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VOLUME 1 ISSUE 2 CASE WM	WM is a 55-year-old man with new onset diabetes.
CHIEF COMPLAINT WM complains of polydipsia, fatigue, and polyuria. LABORATORY VALUES »  Fasting glucose: 123 mg/dL »  Fasting C-peptide: 8 ng/dL (normal: <5) »  A1c: 8.3 % »  Blood pressure: 145/90 mm Hg »  Lipid profile   --  Total cholesterol: 194 mg/dL   --  Triglycerides: 220 mg/dL   --  High-density lipoprotein: 25 mg/dL   --  Calculated low-density lipoprotein: 125 mg/dL   --  Non-HDL cholesterol: 169 mg/dL PROBLEMS This patient displays several features typical of type 2 diabetes, including: 1. Uncontrolled hyperglycemia 2. Moderate hypertension 3. Dyslipidemia NAVIGATION »  Q1: What is your first step? »  Q2: What is your initial treatment plan to manage this patient’s hyperglycemia and dyslipidemia? »  Q3: How would you characterize WM’s cardiovascular risk based on this lipid profile? »  Q4: How could you further characterize WM’s lipid profile? »  Q5: What pharmacologic interventions can increase total HDL and HDL2? »  Q6: What are the expected results if a TZD and statin are used in combination? »  Q7: What other changes, if any, do you make in WM’s treatment plan? »  Q8: What are the advantages and disadvantages of adding a fibrate or niacin? »  Q9: You decide to add fenofibrate 54 mg/d to target triglycerides and HDL-C. What should you do if WM reports suggestive muscle symptoms?	Q: How could you further characterize WM’s lipid profile? A: You could request further lipid testing to establish lipid particle size. Although it is not routine in clinical practice, obtaining lipid subfractions can reveal specific information about the composition of a patient’s lipid profile. WM has a predominance of small dense LDL particles and has an HDL2 level of 6 mg/dL (normal: >10 mg/dL). HDL2 levels provide the best estimate of the antiatherogenic effects of HDL-C, because HDL2 is the only HDL particle that participates in reverse cholesterol transportation (a process in which HDL-C particles transport cholesterol from peripheral cells to the liver). A low HDL2 level increases the risk of a cardiac event.
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