A 47-year-old Caucasian man comes to the office for a follow-up visit. He was recently diagnosed with diabetes mellitus type 2, and was started on a low-carbohydrate diet six months ago. He also has obesity, hypertension and hyperlipidemia. He is a financial advisor. He does not use tobacco or illicit drugs, but drinks alcohol occasionally. His medications include enalapril, simvastatin and hydrochlorothiazide. Examination shows no abnormalities. His laboratory test results show the following:
Serum Chemistry
LFT
Lipid Profile
Which of the following is the most appropriate pharmacotherapy for this patient?

Question

A 47-year-old Caucasian man comes to the office for a follow-up visit.  He was recently diagnosed with diabetes mellitus type 2, and was started on a low-carbohydrate diet six months ago.  He also has obesity, hypertension and hyperlipidemia.  He is a financial advisor.  He does not use tobacco or illicit drugs, but drinks alcohol occasionally.  His medications include enalapril, simvastatin and hydrochlorothiazide. Examination shows no abnormalities.  His laboratory test results show the following:
Serum Chemistry
 LFT
 Lipid Profile
 Which of the following is the most appropriate pharmacotherapy for this patient?

Quizplus · Accepted Answer

Explanation: Despite a low-carbohydrate diet, this patient has uncontrolled diabetes, hypercholesterolemia and hypertriglyceridemia. He probably has non-alcoholic steatohepatitis (NASH), manifested by mild elevations of the liver enzymes (AST/ALT less than one) and alkaline phosphatase. He needs to be started on pharmacologic therapy. Metformin will be very useful in this case. It is a biguanide that is ideal for obese patients because its use is associated with some weight loss. It decreases fasting glucose levels by around 20%. It has proven to be helpful in patients with hypertriglyceridemia and hepatic steatosis by improving glycemic control and helping to stabilize obesity. (Choice A) Sulfonylureas (e.g., glyburide, glipizide or glimepiride) will aggravate the patient's obesity, and will not improve his lipid profile. (Choice C) Insulin is not recommended at this point because other alternatives have not been tried yet. (Choice D) Acarbose's efficacy is low when used alone. Its benefit will be marginal in this case. (Choice B) Although a thiazolidinediones (e.g., pioglitazone) is effective for glycemiccontrol, and can improve NASH, their use is not recommended in obese patients because of an associated weight gain, which is in part due to fluid retention. Like metformin, they decrease the triglyceride levels and increases HDL; however, they are potentially more hepatotoxic. Educational objective: Metformin is especially useful in the management of obese, diabetic patients. This drug, along with pioglitazone, decreases triglycerides, increases HDL and improves NASH. Thiazolidinediones, insulin and sulfonylureas can cause weight gain. Acarbose's action is too weak to be used as monotherapy.

A 47-Year-Old Caucasian Man Comes to the Office for a Follow-Up