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GEM - cardiovascular risk cases - answer (1)

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

A 56 year old man with type 2 diabetes. He smokes 10 cigarettes per day. Treatment for his diabetes is metformin 1g bd. He has been on atenolol 50 mg/d for many years for his blood pressure management. His blood pressure is 130/75 mmHg. His BMI is 31.2 kg/m^2. Recent diabetic review by practice nurse: fasting blood tests revealed HbA1C = 7.7% (61 mmol/mol), cholesterol = 5.2 mmol/l, TG = 4.8 mmol/l; HDL-C = 0.7 mmol/l; Calculated CVD risk > 20%. LFTs normal.

(a) what lipid lowering medication would you consider as first-line therapy:

- a statin would be considered first-line therapy based on evidence of CARDS (GPN reference click here) and HPS(GPN reference click here) showing reduction in cardiovascular risk

- the use of fibrates in diabetics was considered in the FIELD (GPN reference click here) and the results were not definitive for use of fibrates in this population. However with this gentleman's low HDL and raised triglycerides then it may well be that a statin-fibrate combination may be used

- nicotinic acid - very effective at raising HDL (GPN reference click here)

- evidence base relating to ezetimibe was added to with the IMPROVE-IT trial (GPN reference click here)

(b) should this gentleman be treated with aspirin? - no (GPN reference click here)

(c) which one or more of these factors may also be contributing significantly to the dyslipidaemia:

- see GPN reference; metformin has no effect

(d) what are the features of the lipid profile which are suggestive of insulin resistance? (GPN reference)

(e) Which change, if any, to diabetic medication is likely to be of most benefit

- the choices are either to add in a sulphonylurea, glitazone, gliptin, an SGL2 inhibitor or an incretin mimetic. There is evidence of cardiovascular benefit (in addition to the glucose lowering properties) of some SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin) and some incretin mimetics (dulaglutide, liraglutide, semaglutide). A link to guideline concerning type 2 diabetes algorithm (GPN reference)

(f) Name two other interventions that would be of benefit to this patient.

- stop smoking, add an ACE inhibitor, exercise may help to increase his HDL

- ACE inhibitors in diabetes (GPN reference click here)

- exercise and diabetes (GPN reference click here)

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