A 45 year old man with known CHD S/P multiple PCIs/stents, T2DM since 1994, and hypertension for >20 years is hospitalized 5 months previously for chest pain. During his admission, the following is found:
LABORATORY RESULTS:
- TG: 2509 mg/dl
- HbA1c: 10.2%
MEDICATIONS:
- Gemfibrozil 600 mg BID
- DHA + EPA 2.5 g
- Atorvastatin 20 mg
- Glipizide 10 mg
- Metformin 850 mg BID
The patient was discharged on
same medications plus a low fat diet
and insulin glargine 10 units daily.
His home glucose monitoring
recordings have been in the
100-150 mg/dL range during
several months of increasing insulin
dosage. At his next clinic visit:
MEDICATIONS:
- Glargine 72 units daily
- Metformin 1 g BID
- Glipizide 10 mg BID
- Rosuvastatin 20 mg
- Gemfibrozil 600 mg BID
- Fish oils 1.6 g BID
- Clopidogrel 75 mg
- Aspirin 81 mg
PHYSICAL EXAM:
- Weight: maximum 280 lbs; patient had lost 14lbs since his hospitalization on a low fat diet
- BP: 140/68 mmHg
- BMI: 34.7 kg/m2
- Eruptive xanthomata on back and arms
LABORATORY RESULTS:
- TC: 259 mg/dL
- TG: 1965 mg/dL
- HDL-C: 35 mg/dL
- HbA1c: 7.8%
- AST, ALT: normal
- Creatinine: 1.0 mg/dL
- TSH: 1.6 mIU/L
- U/A albumin: ? 789 mg/g
SOCIAL HISTORY:
- Eats fish approximately 1-2 times
per month, whole grains
approximately 1 serving a day,
fruits and vegetables 4-5 servings
a day; occasionally he eats out,
but when he does, he eats salads
- No EtOH
- No tobacco
- Walks approximately 30 minutes
daily, but this is difficult due to
symptoms of peripheral neuropathy
Patient Case Question: What is the next best step in the management of this patient to reduce his triglyceride level?