A 46-year-old man comes to the office for a routine health examination. The patient has no current concerns and says he is taking his medications as prescribed. He has a history of type 2 diabetes mellitus treated with diet, exercise, and metformin. The patient smokes a half pack of cigarettes a day and drinks 1 or 2 glasses of wine 3 times a week. Temperature is 36.7 C (98 F), blood pressure is 128/76 mm Hg, pulse is 80/min, and respirations are 14/min. Laboratory results are as follows: Serum chemistry values are within normal limits. Urinalysis shows no proteinuria. The addition of which of the following is most appropriate in the management of this patient?

Question

A 46-year-old man comes to the office for a routine health examination.  The patient has no current concerns and says he is taking his medications as prescribed.  He has a history of type 2 diabetes mellitus treated with diet, exercise, and metformin.  The patient smokes a half pack of cigarettes a day and drinks 1 or 2 glasses of wine 3 times a week.  Temperature is 36.7 C (98 F), blood pressure is 128/76 mm Hg, pulse is 80/min, and respirations are 14/min.  Laboratory results are as follows:  Serum chemistry values are within normal limits.  Urinalysis shows no proteinuria.  The addition of which of the following is most appropriate in the management of this patient?

Quizplus · Accepted Answer

11ec25c8_d257_34ab_bc81_c79ac570b759_MD0003_00 Diabetes mellitus (DM) accelerates atherosclerosis and increases the risk of developing clinically significant atherosclerotic cardiovascular disease (ASCVD). Statin therapy is effective in reducing this risk and likely does so independent of lipid levels. Therefore, it is recommended that all patients age ≥40 with DM are treated with statin therapy for primary prevention of ASCVD, regardless of LDL level. In younger patients with DM, the decision to initiate statin therapy should be made on an individual basis. In patients at high risk of ASCVD (based on poorly controlled blood sugars or other risk factors [eg, hypertension, family history]) who desire aggressive risk factor management, the initiation of statin therapy prior to age 40 may be considered. (Choices A and D) This patient's blood pressure is already at goal as current guidelines recommend a target of <140/90 mm Hg in patients age <60 with or without DM. Patients with diabetic nephropathy may benefit from tighter blood pressure control of <130/80 mm Hg. Due to renal protective effects, ACE inhibitors are the preferred antihypertensive agent in patients with DM. Dihydropyridine calcium channel blockers (eg, amlodipine) are also appropriate when needed. Conventional beta blockers (eg, metoprolol) are generally an unfavorable option in patients with DM due to negative effects on insulin sensitivity. current guidelines (Choice B) Fibrates (eg, gemfibrozil) are effective in reducing triglyceride levels; however, statins have greater proven cardiovascular benefit and are the preferred first-line therapy for prevention of ASCVD in patients with mild hypertriglyceridemia (ie, 150-500 mg/dL). Fibrates are indicated in patients with severe hypertriglyceridemia (ie, >1000 mg/dL) to reduce the risk of acute pancreatitis. indicated (Choice C) This patient's hemoglobin A1c is already within the goal of <7%; an increase in therapy (eg, the addition of glimepiride) is not indicated and is likely to precipitate episodes of hypoglycemia. Educational objective: Statin therapy is indicated for the primary prevention of atherosclerotic cardiovascular disease in all patients age ≥40 with diabetes mellitus, regardless of LDL level. References: 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/30879355) Effect of intensive treatment of hyperglycaemia on microvascular outcomes in type 2 diabetes: an analysis of the ACCORD randomised trial. (http://www.ncbi.nlm.nih.gov/pubmed/20594588) Effects of intensive blood-pressure control in type 2 diabetes mellitus. (http://www.ncbi.nlm.nih.gov/pubmed/20228401) Effects of combination lipid therapy in type 2 diabetes mellitus. (http://www.ncbi.nlm.nih.gov/pubmed/20228404)

A 46-Year-Old Man Comes to the Office for a Routine