Kimberly Moriarty
Dyslipidemia Case Study #1
Question 1 (60 points)
Ms Richards is a 68 year old Caucasian woman who is in your clinic for her routine
annual physical. She has a sedentary life style, though she tries to eat right. She has been
smoking 1ppd for 20 years but has tried to quit twice without success. Past medical
history includes hypertension for which she takes Lisinopril 10 mg and HCTZ 25 mg
daily. She tells you she has high cholesterol in the past but has not taken any medications
for it, her previous doctor told her she can manage her cholesterol by watching what she
eats. She denies other medical problems. Family history is positive for diabetes and
cardiac disease on father who died at age 68 of an MI.
Vital signs: BP=130/80, HR=68, BMI=38
Exam: WNL except you note skin exam is positive for Acanthosis nigricans posterior
neck area.
You had told her to come to clinic fasting, after ordering her fasting lipid profile to be
done; you receive the following results for your review before Ms. Richards goes
home:
Total Chol=227mg/dl, HDL=28mg/dl, LDL=135mg/dl, and Triglycerides=320mg/dl
a) Given your exam findings would you add any other labs, if so which ones and why. (5
Points)
Yes!!
I would check a fasting or a random blood sugar to evaluate for diabetes, a set of
liver enzymes to check liver health and potentially start her on a statin, A CBC and BMP
for good measure if not done in the last year, also helps to rule out other causes of
hyperlipidemia, and a UA to check for kidney health, diabetes. She is showing physical
signs of insulin resistance (acanthosis nigricans) and has numerous risk factors for
diabetes.
b) According to the NCEP-ATPIII Recommendations there are four categories of risk for
CVD, at which risk category is your patient Ms Richards? (5 Points)
Ms. Richards would have all 5 risk factors, and have a calculated 17% risk in the
next 10 years. This places her in the second category, 2+ risk factors and a 10 year risk of
<20%.
c) Explain how you arrived at your decision for your patients risk category (5 Points)
I arrived at this decision because she has no known CHD events or equivalents at
this time (although I suspect diabetes just hasn’t been officially diagnosed yet) and she
has all five of the major risk factors including; smoking, age, hypertension, low HDL and
family history of CHD. I then calculated her score from the Framingham list (12 points
age, 2 points total cholesterol, 2 points smoker, 4 points for treated hypertension, and 2
points for HDL level).
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d) What would be your therapeutic goal for HDL and LDL for Ms. Richards? Explain
your answer. (5 Points)
Her goal for HDL would be 40-60 (higher the better) and her goal for LDL would
be less than 130. These goals come from the recommendations set forth in the ATP
guidelines. If she had less risk factors, or lower 10 year risk, she would not need these
goals; a LDL goal would be around 160-190, with HDL still needing to be 40 or higher.
e) You review her other labs and find that her liver function tests 1 month ago were as
follows: Alk phos=50, ALT=34, AST=15, TBIL=0.5, Blood Sugar 125 fasting
Given what you know about Ms Richards, what would be your most appropriate
intervention(s) today and why? (15 Points)
Given these labs results, Ms Richards is pre diabetic with normal liver function.
Although diet and exercise must be stressed again with her, the major concern at this
moment is to start her on something to help her lower her cholesterol. Under a time
constraint I would focus the conversation on starting her on a new medication, but
strongly encourage her to make an additional appointment ASAP to further guide her
with diet, exercise and the very real possibility of being diabetic. She may also need an
adjustment on her blood pressure meds, as she is not at goal yet.
Because of her risk factors, and strong family history of CHD, I would strongly
recommend the use of a statin to help lower he cholesterol levels. I would educate her
about CHD, her lipid levels and what her goals should be. I would reinforce how diet,
quitting smoking and exercise would help. I’d offer her assistance with smoking
cessation. The rest of the time would be spent explaining to her the new medication, how
it works, why she needs it, and what warning signs to look out for. In an ideal world, I’d
spent most time trying to set goals for lifestyle changes and medication education.
f) You decide to place your patient on Pharmacological intervention. Name the class, the
drug, your clinical reasoning for choosing it, give dose and at least 2 side effects you
would educate your patient on. (10 Points)
Given she has no known allergies; I would personally start her on a Statin, Lipitor
(atorvastatin) 10 mg po nightly.
