35 Year Old Male with Diabetes and Familial

35 Year Old Male with Diabetes and Familial Hypertriglyceridemia, Medication noncompliance Case category: Diabetes, Familial Hypertriglyceridemia History of present illness: 35 year old male with diabetes and familial hypertriglyceridemia. Well controlled on Crestor 20, Niaspan 2000, Lovaza 6, metformin ER 2000, Actos 15, Victoza 1. 8 and Cycloset 0. 8 (LDL-P: 605, total cholesterol: 91, triglycerides: 121, HDL: 35. ) Off medications for only 6 days prior to 3 month follow-up labs, lipid profile deteriorated. Here for follow-up visit.

Patient Information Age 35 Gender Male Height (in) 72. 75 Weight (lbs) 327 BMI 43. 43 Waste Circumference (in) Blood Pressure (mm/Hg) 120/78 Pulse (beats/min) 70 Allergies or Medication Intolerance None Smoking / Alcohol No Exercise / Diet Light / Low Carb

Patient History Patient and Surgical History Family History HTN MGF: Died age 74, MI Diabetes MGM: Died age 72, Kidney Failure Sleep Apnea PGP: Died age 71, MI Hernia PGM: Died age 69, Bone Cancer Foot/Bone Spur Father: Age 69, Bypass Surgery in 50 s Mother: Age 65, Diabetes, Gastric Bypass, Neuropathy

Current Medications Prior to this Visit Medication Off mediations for 6 days Dose Frequency

Lipid Profile Off Medications for 6 Days Lab Test Normal Range Patient Value H/L Total Cholesterol (mg/d. L) <200 279 LDL-C (mg/d. L) <100 67 LDL-P (nmol/L) <700 -1000 1405 H HDL-C (mg/d. L) > 40 (M), >50 (F) 28 L Triglycerides (mg/d. L) <150 1072 H Small LDL-P (nmol/L) <600 -850 1245 H Non-HDL-C (mg/d. L) <130 251 H Lipoprotein (a) (nmol/L) or mg/d. L <75 or <30 5 Lp. PLA 2 (ng/m. L) <200 132 Apo B (mg/d. L) <60 102 Fasting: F NT = Not Tested H H

Other Labs Worth Noting Off Medications for 6 Days Lab Test Normal Range Patient Value H/L IR-Score (0 -100) <45 100 H Vitamin D 25 -OH (ng/m. L) >30 12 L CRP (mg/L) <1. 0 1. 2 TSH (u. IU/m. L) 0. 27 -4. 20 2. 55 Creatinine (mg/dl) 0. 5 -0. 9 0. 7 ALT (U/L) Up to 33 51 H Glucose (mg/d. L) 70 -99 257 H Hb. A 1 c (%) <5. 6 7. 7 H Homocysteine (umol/L) <10 8 Vitamin B 12 (pg/m. L) >300 605 Fasting: F NT = Not Tested

Labs Off Medications for 6 Days (1 of 5) Note extremely elevated fasting triglycerides.

Labs Off Medications for 6 Days (2 of 5)

Labs Off Medications for 6 Days (3 of 5)

Labs Off Medications for 6 Days (4 of 5)

Labs Off Medications for 6 Days (5 of 5)

NMR Lipo. Profile • Insert NMR Lipoprofile 020812 PW 76 Insert

Questions to Consider • Question 1: Assess reason for noncompliance. Fear of side effects? Each medication should be addressed. Is cost an issue? (He reports he just ran out of medications and figured a week off them would not affect his numbers. ) • Question 2: Address diet. Following a low carb diet is very important in setting of diabetes not optimally controlled (Hb. A 1 C 7. 7).

Initial Treatment & Management • Restart Crestor 20, Niaspan 2000 and Lovaza 6 for hypertriglyceridemia. • Restart metformin 2000, Victoza 1. 8 and Cycloset 0. 8 for diabetes control. It is acceptable to not restart Actos for now. • Restart CO Q 10 300 -600 mg/day for muscle aching which has given him symptom relief in past. • Restart Vitamin D 2 50, 000 IU weekly and Vitamin D 3 5000 IU daily for vitamin D deficiency.

Discussion (1 of 3) Risk Factors: Premature family history of heart disease/stroke, Diabetes, Hypertension, Hyperlipidemia Assessment: Familial Hypertriglyceridemia Issues Treatment Options (1) Triglycerides off medications were very high at 1072. Optimal is <150. On medications, triglycerides were 121. (2) LDL-P is high at 1405. Optimal is <700 due to multiple risk factors. On medications, LDL-P was 605. (3) LDL-P is key driver of atherosclerosis leading to heart attacks and stroke. (4) Total cholesterol was 91, now 279. HDL was 35, now 28. (5) IR score was 66/100 and now 100/100. (6) It’s reassuring that inflammatory markers are normal. (1) Lipids were stable on Crestor 20, Niaspan 2000 and Lovaza 6. (2) Restart Crestor 20, Niaspan 2000 and Lovaza 6. (3) Restart CO Q 10 300 -600 mg/day capsules with oil for muscle aching. We do not have any outcomes data to support routine use but some patients experience improved symptoms with use of supplement. (4) Another option is to reduce Crestor from 20 to 10 mg. (5) Triglycerides may be elevated due to fact he stopped Actos and Victoza and cut back on Cycloset to 3/day. For past 5 days also off Lovaza, Crestor and Niaspan.

