A 40-year-old man comes to the office for follow-up of type 1 diabetes mellitus. He was diagnosed 3 years ago when he was admitted to the hospital for diabetic ketoacidosis. The diabetes is treated with a continuous subcutaneous insulin infusion via an insulin pump, and most blood glucose levels are within 80-120 mg/dL with no significant hypoglycemic episodes. The patient exercises 5 days a week and follows strict dietary restrictions; he has avoided eating "junk food" apart from a small slice of cake on his birthday 3 months ago. Medical history is notable only for mild vitiligo, and his only other medication is a daily multivitamin. The patient does not use tobacco, alcohol, or illicit drugs. Family history is negative for diabetes mellitus and premature coronary artery disease. Blood pressure is 126/80 mm Hg and pulse is 68/min. BMI is 23.4 kg/m². Physical examination, including lower extremity monofilament testing, is normal. Laboratory results are as follows: Which of the following is the best next step in management of this patient's condition?

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Explanation: 11ec2b69_beb0_c96b_8f63_4f11f48d450f_MD0005_00 Although most cases of type 1 diabetes mellitus (DM) present in childhood or adolescence, approximately 25% present in adulthood. Patients with DM are at increased risk for atherosclerotic cardiovascular disease (ASCVD) compared with the general population; this risk can be reduced with statin therapy. Current guidelines recommend statin therapy for the primary prevention of ASCVD in all patients age ≥40 with type 1 or type 2 DM. The intensity of therapy depends on the overall 10-year risk for cardiovascular events, which can be estimated using the Pooled Cohort Equations. This patient's calculated 10-year risk is <20% (ie, ~2%); therefore, moderate-intensity statin therapy is appropriate. Pooled Cohort Equations (Choice A) Continuation of current therapy would be appropriate for a patient age <40 with DM and without established ASCVD; however, statin therapy is indicated for this 40-year-old patient. (Choice C) Screening for diabetic retinopathy is indicated beginning 5 years after the original diagnosis in patients with type 1 DM and at the time of diagnosis in those with type 2 DM. Diabetic retinopathy screening is not yet indicated in this patient with type 1 DM diagnosed 3 years ago. In addition to reducing cardiovascular risk, statin therapy may also delay the onset and slow the progression of diabetic retinopathy in patients with DM. (Choice D) Patients with type 1 DM should be screened for diabetic nephropathy using urine microalbumin testing beginning 5 years after original diagnosis; screening for patients with type 2 DM should begin at the time of diagnosis. Those patients with evidence of diabetic nephropathy should be prescribed an ACE inhibitor, which is also the preferred medication for treating hypertension in patients with DM. This patient has neither indication for ACE inhibitor therapy. (Choice E) Aspirin is indicated for secondary prevention of cardiovascular events in patients with established ASCVD and for primary prevention in at-risk patients age 50-70. It can be considered for primary prevention in those with DM who have a 10-year risk ≥20%, but for younger and relatively low-risk individuals such as this patient, the benefits are likely outweighed by the risks of bleeding. Educational objective: Statin therapy is recommended for the primary prevention of atherosclerotic cardiovascular disease (ASCVD) in all patients age ≥40 with type 1 or type 2 diabetes mellitus. The intensity of therapy depends on the overall 10-year ASCVD risk, with high-intensity statin therapy recommended for those with an estimated risk ≥20%. 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)

A 40-Year-Old Man Comes to the Office for Follow-Up of Type