Clinical Case Reports and Reviews

Case Report ISSN: 2059-0393

A case report of dyslipidemia management in new-onset

type 2 diabetic patient
Danish Mahmood*
Department of Pharmacology and Toxicology, Unaizah College of Pharmacy, Qassim University, Kingdom of Saudi Arabia

Abstract
New-onset diabetes is a serious condition and is characterised by insulin resistance and dyslipidemia affecting adults and more lately children. Diabetic dyslipidemia
is characterised by high plasma triglycerides and low-density lipoprotein cholesterol (LDL-C) particles, and low high-density lipoprotein cholesterol (HDL-C).
Individuals with dyslipidemia have a high 10-year risk of atherosclerotic cardiovascular disease (ASCVD) and can be managed by adopting therapeutic lifestyle
changes (TLC) and medication adherence. The new American College of Cardiology/American Heart Association (ACC/AHA) guideline emphasizes on matching
the intensity of statin treatment to the level of ASCVD risk and replaces the old paradigm of LDL-C target based treatment, and the new guidelines of National
Lipid Association (NLA) have recommended a multifaceted patient centered approach for the management of dyslipidemia. Both ACC/AHA and NLA have
recommended statins as the main stay of drug therapy in patients with high cholesterol. Unlike ACC/AHA guidelines who do not recommend the use of nonstatin
drugs except in the statin-intolerant patients, the NLA advocates nonstatins use in high-risk patients, and in patients with inherited cholesterol disorders, after statin
therapy. Medication non adherence is a frequent problem in developing countries because of the low income and high cost of drugs which are sometimes required
for a long duration of time. TLC has been reported to aid drug therapy to provide best medication benefit but lack of knowledge and illiteracy is another limitation
to achieve maximum benefits from drug therapy in India.
In conclusion, both TLC and medication adherence are important for dyslipidemia management with lipid lowering drugs in new-onset type 2 diabetic patient, and
healthcare providers should provide knowledge on the benefits of TLC and medication adherence in countries with low income/socio-economic status.

Introduction We present here a case report of effective management of

dyslipidemia in a new-onset type 2 diabetic with TLC and strict
New-onset diabetes is a serious condition that adversely affects adherence to pharmacological treatments.
the body’s ability to regulate glucose. The new-onset diabetes is
characterized by a form of insulin resistance that historically affected Case report
individuals in adulthood. In recent years, however, diagnoses of this
A 60-year old man with new-onset, type 2 diabetes mellitus visited
disease have become prevalent in children. It is often observed that
a tertiary care hospital in India. His weight and height was 80 kg and
people who are obese and insulin resistant often have a dyslipidemia.
5’9”, respectively. The patient had a body mass index of 26 kg/m2
Dyslipidemia is commonly characterized by elevated blood triglyceride
and blood pressure measured as 140/90 mm Hg. He had a sedentary
(TG) concentrations and low high-density lipoprotein cholesterol
lifestyle, mild polyphagia, and presented with nonspecific complaints
(HDL-C) [1]. These characteristic are also considered important
of fatigue and lack of general sense of well-being. The patient had strong
cardio-metabolic risk factors, increase the risk of macrovascular and
positive family history of cardiovascular diseases (CVD), his father had
microvascular complications in type 2 diabetes for the development myocardial infarction (MI) which proved to be fatal, mother and elder
of cardiovascular diseases [2]. Dyslipidemia consisting of high TGs sister had type 2 diabetes and younger brother had an ischemic stroke
and low HDL-C is a widely recognized lipid pattern that is frequently 5 years ago. Laboratory findings showed total cholesterol as 227 mg/
associated with the development of coronary heart disease. Study has dL, HDL-C levels as 40 mg/dL, LDL- as 125 mg/dL, TG as 140 mg/
suggested that dyslipidemia in diabetic patients should be treated for dL, fasting blood glucose as 104 mg/dL, and glycated haemoglobin
primary prevention with the same intensity recommended for secondary (HbA1C) as 8%. Patient was taking metformin plus atorvastatin (500
prevention in heart patients, before the development of cardiovascular mg + 10 mg, once daily) for past 3 months but had poor adherence
disease [3]. Strict adherence to treatment is essential to avail maximum to treatment. His 10-year risk of atherosclerotic cardiovascular disease
benefits of therapy. Further, Therapeutic Lifestyle changes (TLC) have (ASCVD) risk was calculated as 23.5% using pooled cohort risk
been reported to reduce LDL-C, TG, blood pressure, glucose and body assessment equations.
weight and increase HDL-C level and have greatly complemented
the drug therapy [4]. Therefore, strict adherence to the prescribed
therapy and TLC are key to obtain optimum therapeutic benefits. In
poor countries like India and others, socio-economic states are major Correspondence to: Danish Mahmood, Department of Pharmacology and
determinant of medication continuation and play an important role Toxicology, Unaizah College of Pharmacy, Qassim University, Kingdom of Saudi
Arabia, Tel: +966594016751; E-mail: ma.alam@qu.edu.sa
in deciding adherence rate. There has been a significant association
between patients with low-income and non-adherence to drugs, and Key words: dyslipidemia, LDL-C, TLC, diabetes, ACC/AHA, ASCVD
high cost of newer oral hypoglycaemic agents have hindered optimal Received: February 14, 2015; Accepted: March 17, 2015; Published: March 21,
adherence to the treatment [5]. 2015

