Patient Care Endocrinology & Cardiology - October 2007 - (Page 17)

Metabolic syndrome I 500 mg/dL.33 When statin therapy alone does not achieve target LDL-C levels, ezetimibe (Zetia) provides an additional 15% to 20% decrease of LDL-C. It also has a modest effect in lowering triglycerides. Once LDL-C goals have been attained, other elements of dyslipidemia should be addressed. The second treatment goal for the management of dyslipidemia is correction of low levels of HDL-C and elevated triglycerides. If triglycerides are substantially elevated ( 250 mg/dL), this goal may be attained by prescribing a fibric acid derivative. Recently, however, it has been recognized that gemfibrozil (Lopid) inhibits the glucuronidation of many statins, thereby resulting in elevated serum statin levels. In patients with substantially elevated triglycerides who are already receiving statin therapy, fenofibrate (Tricor) is thus preferred. The smallest possible dosage that produces an acceptable modification of triglyceride levels should be used. In patients with low HDL-C ( 40 mg/dL in men, 50 mg/dL in women) in whom triglycerides are REFERENCES 1. Reaven GM. Banting lecture 1988: role of insulin resistance in human disease. Diabetes. 1988;37:1595-1607. 2. Alberti KG, Zimmet PZ. Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus provisional report of a WHO consultation. Diabetes Med. 1998;15:539-553. 3. Balkau B, Charles MA. Comment on the provisional report from the WHO consultation. European Group for the Study of Insulin Resistance (EGIR). Diabetes Med. 1999;16:442-443. 4. Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA. 2001;285:2486-2497. 5. Einhorn D, Reaven GM, Cobin RH, et al. American College of Endocrinology position statement on the insulin resistance syndrome. Endocr Pract. 2003;9:237-252. 6. Grundy SM, Cleeman JI, Daniels SR, et al. Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute scientific statement. Circulation. 2005; 112:2735-2752. 7. Diagnosis and classification of diabetes mellitus. American Diabetes Association position statement. Diabetes Care. 2006;29:S43-S48. 8. Ford ES, Giles WH, Dietz WH. Prevalence of the metabolic syndrome among US adults: findings from the third National Health and Nutrition Examination Survey. JAMA. 2002;287:356-359. 9. Isomaa B, Almgren P, Tuomi T, et al. Cardiovascular morbidity and mortality associated with the metabolic syndrome. Diabetes Care. 2001; 24:683-689. 10. Gupta AK, Poulter NR, Dahlot B, et al. Role of metabolic syndrome, independent of its components, in prediction of cardiovascular outcomes in hypertensive patients of ASCOT-BPLA [abstract]. J Am Coll Cardiol. 2007; 49:417A. not markedly elevated, direct intervention with nicotinic acid may be useful. Generally, for every 1 g of nicotinic acid administered, a 10% increase in HDLC can be expected. Nicotinic acid, used as part of a treatment program with statins, has produced remarkable event reductions in trials such as HATS.34 Treatment of prediabetes includes both lifestyle modification and pharmacologic therapies, such as metformin, thiazolidinediones, and acarbose (Precose), which have been shown to lower the risk of type 2 DM in persons with IFG or IGT. No clinical evidence is yet available to document that insulin sensitizers can reduce the risk of CV events and are cost effective in the prevention of DM. In the Diabetes Prevention Program (DPP), intensive lifestyle modifications reduced the risk of type 2 DM by 58% in all age-groups, and metformin demonstrated reduction of DM risk by 31%.35 Metformin was effective in men and women in all the ethnic groups but was relatively ineffective in older and less overweight patients. Metformin has also shown efficacy in reducing 11. Ginsberg HN. New perspectives on atherogenesis: role of abnormal triglyceride-rich lipoprotein metabolism. Circulation. 2002;106:2137-2142. 12. Hokanson JE, Austin MA. Plasma triglyceride level is a risk factor for cardiovascular disease independent of high-density lipoprotein cholesterol level: a meta-analysis of population-based prospective studies. J Cardiovasc Risk. 1996;3:213-219. 13. Jeppesen J, Hein HO, Suadicani P, et al. Relation of high TG-low HDL cholesterol and LDL cholesterol to the incidence of ischemic heart disease: an 8-year follow-up in the Copenhagen Male Study. Arterioscler Thromb Vasc Biol. 1997;17:1114-1120. 14. Lemieux I, Pascot A, Couillard C, et al. Hypertriglyceridemic waist a marker of the atherogenic metabolic triad (hyperinsulinemia; hyperapolipoprotein B; small, dense LDL) in men? Circulation. 2000;102: 179-184. 15. Chiasson JL, Josse RG, Gomis R, et al. Acarbose treatment and the risk of cardiovascular disease and hypertension in patients with impaired glucose tolerance: the STOP-NIDDM trial. JAMA. 2003;290:486-494. 16. Yusuf S. Two decades of progress in preventing vascular disease. Lancet. 2002;360:2-3. 17. Galassi A, Reynolds K, He J. Metabolic syndrome and risk of cardiovascular disease: a meta-analysis. Am J Med. 2006;119:812-819. 18. Sattar N, Gaw A, Scherbakova O, et al. Metabolic syndrome with and without C-reactive protein as a predictor of coronary heart disease and diabetes in the West of Scotland Coronary Prevention Study. Circulation. 2003;108:414-419. 19. Garber AJ. The metabolic syndrome. Med Clin North Am. 2004;88: 837-846. 20. Standards of medical care in diabetes—2007. American Diabetes Association position statement. Diabetes Care. 2007;30:S4-S41. OCTOBER 2007 PATIENT CARE ENDOCRINOLOGY & CARDIOLOGY 17

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Patient Care - Endocrinology & Cardiology - October 2007 Research Digest Contents Medicine in the News Recognizing and Managing Patients with the Metabolic Syndrome and Prediabetes Using Troponins to Evaluate Cardiac Injury The 15-Minute Visit Classified Advertising Clinical Clips

Patient Care Endocrinology & Cardiology - October 2007

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