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VOLUME 8 NUMBER 4 • NOVEMBER 2011
CASE STUDY 1
SA JOURNAL OF DIABETES & VASCULAR DISEASE
mended in patients with evidence of reduced renal function, as is the
case for James.
To manage his elevated triglyceride levels (2.7 mmol/l, despite statin
therapy), James should be encouraged to lose weight and eat a healthier,
more balanced diet, as recommended by guidelines. He should increase
his intake of high-fibre, low-glycaemic index sources of carbohydrate,
low-fat dairy products and oily fish, and limit foods containing saturated
and trans fatty acids. His elevated triglyceride levels might also be man-
aged by adding fenofibrate to statin therapy.
Encouraging lifestyle change is also important. In accordance with
NICE Public Health Intervention Guidance, James should be advised to
quit smoking, and offered a referral to an intensive support service. If he
is unwilling to accept this, he could be offered pharmacotherapy.
EXPERT CONSENSUS
It is important that James achieves the lipid targets recommended in
guidelines in order to reduce his cardiovascular risk. Given his irregu-
lar working hours and unhealthy lifestyle, his compliance with treatment
should be checked first as a possible reason for failure. If compliance is
an issue, this should be discussed with James. The use of a statin with a
longer half-life, such as rosuvastatin or atorvastatin, may be preferable.
These higher-intensity, longer half-life statins also provide additional LDL
cholesterol-lowering efficacy compared to simvastatin 40 mg.
James also presents with the mixed dyslipidaemic profile – elevated
triglycerides and low HDL cholesterol – typical of type 2 diabetes, which
persists despite statin therapy. Addition of fenofibrate to his statin
might be considered to manage his non-LDL lipids, based on guideline
recommendations and clinical evidence. Nicotinic acid can have an
advantageous effect on serum HDL cholesterol in addition to other lipids,
but would not be recommended for James because of possible negative
effects on his blood glucose control.
The target blood pressure for James should be < 130/80 mmHg given
that his eGFR is < 60 ml/min/1.73 m
2
. With his irregular working hours,
his antihypertensive medication should be changed to a once-daily ACE
inhibitor or ARB. Ramipril use is supported by findings from the Heart
Outcomes Prevention Evaluation (HOPE) study, which showed significant
reduction in CVD events and the MICRO-HOPE sub-study, which showed
reduction in overt nephropathy. Dosage should be titrated to 10 mg daily
as used in the HOPE study, with urea and electrolytes being checked
after each increase in dose.
Lifestyle advice is extremely important in this patient, and he should be
actively encouraged to improve his lipid, blood pressure and glycaemic
control.
• Consider the possibility of poor compliance, especially if the patient is not
following lifestyle advice. Emphasise the importance of concordance with
therapy
• Improve lipid control by switching to a longer-acting, higher-intensity sta-
tin; consider adding fenofibrate for management of mixed dyslipidaemia
• Emphasise the importance of lifestyle intervention
Take-home messages: type 2 diabetes patient not achieving lipid
targets
KEY GUIDANCE AND TRIALS
• NICE gives specific guidance in type 2 diabetes: CG 87 (an update
of CG66), May 2009.
and
nice.org.uk/CG66
• For information on smoking cessation, refer to NICE – Brief Interven-
tions and referral for smoking cessation in primary care and other
settings.
_
cessation.pdf and NICE Public Health Guidance 10. Smoking cessa-
tion services.
/
English
• The HOPE Study (Heart Outcomes Prevention Evaluation Study) showed
that ramipril significantly reduced the risk of the primary compos-
ite cardiovascular outcome (MI, stroke and cardiovascular death) by
25% (95% CI: 12–36,
p
= 0.0004). The MICRO-HOPE substudy also
showed reduction in overt nephropathy by 24% (95% CI: 3–40,
p
=
0.027). Treatment was well tolerated and most patients continued on
the 10-mg dose.
