2min read - Diabetes Obesity and Hyperlipidemia

A 48 years old female patient came to a GP for a routine check up. She was asymptomatic.

BMI - 25.8kg/m2
Blood pressure - 135/85


FBS - 145
HbA1C - 7.6%

She was started on metformin 500mg three times a day.

A month later she was reviewed with following investigations.

Lipid Profile

Total C - 255
LDL C - 168
HDL C - 38
TG C - 215

FBS - 96mg/dl

ALT - 56 u/l
AST - 38 u/l

How are you going to approach this patient?


(Please note the following discussion is fairly superficial as it is intended to be read by medical students. They hardly ever read though!)


What are the problems this patient has got?

She has diabetes mellitus which is under reasonable control.
She has obesity.
She has hypercholesterolemia.
She has abnormal liver functions.
Her blood pressure is just around the margin for hypertension.


What are you going to do about her diabetes?

With metformin alone her blood sugar is controlled. Therefore, I shall continue it. However I would review her in three months with HbA1C to assess control.

In the meantime I will also arrange a screening for microvascular complications with ophthalmological examination and microalbuminuria.



Why should we even worry about her lipid status if the sugar control is good?

It's proven beyond doubt that good control of blood sugar will prevent the patient from getting microvascular complications of diabetes. So blood sugar control is paramount.

However, patients with diabetes mainly die of other complications such as ischemic heart disease, heart failure or strokes. Tight sugar control alone can not prevent the patient from getting those.

For that reason we have to control other risk factors for development of macrovascular complications. Out of them major risk factors include but not limited to,

• Smoking
• Hypercholesterolemia
• Hypertension

So basically, to prevent death controlling above may be more important than controlling diabetes! Of course, I'm not talking about a patient with sky high sugar. They can die of diabetic emergencies or infections.



So what's your plan for this patient. His liver tests are abnormal. Can you start statins?

In this context the abnormal liver tests are most likely to be due to non-alcoholic fatty liver disease. You should take a detailed history and examine thoroughly to exclude possibility of other diseases too. If there is a suspicion you will have to investigate further.

Fatty liver per se is not a contraindication to start statins, provided that transaminase levels are less than 3 times the ULN. If they are higher, always take an advice from a hepatologist.



Which statin and what dose?

Current guidelines base target LDL level according to the patients risk category. If you are really interested you can refer a guideline. But, knowing following principles will be sufficient to manage most of the patients.

1. Any patient with established cardiovascular disease - High intensity statin (40-80mg Atorvastatin) . Aim for LDL less than 70.
2. Any patient with DM above 40 years - Moderate intensity statin (20-40mg Atorvastatin). Aim for LDL less than 100.
3. Any patient with LDL > 190 - Moderate intensity statin.

In the presence of other risk factors you may consider higher doses. It's always good to estimate 10-year cardiovascular risk using one of the calculator. If it's more than 20% always think of starting high dose statin.

Let me show her risk using ASCVD risk estimator provided by American college of cardiology.
(http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/)

You will note that her risk is not that high at 5.2%. So moderate intensity statin would be adequate.



So what about fatty liver?

You can always arrange a ultrasound scan to look for presence of fatty liver. You may not need to investigate further.

Diet control and weight reduction by 5% can 'cure' her fatty liver. No need of starting other drugs. You may follow up her with liver tests.



Thats a lot for the day. Can you sum up her management please?

Diet and Exercise, try a target weight reduction of 5%. Continue Metformin. Add Atorvastatin 20mg (Some may prefer 40mg!). Review her with HbA1C, AST, ALT and USS abdomen. Monitor blood pressure. Assess her for diabetes related other complications.