I chose this drug because it lowers LDL by 35-60% and increases HDL by 7-12%; it
offers the ability to increase the dose if needed as well. It may be too expensive, so a
substitute may be needed depending on her financial situation. It is generally very
tolerated with patients, few side effects. Any of the statins would be acceptable to start
with her, they would all offer benefit.
Two side effects to teach her about are: muscle pains and constipation. These side
effects are very rare, but muscle pain may indicate a serious side effect. She needs to
know to come back immediately if she develops muscle pain. Although constipation can
be annoying and uncomfortable, she may take an over the counter softener and increase
fluids. Also she should not take this medication with grapefruit juice; it would increase
the level of the drug in the system, possibly to toxic levels.
g) When would your next labs be? Indicate what these labs would be. (5 points)
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The next round of lab work would need to be taken every 2 months after starting
this medication for 6 months, and then every 6-12 months after that. The lab work needed
is LFTs. This monitors for potential side effects of this drug on the liver. If those levels
double form baseline, the medication needs to be stopped.
h) You decided to place Ms. Richards on a Statin. After 4 weeks she, returns to your
office complaining of severe muscle pain that is new for her. What do you think is going
on with your patient? What is your next intervention? Describe what labs if any and your
rationale for ordering them. (10 Points)
She could be showing signs of rhabdomyolysis. These are classic signs, especially
after starting a statin. I would tell her to come into the office immediately, or head to the
nearest emergency room/urgent care. Labs would need to be drawn including; CPK, basic
chem, CBC, LDH, SGPT (ALT), SGOT (AST), serum myoglobin. She would need
hydration and monitoring if these labs levels were elevated. All of the above labs would
show muscle damage with an elevation in their values. Elevated potassium is also seen
with muscle damage. The rapid destruction of the muscle causes leakages of protein into
the blood stream and urine. These labs would indicate if this was happening in this
patient.
Question 2 (20 points)
Mr. Brown is a 62 year old African American man that has been followed up by another
health care provider who is away from the clinic for 3 months. You decide to see the
patient after reviewing your colleagues’ patient’s labs. You note that Mr. Brown has
history of insulin-requiring diabetes mellitus and is treated for hypertension. His
HbA1c=6.9, and His BP=120/60, BMI=29. His total cholesterol is 270mg/dl, HDL is
35mg/dl, LDL=185, Triglycerides is 250 mg/dl. These values are similar to the ones
obtained 6 months earlier, when questioned, she reports that she is following her diet as
well as he can, he does not smoke.
a) What is your next most appropriate step in managing this patient’s hyperlipidemia
and why? (5 Points)
This patient would greatly benefit from a cholesterol lowering medication, especially
given that he has diabetes. This is a CHD risk equivalent and medication is
recommended according to the guidelines. His BMI is borderline obese. I would start
him on a statin, given he has had labs drawn recently. I’d place him on Zocor 20mg
PO nightly. I’d continue to encourage his diet and lifestyle modifications.
b) You see Mr. Brown back after 3 months and discover his total Chol=267mg/dl,
HDL=38mg/dl, LDL=150mg/dl, and his triglycerides are 395mg/dl, you are concerned
and you decide to add another medication. After reviewing the current NCEP-ATPIII
guidelines on hyperlipidemia pharmacological management options you chose one
medication class to add to your patient’s current treatment. Discuss your decision, include
drug class, name, dose and side effects if any and any special instructions for your
patient. Indicate the anticipated impact on HDL, LDL, and Triglycerides. (15 Points)
Well, he has met his LDL goal, which is great, but now his other numbers are
really messed up. I would first try increasing his dose of zocor. According to the
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guidelines, trying to intensify his LDL lowering drug therapy, or adding another drug is
recommended. I would probably do both. The drug of choice to add to his therapy is a
nicotinic acid or fibrate. I would lean towards Niacin (nicotinic acid) 500mg PO QHS for
three weeks, and then increase to1000mg PO QHS. Although this drug is not always well
tolerated, it does have great effects on numbers when used in combination with a statin. It
has the potential to lower HDL 10-14%, increase HDL by 24% and lower TG by 24%.
