A 47-year-old man comes to the office for a routine health examination. He has no symptoms except for a mild increase in frequency of urination. The patient has a history of elevated glucose levels but no other medical conditions, and he takes no medications. Family history is significant for type 2 diabetes mellitus. He does not use tobacco, alcohol, or illicit drugs. Temperature is 36.7 C (98 F), blood pressure is 132/80 mm Hg, pulse is 72/min, and respirations are 16/min. BMI is 33 kg/m². Fasting laboratory results are as follows: Which of the following is the most appropriate next step in management of this patient's condition?

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11ec25c8_d241_3b90_bc81_9526e2cfea67_MD0003_00 This patient has diabetes mellitus, confirmed with a fasting blood glucose ≥126 mg/dL and a hemoglobin A1c ≥6.5%. Patients with diabetes have an increased risk of atherosclerotic cardiovascular disease (ASCVD) and warrant aggressive management of cardiovascular risk factors. Patients with diabetes should initiate lifestyle modification (ie, dietary changes, exercise) to lower blood glucose; some experts also advise prescribing metformin at the time of diagnosis, whereas others suggest a brief trial of lifestyle measures without medication for those whose A1c is only mildly elevated. Lifestyle measures, with or without medication, are also warranted to lower blood pressure to <140/90 mm Hg; if tolerated, efforts may be intensified to a target of <120/80 mm Hg. In addition, lipid-lowering therapy with a statin is recommended for all patients age ≥40 with diabetes. It is also recommended for those age <40 with established ASCVD or multiple additional risk factors. In general, moderate-intensity statin therapy (eg, atorvastatin 10-20 mg, rosuvastatin 5-10 mg, simvastatin 20-40 mg) is recommended for patients without known ASCVD, whereas high-intensity therapy (eg, rosuvastatin 20-40 mg, atorvastatin 40-80 mg) is recommended for patients with established ASCVD or with an estimated 10-year ASCVD risk ≥20% using the Pooled Cohort Equations calculator. calculator (Choice A) Lifestyle measures without lipid-lowering medication can be considered for patients with diabetes age <40 who are otherwise at low risk for ASCVD. This patient is age 47 and a statin is indicated. (Choices B and C) Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors (eg, evolocumab) and ezetimibe are second-line lipid-lowering agents that can be considered for high-risk patients with established ASCVD whose LDL cholesterol level is not at goal despite maximally tolerated statin therapy. However, statins are the preferred first-line drugs. (Choice D) Phentermine is a centrally acting appetite suppressant that is indicated for weight loss in patients with a BMI ≥30 kg/m² or a BMI ≥27 kg/m² with additional weight-related comorbidity (eg, diabetes). Although it can induce rapid weight loss, phentermine has little long-term efficacy, and weight loss medications are generally reserved for patients who do not achieve significant weight loss despite 3-6 months of lifestyle measures. Educational objective: Lipid-lowering therapy with a statin is recommended for patients with type 2 diabetes mellitus age ≥40 and for those age <40 with established atherosclerotic cardiovascular disease (ASCVD). In general, moderate-intensity statin therapy is recommended for patients without known ASCVD, whereas high-intensity therapy is recommended for those with established cardiovascular disease. References: Primary prevention of major cardiovascular and cerebrovascular events with statins in diabetic patients: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/23186103)

A 47-Year-Old Man Comes to the Office for a Routine