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VOLUME 1 ISSUE 2 CASE WM	WM is a 55-year-old man with new onset diabetes.
CHIEF COMPLAINT WM complains of polydipsia, fatigue, and polyuria. LABORATORY VALUES »  Fasting glucose: 123 mg/dL »  Fasting C-peptide: 8 ng/dL (normal: <5) »  A1c: 8.3 % »  Blood pressure: 145/90 mm Hg »  Lipid profile   --  Total cholesterol: 194 mg/dL   --  Triglycerides: 220 mg/dL   --  High-density lipoprotein: 25 mg/dL   --  Calculated low-density lipoprotein: 125 mg/dL   --  Non-HDL cholesterol: 169 mg/dL PROBLEMS This patient displays several features typical of type 2 diabetes, including: 1. Uncontrolled hyperglycemia 2. Moderate hypertension 3. Dyslipidemia NAVIGATION »  Q1: What is your first step? »  Q2: What is your initial treatment plan to manage this patient’s hyperglycemia and dyslipidemia? »  Q3: How would you characterize WM’s cardiovascular risk based on this lipid profile? »  Q4: How could you further characterize WM’s lipid profile? »  Q5: What pharmacologic interventions can increase total HDL and HDL2? »  Q6: What are the expected results if a TZD and statin are used in combination? »  Q7: What other changes, if any, do you make in WM’s treatment plan? »  Q8: What are the advantages and disadvantages of adding a fibrate or niacin? »  Q9: You decide to add fenofibrate 54 mg/d to target triglycerides and HDL-C. What should you do if WM reports suggestive muscle symptoms?	Q: What pharmacologic interventions can increase total HDL and HDL2? A: Several pharmacologic options may increase the total HDL and HDL2. The first option would be to change the agent used for glucose control, because different classes of drugs have variable effects on lipid parameters. You change WM from a sulfonylurea to a thiazolidinedione (rosiglitazone 4 mg/d). Thiazolidinediones have been shown to increase the total HDL-C by up to 20%.4,5 However, emerging evidence suggests that increases in the 30% to 35% range are possible when the total HDL-C is below 30. Therefore, a TZD at this point could raise the HDL to as high as 37 mg/dL. In addition, rosiglitazone has been shown to elevate the level of HDL2,6,7 which would confer additional benefits by decreasing the size of the LDL particles. Any rise in LDL-C levels is due to a shift from small dense to large buoyant LDL-C particles, which are less atherogenic. Other classes of drugs (eg, metformin, sulfonylureas) have negligible effects on HDL-C.
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