Clin Case Rep Rev, 2015 doi: 10.15761/CCRR.1000114 Volume 1(2): 37-39
 Mahmood D (2015) A case report of dyslipidemia management in new-onset type 2 diabetic patient

After strict adherence to the prescribed treatment (metformin and recommended to lower ASCVD and can be achieved by atherogenic
atorvastatin) and lifestyle modifications, his HbA1C level improved to cholesterol lowering through multiple modalities, including lifestyle
7% and LDL-C dropped to 73 mg/dL at 3-month follow-up. and drug therapies. The intensity of risk-reduction therapy should be
individualised based on the patient’s absolute risk for an ASCVD event
However, there was no significant improvement in HDL-C and TG
and, both intermediate-term and long-term/lifetime risk should be
levels after initiation of atorvastatin. During treatment, the clinician
considered when assessing the potential benefits and hazards of risk-
increased the atorvastatin dose to 80 mg/day which further reduced
reduction therapies [14]. Both NLA and ACC/AHA recommend statin
LDL-C level. The high atorvastatin dose was well-tolerated by the
treatment as the mainstay of drug therapy to reduce ASCVD risk in
patient with no elevations of alanine/aspartate aminotransferase. At
patients who have been considered for treatment with lipid-lowering
6-month follow-up, the LDL-C level again rose to 85 mg/dL, which
drug therapy. Further, NLA recommends management of non-
was found to be due to medication noncompliance.
lipid ASCVD risk factors particularly high blood pressure, cigarette
Discussion smoking, and diabetes mellitus.

