A 54-year-old man from India has a history of type 2 diabetes, hypertension, and dyslipidemia. His daily medication regimen includes losartan (Cozaar) 100 mg, atorvastatin (Lipitor) 10 mg, metformin (Glucophage) 1,500 mg (in the morning), and vitamin E with calcium 1,000 mg. His chief complaint is a 20-year history of cold intolerance that has worsened over the past two years, with body temperatures that range from 96.7°F-97.4°F. He must drink hot water or tea frequently to stay warm, and although he wears sufficient clothing, he has cold hands and feet. A specialist has ruled out Raynaud’s disease. There are no signs of cyanosis. The patient is 5 ft 8 in tall and weighs 145 lb. Results of a thyroid panel were within normal limits, although the thyroid-stimulating hormone (TSH) level had risen from 1.84 µU/mL in 2001 to 4.42 in 2004; results of testing for Hashimoto’s thyroiditis are pending. His total cholesterol is 122 mg/dL, LDL 61 mg/dL, HDL 43 mg/dL, and triglycerides 92 mg/dL. The patient has good glycemic control; his glycosylated hemoglobin is 5.6% and fasting blood sugar is 93 mg/dL. What further workup should be done for his cold intolerance? Should he start thyroid supplementation or simply be observed? Could the cold intolerance be related to the lowering of his LDL to 61? Would further lowering of his LDL be of any benefit?—MADHU B. GOYAL, MD, South Plainfield, N.J.
No further workup is indicated. Given this patient’s longstanding cold intolerance and its recent worsening coincident with an increase in TSH, it would be reasonable to try thyroid supplementation, aiming for a TSH closer to 1.0. If the thyroid antibodies are positive, there is even more reason to initiate thyroid replacement therapy, as this indicates a higher probability of progression to hypothyroidism. In terms of his lipid therapy, there is no known association between lipid-lowering therapy and cold intolerance. No evidence at this time suggests that further lowering of his LDL would be beneficial.—Susan Kashaf, MD (146-5)