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C ase category: Familial Hypertriglyceridemia, Metabolic Syndrome

51 Year Old Female with Family H istory of Premature H eart D isease and H igh Triglycerides. Case Categories Primary Prevention Secondary Prevention Pediatric Case Familial Hypertriglyceridemia Diabetes Metabolic Syndrome Low HDL Familial Combined Hyperlipidemia

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C ase category: Familial Hypertriglyceridemia, Metabolic Syndrome

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  1. 51 Year Old Female with Family History of Premature Heart Disease and High Triglycerides Case Categories Primary Prevention Secondary Prevention Pediatric Case Familial Hypertriglyceridemia Diabetes Metabolic Syndrome Low HDL Familial Combined Hyperlipidemia Familial Hypercholesterolemia Elevated Lipoprotein (a) Statin Intolerance Case category: Familial Hypertriglyceridemia, Metabolic Syndrome History of present illness: 51 year old female with family history of premature heart disease and history of gestational diabetes. During a recent hospital admission for severe pancreatitis, glucose was abnormal and triglycerides were >9000. Started gemfibrozil.

  2. Patient Information

  3. Patient History

  4. Current Medications

  5. Labs Worth Noting

  6. Questions to Consider • Question 1 • Question 2 • Question 3 • Question 4

  7. Labs

  8. NMR LipoProfile • Insert NMR LipoProfile

  9. Other Labs

  10. Initial Treatment & Management • Continue gemfibrozil. • Start Lovaza 4 g/day to lower triglycerides. • Recommend CIMT.

  11. Discussion (1 of 2)

  12. Discussion (2 of 2)

  13. Follow Up on Gemfibrozil 1200 and Lovaza 4 • Familial Hypertriglyceridemia – Improved. • Currently taking gemfibrozil 1200 and Lovaza 4. • Triglycerides lowered from 303 to 63. Excellent improvement. • LDL-P lowered from >3500 to 2189. LDL-C reduced from 246 to 180. Small dense LDL-P dropped from 2466 to 140. HDL increased from 38 to 75. Total cholesterol dropped from 345 to 168. IR Score lowered to 12 from 60. • Treatment options include adding a statin and/or changing to a low carb diet and increasing exercise. • Continue current therapy. • Metabolic Syndrome / Impaired Fasting Glucose – Improved. • HbA1c is stable at 5.6. IR-score improved from 68 to 12. Fasting glucose reduced from 124 to 112. • At this time, treatment with metformin is not necessary. • Elevated Transaminases – New. • ALT and AST are high at 165 and 144. • Will monitor and add hepatitis panel and work up for other etiologies.

  14. CIMT Results • CIMT Results: • Normal. • R CCA: 0.633 mm; 50-75% • L CCA: 0.591 mm; 50-75% • No plaque present.

  15. Clinical Pearls

  16. Case Summary

  17. References (1 of 2) Familial Combined Hyperlipidemia • Mora S, Szklo M, Otvos JD, et al. LDL particle subclasses, LDL particle size, and carotid atherosclerosis in the Multi-Ethnic Study of Atherosclerosis (MESA). Atherosclerosis. 2007 May;192(1):211-7. • Cromwell WC, Otvos JD, Keyes MJ, et al. LDL particle number and risk of future cardiovascular disease in the Framingham offspring study – implications for LDL management. J ClinLipidol. 2007 Dec;1(6):583-92 • Brunzell JD, Davidson M, Furberg CD, et al. Lipoprotein management in patients with cardiometabolic risk: consensus statement from the American Diabetes Association and the American College of Cardiology Foundation. Diabetes Care. 2008 Apr;31(4):811-22. • TalayeroBG, Sacks FM. The role of triglycerides in atherosclerosis. CurrCardiol Rep. 2011 Dec;13(6):544-52. • Roth EM, Bays HE, Forker AD, et al. Prescription omega-3 fatty acid as an adjunct to fenofibrate therapy in hypertriglyceridemic subjects. J CardiovascPharmacol. Jul 10 2009. • Dietary supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial infarction: results of the GISSI-Prevenzione trial. Lancet. 1999 Aug 7;354(9177):447-55. • Otvos JD, Mora S, Shalaurova I, et al. Clinical implications of discordance between low-density lipoprotein cholesterol and particle number. J ClinLipidol. 2011 Mar-Apr 5(2):105-13.

  18. References (2 of 2) Metabolic Syndrome • Rosenson RS, Otvos JD and Hsia J. Effects of rosuvastatin and atovastatin on LDL and HDL particle concentrations in patients with metabolic syndrome: a randomized, double-blind, controlled study. Diabetes Care. 2009 Jun;32(6):1087-91. • Orchard TJ, Temprosa M, Goldberg R, et al. The effect of metformin and intensive lifestyle intervention on the metabolic syndrome: the Diabetes Prevention Program randomized trial. Ann Intern Med. 2005 Apr 19;142(8):611-9. • ADA Standards of Medical Care in Diabetes - 2012. Diabetes Care. Jan 2012 35(1)11-63. • DeFronzo RA, Abdul-Ghani M. Assessment and treatment of cardiovascular risk in prediabetes: impaired glucose tolerance and impaired fasting glucose. Am J Cardiol. 2011 Aug 2;108(3 Suppl):3B-24B. • Goff DC Jr, D'Agostino RB Jr, Haffner SM. Insulin resistance and adiposity influence lipoprotein size and subclass concentrations. Results from the Insulin Resistance Atherosclerosis Study. Metabolism. 2005 Feb;54(2):264-70.

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