doc_clotaire
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A 39-year-old Caucasian male with known type 2 diabetes mellitus visits with his family physician for the results of some recent blood work. His results are
• Total cholesterol = 230 mg/dL
• Low-density lipoprotein level = 130 mg/dL
• Triglyceride level = 200 mg/dL
• Fasting serum glucose = 130mg/dL
• Hemoglobin A1c= 6. 5%
His liver panel is normal. He is taking glyburide 5 milligram once daily. His physical examination is normal. The next best step in the treatment of this patient is
A. Add metformin to the regimen
B. Increase his dose of glyburide
C. Recommend diet and exercise only
D. Start administering simvastatin
E. Start administering simvastatin and ramipril
F. Switch his treatment to insulin therapy
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| mjl1717
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he needs a statin so I go with answer d!
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| robin082006
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E,
Goal LDL<70 in diabetic
ACEI to prevent renal complication.
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| CocaCola
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definately give a statin...
what i find confusing - do we give an ACE inh now or should we have microalbuminuria before giving it??? is HbA1c levels of 6.5 enough to give ACEinh or should it be above 7 to give it???
Sorry to answer questions with questions but i really want to know... i understand the concepts, but sometimes have problems applying them... lol
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| 92306
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A. Add metformin to the regimen
Metformin and glyburide combination brings down the HbA1c levels(His Hemoglobin A1c= 6. 5% . )
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| doc_clotaire
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Wao , discussion 's getting HOT in here , I like that guys
Come on now , we need more opinions , Remember guys , it doesn ' t matter that we screw up , that 's the way we LURN ....... sreewing up here so we won ' t do it in exam day .
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| IceAge
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I agree with 92306 ........ HbA1c is not under control ...... add metformin ...... watch cholesterol and ask patient to do other things ....... if still not controlled then give statins.
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| sarika
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i think this is diabetic nephropathy induced hyperlipidemia. Dont really know what to do with it. If i ahd to choose i would choose E or A
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| mitty
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HgbA1c is below 7% that means long time glycemic control.No need to add metformin.
ACEIs are given if there is microalbuminuria.(In the kaplan endocrinology DVD the man says,though ACEis prevent microalbuminuria giving them before microalbuminuria is not a standard yet) so I will pick D
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| Geroo
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D
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| snowdrops
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The best treatment for DM 2 is diet and exercise. So, answer is C.
Hope I am right.
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| NE
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I guess it is D.
His blood sugar is under control so we don't need to change something (The International Diabetes Federation and American College of Endocrinology recommends HbA1c values below 6.5%, while the range recommended by the American Diabetes Association extends to 7%. )
We don't know anything about urine analysis - so I don't think ACE inhibitors is a choice ( like mitty wrote - giving them before microalbuminuria is not a standard yet)
The only problem here is lipid control so he needs statins.
Actually elevated LDL is a risk factors for microalbuminuria in normotensive and normocholesterolemic patients with type 2 diabetes.
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| doc_clotaire
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CORRECT: E
The patient currently has good control of his diabetes mellitus based on the hemoglobin A1c and serum plasma glucose. According to the new guidelines of the National Cholesterol Education Program regarding adenosine triphosphate III, diabetes mellitus is regarded as a coronary artery disease risk equivalent, and the goals for lipid levels in patients with the disease should be a low-density lipoprotein level of less than 100 mg/dL, a total cholesterol level less than 200 mg/dL, and a triglyceride level less than 150 mg/dL. The high-density level lipoprotein should be as high as possible. Therefore adding simvastatin (An HMG-Co A reductase therapy for lipid control) is a good idea. Angiotensin converting enzyme inhibitor (ACE inhibitor) regardless of hypertension or early nephropathy is nephroprotective in patients with diabetes mellitus.
ACE inhibition therapy both reduces the degree of proteinuria in patients who have proteinuria and independently retards the progression of renal insufficiency. Some small studies and expert opinion are even recommending the prophylactic use of ACE inhibition therapy in normotensive diabetics specifically for this purpose.
Changing his current diabetic regimen, increase the dose of glyburide, or adding metformin to the regimen, or switching to insulin would not affect the lipid panel. recent meta-analysis of all studies performed between 1966 and 1991 to evaluate the efficacy of combination therapy concluded that only a modest benefit was achieved at a significant increase in cost and the risk of hypoglycemia.
Diet and exercise are a crucial component to the long term care of diabetes mellitus. Weight reduction may decrease insulin tolerance. For most patients with diabetes mellitus, diet and exercise alone is insufficient and some form of pharmacotherapy is eventually needed. The first choice is actually metformin.
EXAM MASTER CORPORATION
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| snowdrops
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snowdrops wrote:
The best treatment for DM 2 is diet and exercise. So, answer is C.
Hope I am right.
Too bad, I didn't notice ONLY at the end of C.
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| liwei
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DM patients need statins if LDL >= 130, need ACEI if they have HBP or microalbuminuria.
HbA1C 6.5 is good enough
So D
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| liwei
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this patient should be on diet already
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| NE
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I, sorry but I still don't understand. The q should refer to STANDARD therapy. Where is any referral at his renal status/blood pressure?
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| NE
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There is preliminary evidence that ACEIs and ARBs can retard the development of microalbuminuria amongst patients with type 2 diabetes and this treatment may prove cost-effective; whether these findings indicate that all patients with type 2 diabetes should be so treated requires further analysis.
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| Geroo
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I'm still thinking that D should be the answer,we don't give ACEI to all diabetics without any evidence of renal impairement.I don't think that E should be the answer.
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| Aashi
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Many studies has shown that TYPE2 D.M when first time dx has already has some renal impairment like microalbuminuria until proven otherwise,coz type 2DM is first time dx ten yrs later coz its highly asymtomatic in the beginning....unlike type 1 its takes almost 5 yrs after the dx for renal impairement to set in.coz type 1 D.M is very symptomatic and they dx of type 1 is made very early in the course of the disease unlike type 2...and thatz y the screening tests for renal,and opthalmologic testing is done rt from the day 1 of dx for type 2 and only at puberty or 3-5 yrs later for type 1 DM
ACE(-) prevents the further progression of the renal disease and also can be given in pts who r normotensive...and the option E according to me is absolutely right!
GL
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| liwei
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we need indication to give a medication
I still choose D
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| Geroo
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doc_clotaire may I ask where is this question from.
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| doc_clotaire
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Exam Master !
Just copy and paste
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| Geroo
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thanks doc_clotaire
I never heard of master exam,is it a good source of questions like USMLE world?
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| NE
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Guys, I guess we have to know what the guidelines say about a indication. Aashsi is right but :
"ACE inhibitors slow the onset of diabetic nephropathy in patients with microalbuminuria and type 1 diabetes. Normotensive, nonalbuminuric diabetics also have a slower onset of nephropathy; however, the ADA currently does not recommend ACE inhibitors as primary prevention in these patients, and there is no evidence that this practice affects outcomes." (from American diabetes assoc)
http://docnews.diabetesjournals.org/cgi/content/f... ( read the first and last paragraph if you don't have time)
So I guess it is D.
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