A diabetic patient with hemoglobin A1c 6.5%, total cholesterol 195 mg/dL, HDL 32 mg/dL, LDL 98 mg/dL, and triglycerides 195 mg/dL takes atorvastatin (Lipitor) 20 mg daily. Should I try to bring down the triglycerides to <150 while “raising” the HDL a bit? The patient is on seven medications for comorbid conditions. Are omega-3-acid ethyl esters (Omacor) worthwhile?
—Anh T. Nong, MD, Redlands, Calif.
According to guidelines established by the Adult Treatment Panel III (ATP III), the primary concern for a patient such as this one remains LDL (Circulation. 2002;106:3143-3421). In this context, the central question is whether or not the patient has a known history of coronary artery disease (CAD). In the absence of CAD, diabetes would be considered an equivalent risk factor, and as such, the LDL treatment goal would be <100. If, in fact, your patient has known CAD, then diabetes may place him in a “very high risk” category with an optional goal of lowering LDL to around 70 (Circulation. 2004;110:227-239).
Triglyceride and HDL treatment goals thus become secondary to LDL-lowering therapy. According to the ATP III, triglyceride levels of 150-199 should primarily be treated with lifestyle modification, including exercise, smoking cessation, and weight control. At levels of 200-499, one would consider the use of nicotinic acid or a fibrate. The ATP III guidelines also propose the potential use of either nicotinic acid or a fibrate in patients who have a high-risk HDL (i.e., <40) with triglycerides <200 mg/dL. Treatment of hypertriglyceridemia with fish oil or omega-3 fatty acids requires relatively high doses (>6 g/day) to have a substantial effect and is generally thought to be reserved for refractory situations. Nonetheless, meta-analyses looking at diets rich in omega-3 fatty acids or supplements have shown a reduction in fatal MI, sudden death, and total mortality, perhaps providing impetus to recommend supplements for “general” cardiovascular health (Am J Med. 2002;112:298-304).
Specific to this patient, efforts should be made to increase exercise, lose weight, alter diet to include at least two servings of fish per week, stop smoking if this is an issue, and consider potential addition of nicotinic acid or a fibrate if the preceding recommendations prove unsuccessful. In the presence of CAD, one could make an argument for simply increasing his atorvastatin. While the primary aim of such therapy would be to lower LDL, small increases in HDL and decreases in triglycerides might be seen, and this would spare the burden of an extra medication.
—Christopher Ruser, MD (120-8)