Discussion (2 of 3) Assessment: Diabetes Type II Issues (1) Hb. A 1 c is high at 7. 7. Off medications, Hb. A 1 c increased from 6. 3 to 7. 7 (stopped Actos, Victoza and cut back on Cycloset (3/day). (2) Diabetes is a risk factor for CVD. Treatment Options (1) Restart Victoza 1. 8, metformin 2000 and Cycloset 0. 8. (2) It’s acceptable to stop Actos, but increase Cycloset to 4 -5/day if tolerated. (3) It’s very important to get diabetes under control as uncontrolled diabetes impacts lipids and reason for high triglycerides.

Discussion (3 of 3) Assessment: Vitamin D Deficiency Issues (1) Vitamin D level off medications is low at 12. (2) Vitamin D deficiency is defined at < 20. Vitamin D insufficiency is 20 -30. Optimal is >60 -90. (3) Vitamin D deficiency is associated with increased risk for CVD if < 10. Deficiency is associated with increased incidence of CVD events, atherosclerosis, hypertension, insulin resistance, cancer, osteoporosis, diabetes, metabolic syndrome and all cause mortality. Vitamin D deficiency can cause worsening muscle aches and make statin treatment more difficult. Treatment Options (1) Restart vitamin D 2 50, 000 weekly. (2) Start vitamin D 3 5000 IU daily. Take D 3, not D 2. Choose an oil based capsule rather than a tablet for better absorption.

Follow Up on Crestor 20, Niaspan 2000, Lovaza 6, Metformin 2000, Victoza 1. 8, Cycloset 0. 8 and Vitamin D 2 50, 000 / D 3 5000 (1 of 2) • Familial Combined hypertriglyceridemia – Improved. – Restarted Crestor 20, Niaspan 2000 and Lovaza 6. – LDL-P is now reduced from 1405 to 655. Total cholesterol is reduced from 279 to 84. Triglycerides dropped from 1072 to 252. HDL is now 30. IR Score was reduced from 100 to 74. – Continue therapy. • Diabetes Type 2 – Unchanged. – – Restarted metformin 2000, Victoza 1. 8 and Cycloset 0. 8. Hb. A 1 C remained the same at 7. 7. IR Score did lower from 100 to 74. Optimal is <45. Continue therapy.

Follow Up on Crestor 20, Niaspan 2000, Lovaza 6, Metformin 2000, Victoza 1. 8, Cycloset 0. 8 and Vitamin D 2 50, 000 / D 3 5000 (2 of 2) • Vitamin D Deficiency – Improved. – Restarted vitamin D 2 50, 000 IU weekly and started vitamin D 3 5000 IU/day. – Levels increased from 12 to 54. – Continue therapy.

Follow Up Labs on Medications (1 of 4)

Follow Up Labs on Medications (2 of 4)

Follow Up Labs on Medications (3 of 4)

Follow Up Labs on Medications (4 of 4)

NMR Lipo. Profile • Insert NMR Lipoprofile 030612 PW 76 Insert

Collaborative Treatment Approach Empower Patient for Self-Care • Interventions that empower patients help them make informed, selfdirected decisions and manage their diabetes in a way that works for their lives. Assessment of self-management beliefs, behavior, and knowledge Individually tailored strategies and problem solving Personal Action Plan Collaborative goal setting Identification of personal barriers and supports Funnell MM. Eur J Endocrinol. 2004. Oct; 151 Suppl 2: T 19 -22. Denver, EA et al. Diabetes Care. 2003 Aug; 26(8): 2256 -60.

Work Together to Prioritize Treatment Goals and Establish Good Self-Care Agree on an agenda by using communication strategies that avoid overwhelming newly diagnosed patients with “too much, too soon” Exchange Information Multiple Behaviors Establish Rapport Set Agenda Single Behavior Explore Importance Assess Importance and Confidence Readiness Build Confidence Reduce Resistance Rollnick S, Mason P, and Butler C. Health behavior change: a guide for practitioners. Edinburgh, Scotland: Churchill Livingstone, 2000.

Case Summary 1 st Visit Follow Up Goal Medications Crestor 20, Niaspan No Medications 2000, Lovaza 6, Metformin 2000, Victoza 1. 8 , Actos 15, Cycloset 0. 8 Crestor 20, Niaspan 2000, Lovaza 6, Metformin 2000, Victoza 1. 8, Cycloset 0. 8 LDL-P (nmol/L) 605 1405 655 <700 LDL-C (mg/d. L) 31 67 29 <100 HDL-C (mg/d. L) 35 28 30 >40 Triglycerides (mg/d. L) 121 1072 252 <150 Total Cholesterol (mg/d. L) 91 279 84 <200 Small LDL-P (nmol/L) 362 1245 655 <850 Non-HDL-C (mg/d. L) 56 251 54 <45 LP-IR Score (0 -100) 66 100 74 <130 12 54 >30 Vitamin D (ng/m. L)