The present case report highlights how life style modification The ACC/AHA have recommended 80 mg (40 less preferred) dose
and strict adherence to treatment can effectively manage diabetic of high intensity atorvastatin. Hence, atorvastatin dose was increased
dyslipidemia in type 2 diabetes. from 10 mg to 80 mg. He was advised to adopt TLC as the 2013 ACC.
AHA guideline have laid extra emphasis on lifestyle modification (i.e.,
Lifestyle changes, including increased physical activity and dietary adhering to a heart healthy diet, regular exercise habits, avoidance
modifications remains the cornerstone of management of atherogenic of tobacco products, and maintenance of a healthy weight). TLC
dyslipidemia in type 2 diabetes [6-8]. In our report, when the lifestyle constitutes an important element in the health promotion and ASCVD
of the patient was modified and he strictly adhered to the treatment as risk reduction, both prior to and in concert with the use of cholesterol
suggested by the physician, his HbA1c and LDL-C levels significantly lowering drug therapies. TLC is a comprehensive lifestyle approach
improved. thatincludes specific dietary recommendations (TLCdiet), weight
Our findings are in concordance with earlier reported literature management, and increased physicalactivity. The TLC emphasizes
where intensive lifestyle interventions yielded better long-term impact reducing dietary cholesterol (<200 mg/day), saturated fats (<7% of total
on cardiovascular morbidity and mortality in overweight patients calories), and trans fats (lower intake). Total fat comprises 25-35% of
with type 2 diabetes than standard diabetes support and education total calories, with up to 20% coming from monounsaturated fats and
programs [9]. Similarly, stepwise introduction of lifestyle modification 10% from polyunsaturated fats. The optional nutrient considerations
with pharmacologic interventions helped to reduce the risk of deaths for augmented LDL-C reduction and reducing coronaryheart disease
(53%) due to CVD, nonfatal MI, percutaneous coronary interventions, risk include stanols/sterols (2 g/day) and viscous (soluble) fibers (5-10
nonfatal stroke, and coronary artery bypass grafting in patients g/day), and including fish (especially oily fish such as salmon, tuna, and
with type 2 diabetes and microalbuminuria [10]. Metformin is most mackerel) as part ofone’s overall eating plan [4].
prescribed oral antidiabetic agent [11]. Statins, the lipid-lowering After the use of high intensity atorvastatin dose (80 mg/day),
therapy, is the recommended initial pharmacological treatment for his significantly LDL-C reduced with no adverse events indicating
lowering LDL-C levels in “very high risk” and “high-risk” categories of that the dose was safe. The diabetes atorvastatin lipid intervention
type 2 diabetes. Atorvastatin is one of the most worldwide prescribed (DALI) study have reported that either 10 or 80 mg of atorvastatin
statins [12]. is equally effective in the treatment of diabetic dyslipidemia [15]. In
Looking at the calculated 10 year risk of ASCVD of the patient, he 2008, Balasubramanian et al. in a study on Indian patients assessed
was at an elevated 10-year risk (≥ 7.5%) for ASCVD. As per the Pooled the efficacy, safety and tolerability of a fixed dose combination of
Cohort Risk Assessment Equation, a high-intensity statin should be atorvastatin 10 mg + metformin SR 500 mg in adult Indian patients
considered for this patient who has a 10-year ASCVD risk ≥ 7.5% with diabetic dyslipidaemia. Further, increased dose of atorvastatin was
and fall in the age bracket of 40-75 years and also have LDL 70-189 safe in the present case [16]. This was consistent with previous study
mg/dL. The 2013 American College of Cardiology (ACC)/American reporting that atorvastatin initiated at doses of 10, 20, 40, and 80 mg
was effective and safe for the treatment of patients with dyslipidemia.
Heart Association (AHA) have recommended either a high-intensity
It was further stated that the dose of atorvastatin should depend on the
or moderate-intensity statin regimen in patients who have an elevated
percentage reduction needed to achieve an LDL-C goal, patients with
ASCVD risk (≥ 7.5%) for primary prevention of cardiovascular disease
or at risk of coronary heart disease may benefit from starting therapy at
[13]. The new ACC/AHA guideline emphasizes matching the intensity
a higher dose of atorvastatin [17].
of statin treatment to the level of ASCVD risk and replaces the old
paradigm of pursuing LDL-C targets. While, the new guidelines of Our results were parallel with the earlier reported literature where
National Lipid Association (NLA) have recommended a multifaceted high-dose statins led to significant reduction in the mean LDL-C
approach to incorporate each patient risk and risk factors, rather than levels and in the occurrence of major CV events (CHD, stroke,
specific medication categories for the management of dyslipidemia. revascularizations) in comparison to low-dose statins [18]. In 2006,
The NLA recommendations differ from the ACC/AHA guidelines in Shepherd et al. [19] reported high-dose statin monotherapy as safe
that it continued the use of lipid-goals and non-HDL treatment goals, with no treatment-related adverse events and no elevated levels of liver
as it considers non-HDL to be a better predictor of ASCVD morbidity enzymes.
and mortality than LDL. Also, unlike ACC/AHA, NLA do not advocate In developing and poor economic countries including India, there
the use of a particular risk calculator. An elevated level of atherogenic continues to be low medical education and awareness on effective
cholesterol is regarded as the root cause of atherosclerosis, the key usage of medications prescribed by doctors. The illiterate and poor
underlying process contributing to most clinical ASCVD. Hence, patients tend to abruptly quit medication or do not stick to the
reducing elevated levels of atherogenic cholesterol particles has been prescribed dosage regimen of the medication leading to suboptimal

Clin Case Rep Rev, 2015 doi: 10.15761/CCRR.1000114 Volume 1(2): 37-39
 Mahmood D (2015) A case report of dyslipidemia management in new-onset type 2 diabetic patient

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Copyright: ©2015 Mahmood D. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.

Clin Case Rep Rev, 2015 doi: 10.15761/CCRR.1000114 Volume 1(2): 37-39