Item: ~?Mark <?

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A 46-year-old man comes to the physician for a routine health examination. He has no
current physical complaints and says he is compliant with his medications. He has a
history of type 2 diabetes treated with diet, exercise, and metformin. The patient also
takes a daily aspirin. He smokes a half pack of cigarettes a day and drinks 1 or 2
glasses of wine 3 times a week. His temperature is 36.7 C (98 F), blood pressure is
138/86 mm Hg, pulse is 80/min, and respirations are 14/min. Laboratory results are as
follows:

160
Total cholesterol
mg/dL
High-density
50 mg/dL
lipoprotein
Low-density
70 mg/dL
lipoprotein
250
Triglycerides
mg/dL
HbA1 C 6.5%
1.1
Creatinine
mg/dL

Serum chemistries are within normal limits. Urinalysis shows no proteinuria. Which of
the following is the most appropriate next step in management of this patient?

0 A. Add amlodipine
0 B. Add gemfibrozil
0 C. Add glimepiride
0 D. Add lisinopril
0 E. Add rosuvastatin

Submit
Item: ~?Mark <? C> S ~ ~ , ~
Q. ld : 4336 Prev1ous Next Lab Values Notes Calculator Reverse Color Text Zoom

A 46-year-old man comes to the physician for a routine health examination. He has no
current physical complaints and says he is compliant with his medications. He has a
history of type 2 diabetes treated with diet, exercise, and metformin. The patient also
takes a daily aspirin. He smokes a half pack of cigarettes a day and drinks 1 or 2
glasses of wine 3 times a week. His temperature is 36.7 C (98 F), blood pressure is
138/86 mm Hg, pulse is 80/min, and respirations are 14/min. Laboratory results are as
follows:

160
Total cholesterol
mg/dL
High-density
50 mg/dL
lipoprotein
Low-density
70 mg/dL
lipoprotein
250
Triglycerides
mg/dL
HbA1C 6.5%
1.1
Creatinine
mg/dL

Serum chemistries are within normal limits. Urinalysis shows no proteinuria. Which of
the following is the most appropriate next step in management of this patient?

A Add amlodipine [1%)

B. Add gemfibrozil [37%)
C. Add glimepiride [2%)
D. Add lisinopril [23%)
E. Add rosuvastatin [38%)

Proceed to Next Item

Explanation: User

Guidelines for lipid-lowering therapy

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Guidelines for lipid-lowering therapy

Indication Recommended therapy

Clinically significant atherosclerotic disease

• ACS, Ml • Age :>75: High-intensity statin
• Stable or unstable angina • Age >75: Moderate-intensity
• Coronary or other arterial revascularization stalin
• Stroke, TIA, PAD

LDL ~190 mg/dl High-intensity statin

• 10-year ASCVD risk ~7.5%:

High-intensity stalin
Age 40-75 with diabetes
• 10-year ASCVD risk <7.5%:
Moderate-intensity stalin

Estimated 10-year ASCVD risk ~7.5% Moderate- to high-intensity stalin•

(Pooled Cohort Equations)
ACS =Acute coronary syndrome; ASCVO =atherosclerotic cardiovascular disease; Ml =myocardial infarction;
PAD = peripheral arterial disease; TIA = transient ischemic attack.
• High-intensity statins include atorvastatin 40-80 mg, rosuvastatin 20-40 mg; moderate-intensity statins include
atorvastatin 10-20 mg, rosuvastatin 5-10 mg, simvastatin 20-40 mg, pravastatin 40-80 mg,lovastatin 40 mg.
©uwond

This patient has 2 significant risk factors for coronary heart disease (CHD), diabetes and
smoking. His diabetes is adequately controlled with a hemoglobin A1c <7.0% and does
not require further therapy (Choice C). However, because diabetes is a strong predictor
for the risk of cardiac events, current guidelines recommend statins for all diabetics
age 40-75. Statins lower low-density lipoprotein and reduce CHD risk for any baseline
lipid level.

High-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily) is

suggested for patients with diabetes who have a calculated 10-year risk of cardiac
events ~7.5% . Moderate-intensity statin therapy (eg, atorvastatin 10-20 mg, rosuvastatin
5-10 mg, simvastatin 20-40 mg daily) is recommended for patients with a calculated 10-
year risk of cardiac events <7.5%. Using the pooled cohort equations risk calculator,
this patient's estimated 10-year risk of cardiac events is approximately 7%, based on his
age and risk factors.

