index 29 kg/m2; waist circumference of 38"; T 98.6°F (37°C); BP 128/78; HR 88; RR 18
His estimated 10-year ASCVD risk is around 11%.
Otherwise, the results of the physical examination were unremarkable.
Most recent lipid panel:
- Total Cholesterol: 238 mg/dL
- Triglycerides: 170 mg/dL
- High-Density Lipoprotein Cholesterol (HDL-C): 38 mg/dL
- Friedewald-Estimated Low-Density Lipoprotein Cholesterol (LDL-C): 166 mg/dL
Fasting glucose 89; A1c 5.2%; urine albumin 62 mcg of albumin/mg creatinine
His creatinine, liver enzymes, thyroid stimulating hormone (TSH) and vitamin D levels are within normal limits.
His diabetes and blood pressure are well-controlled on his current regimen. The patient was counseled on lifestyle modifications.
The correct answer is: A. Initiate atorvastatin 40 mg PO daily
Answer choice A is correct. He is in the third statin treatment category: those aged 40-75 with diabetes and LDL-C between 70-189 mg/dL. In addition, he is over 50 years old and has multiple diabetes-specific risk enhancers including long duration of T2D (≥10 years), albuminuria ≥30 mcg of albumin/mg creatinine, and neuropathy. In addition to the diabetes-specific risk enhancers, this patient has metabolic syndrome, which also increases his risk of ASCVD event. According to the 2018 ACC/AHA cholesterol guidelines,1 it is reasonable to prescribe a high-intensity statin to lower LDL-C by at least 50%. Data suggest that while patients treated with moderate intensity statin had significant reduction of ASCVD risk, these patients continue to have substantial residual risk of major cardiovascular events (8.5% in 3.8 years).2
Answer choice B is incorrect. While the guidelines recommend that a patient with diabetes mellitus and LDL-C ≥70 mg/dL receive at least a moderate-intensity statin, this patient has additional diabetes-specific risk enhancers and metabolic syndrome. As such, the patient may derive further risk reduction by using a high-intensity statin.
Answer choice C is incorrect. According to the 2018 ACC/AHA cholesterol guidelines, the combination of a maximally tolerated statin and ezetimibe may be reasonable in diabetic patients who are considered higher risk (i.e. 10-year ASCVD risk is ≥20%) with goal to reduce LDL-C ≥50%. While a moderate-intensity statin such as rosuvastatin 5 mg with ezetimibe may be an option in a high risk patient who cannot tolerate a high-intensity statin, a high-intensity statin should be tried first and assessed for tolerability and efficacy prior to using a combination of a moderate-intensity statin and ezetimibe.
Answer choice D is incorrect. According to the 2018 ACC/AHA cholesterol guidelines, the combination of a maximally tolerated statin and ezetimibe may be reasonable when the 10-year ASCVD risk is ≥20% to reduce LDL-C by 50% or more. However, this patient's 10-year risk is estimated to be around 11%, making this answer choice incorrect. Also, a high-intensity statin should be tried alone first and assessed for tolerability and efficacy prior to using a combination of a high-intensity statin and ezetimibe. If the patient has a good efficacy response and can tolerate a high-intensity statin, then it is not necessary to add ezetimibe.
References
- Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019;73:3168-3209.
- de Vries FM, Denig P, Pouwels KB, Postma MJ, Hak E. Primary prevention of major cardiovascular and cerebrovascular events with statins in diabetic patients: a meta-analysis. Drugs 2012;72:2365–73.
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