Plus it is available as a combo drug with lovastatin, which would make compliance a bit
easier with only one administration needed daily. This drug is on the market as a vitamin
and antihyperlipidemic. Niacin does have some potential unmanageable side effects. The
main complaint is of facial flushing, headache and GI upset. He shouldn’t be taking this
drug with anticoagulants, and it may increase the effects of any blood pressure
medications. As always, I need to know of any drug allergies. I would prefer he takes the
ER form, at bedtime to minimize any potential side effects. He may take this with aspirin
to see if it helps with the flushing. He should not drink alcohol. Routine labs should be
checked. He should return if he has unexplained muscle pain or weakness.
I stayed away from lopid, and other fibric acids because the risk of developing
rhabdo is increased by taking it with a statin (the risk is also present with niacin). My
experience with this class of drugs is almost nonexistent, and my gut told me he wouldn’t
be a good candidate for it at this time.
Question 3 (Total 20 points)
Johnny is a 10 year old boy who is your patient at the clinic. You have been Johnny’s
primary care provider since you started in the practice 4 yrs ago. Johnny’s wt is above
99th percentile for wt for his age and ht. His grandfather died at age 50 of heart attack and
now his father who is 45 years old is on cholesterol lowing medications. The last LDL
was elevated at 150mg/dl 1 year ago, at that time you had sent Johnny and his mom to a
dietician and he has been “trying” to follow the dietary and exercise recommendations
from the dietician. You decide to recheck Johnny’s fasting lipid profile on his visit today:
Total Chol=244mg/dl HD=40mg/dl, LDL=165mg/dl, Triglycerides=195mg/dl
After completing your clinical evaluation you decide to initiate pharmacological
intervention. What would be your first line drug treatment and why (state name of
medication, dose, and side effects). (10 Points)
This may be a trick question….There is not set in stone recommendations for
treatment in children. Bile acid sequestrants are the safest for children. However, children
don’t tolerate them well and they are not compliant with them. Soooo…
The first line drug of choice in children is a statin. There is much debate and
uncertainty with using drug in children for elevated cholesterol levels. The American
Academy of Pediatrics recently (2008) came out saying that a stain should be used as first
line. However, our trusty pediatric book states that a bile acid sequestrant should be first
line, going on to state the nasty GI side effects and issues with compliance. Much debate
is present and there is not enough research to know about long term side effects of these
drugs on children. In any event, this child is being put in danger with his weight, diet and
family history. I don’t think the parents really understand, and I would spend as much
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time as possible explaining the very serious state the child is in. I would also like to refer
them to a pediatric lipid center immediately.
And I would place the child on Pravachol, 20mg po QD, the only currently recommended
drug by the FDA for children. Side effects include headaches and GI upset. Take at
bedtime (when most cholesterol is being synthesized).
And if I should be starting with a bile acid sequestrant, it would be cholestyramine 4mg
PO daily. Side effects are all GI related; nausea, gas, nausea, vomiting, diarrhea,
constipation, heartburn.
This question is tough for me, I find myself being frustrated even having to imagine
putting a 10 year old boy on a medication for something which can be prevented. I know
I’ll run into it, I just hope I can get through to the parents enough to get the child back on
a safe road.
b) What is the minimum LDL goal for Johnny? (2 Points)
The minimum LDL goal according to AHA is those with heart disease risk factors
to be under 160, those without, under 190.
c) Name at least four dietary and lifestyle recommendations you would review with
Johnny and his mom today. (8 points)
There are a bunch of recommendations I would make, but to start with the basics
might be the best. I’d also like to see a food log of everything he eats. It’s easiest
to cut things out that just talk about his diet generally.
-Limit sedentary time (TV, video games etc) to 30min daily. Start a sport or
activity the child is interested in.
-Increase fiber in diet. Whole grains, vegetables, beans.
-Replace juice soda and other beverages with water.
-No fast foods.
-If it’s in a box, it’s bad. Most of his meals should be coming from food found
around the edges of the grocery store. Stuff down the aisles is processed, and
usually high in fat.
-Mom and Dad may want to take a class on healthy eating, how to read food
labels. Set good examples by eating healthy themselves.
I could go on and on….
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