(Choices A and 0) Current guidelines recommend blood pressure <140/90 mm Hg in

patients with diabetes. Patients with diabetic nephropathy may benefit from lower blood
pressures (<130/80 mm Hg), but more aggressive blood pressure control is not
Item: ~?Mark <? C> S ~ ~ , ~
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This patient has 2 significant risk factors for coronary heart disease (CHD), diabetes and
smoking. His diabetes is adequately controlled with a hemoglobin A1c <7.0% and does
not require further therapy (Choice C). However, because diabetes is a strong predictor
for the risk of cardiac events, current guidelines recommend statins for all diabetics
age 40-75. Statins lower low-density lipoprotein and reduce CHD risk for any baseline
lipid level.
High~intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily) is
suggested for patients with diabetes who have a calculated 10-year risk of cardiac
events :::7.5%. Moderate-intensity statin therapy (eg, atorvastatin 10-20 mg, rosuvastatin
5-10 mg, simvastatin 20-40 mg daily) is recommended for patients with a calculated 10-
year risk of cardiac events <7.5%. Using the pooled cohort equations risk calculator,
this patient's estimated 10-year risk of cardiac events is approximately 7%, based on his
age and risk factors.
(Choices A and 0) Current guidelines recommend blood pressure <140/90 mm Hg in
patients with diabetes. Patients with diabetic nephropathy may benefit from lower blood
pressures (<130/80 mm Hg), but more aggressive blood pressure control is not
necessary in otherwise healthy diabetics. Angiotensin-converting enzyme inhibitors are
the preferred antihypertensive medication for patients with diabetes, when medication is
indicated. They are also recommended for patients with proteinuria, heart failure, or
chronic kidney disease with hypertension. This patient's blood pressure is at goal
without evidence of chronic kidney disease or heart failure.
(Choice B) Statins can also reduce triglycerides, and patients who take statins based
on their cardiac risk may have correction of mild hypertriglyceridemia (<500
mg/dl). Classes of lipid-lowering drugs other than statins are not routinely recommended
for mild-to-moderate hypertriglyceridemia as they have not been shown consistently to
reduce the risk of cardiac events.
Educational objective:
Diabetic patients age 40-75 should receive statin therapy regardless of baseline lipid
levels. Dose intensity can be selected based on overall risk of cardiac events.

References:
1. Effect of intensive treatment of hyperglycaemia on microvascular
outcomes in type 2 diabetes: an analysis of the ACCORD randomised
trial.
2. Effects of intensive blood-pressure control in type 2 diabetes mellitus.
3. Effects of combination lipid therapy in type 2 diabetes mellitus.

Time Spent: 3 seconds Copyright © UWorld Last updated: [08/04/201 6)

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Media Exhibit

Cohort Equation for estimating 10-year risk

Sample screenshot of 10-year ASCVD risk calculator

Gender Age

I Male Female

Race Total Cholesterol (mg/dl)

• White
I African American
HDL - Cholesterol (mg/dL)
• Other

Systolic Blood Pressure

Treatment for Hypertension

I Yes I No
Diabetes
Smoker
Yes No
Yes No Calculate

©UWorld

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Media Exhibit

ecommendations for treating hypertension

JNC 8 recommendations for treating hypertension

Initiate Rx Goal blood pressure

>150 mm Hg systolic BP
Age~O or <150/90 mm Hg
>90 mm Hg diastolic BP

Age <60,
>140 mm Hg systolic BP
chronic kidney
or <140/90 mm Hg
disease,
>90 mm Hg diastolic BP
diabetes

Thiazide diuretic or CCB, alone or in

Black
combination (ACE/ARB not first-line)

Initial
Thiazide diuretic, ACEI, ARB, or
treatment Other ethnicities
CCB alone or in combination
choice

All ethnicities with chronic ACEI or ARB, alone or in

kidney disease or diabetes combination with other drug classes

ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker;

BP = blood pressure; CCB = calcium channel blocker.
© UWOI1d

Q
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I Endocrine, Diabetes & Metabolism
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