Question of the Week # 190

190) A 45 year old man presents to your office for follow up of his dyslipidemia that was diagnosed 6 month. His lipid panel at that time was consistent with high Total cholesterol , Low HDL and high triglyceride levels. He was instructed on dietary modification. He presents for a follow up visit today and reports that he had been strictly compliant with reduced fat diet. His social history is significant for smoking 1 pack per day for the past 25 years . He reports drinking about 1 pint vodka per day for past 10 years. He read on an online magazine  that drinking alcohol would boost his “Good” cholesterol. At this time, a repeat fasting lipid profile reveals:

Total Cholesterol : 250mg%

HDL cholesterol : 35mg%

Triglycerides: 500mg%

The most important step at this time to address his lipid abnormalities:

A) Niacin

B) Gemfibrozil

C) Fenofibrate

D) Alcohol cessation

E) Smoking cessation

21 Responses

  1. fenofibrate

  2. alcohol cessation

  3. b

  4. A)Niacin
    Niacin Increases HDL level while
    able to lowering LDL level stimulant

  5. niacin

  6. e smoking cessation

  7. c fenofibrate ….since when Triglyceride is 500 or more you have to treat the hypertrigylceridemia first to prevent pancreatitis

  8. guille, niacin,but pls we need the corret answer

  9. C -> Triglycerides Pancreatitis -> mitigated by Fenofibrate

  10. You cannot have 2 drugs that lower triglicerides in the answer.
    Both can be used
    Fenofibrate and gemfibrozil

    • This patient is a chronic alcoholic and has alcohol induced Hypertriglyceridemia. The first step is to counsel against Alcohol consumption. Remember simple and most effective measures first! Alcohol cessation will address the etiology and will eventually, reduce his TG level. If patient continues to have increased TG , drug therapy can be considered at a later date.
      Elimination strategy to answer this question: Niacin, fenofibrate and gemfibrozil – all of these can reduce triglyceride levels. However, when the question gives three drugs in the choices that can reduce triglycerides, you can use elimination strategy to arrive at the correct answer. Often, it indicates the drug is probably, not even the answer.

      • totally correct hard point to test since most argue to tx tri’s is 500-1000 but correct since he is not symptomatic we must KIS Keep It Simple and just address the need to stop or cut down on ETOH

  11. ans c

  12. If statin and alcohol cessation both present in choices, which one should I pick?

    • First step is to evaluate and stop the offending agent always! ETOH abuse can lead to hypertriglyceridemia and stopping ETOH can bring back TGs to normal.
      If patient persistently has hypertriglyceridemia even after ETOH cessation, then fibrates or niacin or statin are appropriate depending on whether TG alone is elevated ( TG alone – fibrates are first choice) or if there are concomitant HDL/ LDL abnormalities.

      Which anti-lipid therapy to choose. Here is a general guideline on treating lipid abnormalities – combinations :

      LDL high – Statin
      LDL high + HDL low – statin
      TG moderately high + LDL high – Statin
      TG moderately high + HDL low – Niacin
      TG very high – Fibrates
      TG very high + HDL low – Fibrates
      TG very high + LDL high – Statin + Fibrates

      What is needed for your exam?

      Remember when LDL is high, STATIN always gets first preference and statin can also modestly increase HDL level. If you do not achieve the LDL or HDL goals, you can always combine other agents.

      If low HDL is the only risk factor; NIACIN gets the preference ( It can increase HDL by 35% max – no other drug can increase more than 20%). Side effects of Niacin are severe flushing and headaches. Start low dose and slowly tit-rate up based on tolerance.
      If severe elevation in TGs are the only problem, fibrates get preference. No other drug can reduce TGs as much as fibrates do. ( Niacin reduces by 25, Statins by 15% % where as fibrates reduce TG by 40%)

  13. with respect to the above comment-in what scenario would gemfibrozil be my first choice? does such a scenario exist?

    • Lipid lowering class of Fibrates: Gemfibrozil, Clofibrate, Fenofibrate

      Gemfibrozil belong to the same class “fibrates” and can be used in pure hypertriglyceridemia and it is a cheaper alternative to other fibrates ( Clofibrate and fenofibrate). If a patient has acute pancreatitis from hypertriglyceridemia, pharmacological intervention is needed to prevent future attacks and in such cases fibrates can be used . All Fibrates have an additional advantage of increasing HDL cholesterol. Gemfibrozil can cause rhabdomyolysis especially, when combined with statins ( this toxic effect is lesser with other fibrates)
      So, when a patient has high TG and low HDL –> any fibrtae is a preferred choice but if they are also on statins, would use other fibrates rather than gemfibrozil because it has higher incidence of rhabdomyolysis.

  14. Thanks!

  15. Niacin is a good supplement because it can keep cholesterol level down and it has also a mild anti-depressant effect. .;,”:


  16. Thank’s

  17. C drug of choice for hypertriglyceridemia

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