Interactive diabetes case 14: A 41-year-old man with type 2 diabetes and hypertriglyceridemia
- Lloyd Axelrod, MD
Lloyd Axelrod, MD
- Associate Professor of Medicine
- Harvard Medical School
You are asked to evaluate and manage a 41-year-old man with type 2 diabetes who was recently noted to have a triglyceride level of 1118 mg/dL on routine lipid evaluation.
Three years ago the patient had the following fasting laboratory values, obtained on a routine basis because of obesity: glucose 102 mg/dL (5.66 mmol/L), total cholesterol 209 mg/dL, triglycerides 394 mg/dL, high-density lipoprotein (HDL) cholesterol 33 mg/dL, low-density lipoprotein (LDL) cholesterol 116 mg/dL.
Two and a half years ago, the patient had a fasting blood glucose level of 138 mg/dL (7.66 mmol/L). A glycated hemoglobin (A1C) value a few days later was 7.1 percent. The patient was told that he has type 2 diabetes and met with a nutritionist for medical nutrition therapy.
His efforts to reduce weight were unsuccessful despite regular visits to his clinician. Two years ago, he was started on metformin with doses titrated to 1000 mg twice a day. Repaglinide was added soon thereafter, with doses titrated to 4 mg three times daily before meals. One month before his visit to you, his fasting laboratory values were as follows: glucose 173 mg/dL (9.6 mmol/L), A1C 8.9 percent, total cholesterol 231 mg/dL, triglycerides 1118 mg/dL, and HDL cholesterol 36 mg/dL. The LDL cholesterol was not calculated by the laboratory because these calculations are inaccurate when the triglyceride level exceeds approximately 400 mg/dL.
The patient eats out in restaurants three times a week, where he has 16-ounce portions of untrimmed red meat with a baked potato. He has two eggs with two sausages for breakfast three times a week, does not drink milk, and consumes about a quarter of a pound of cheese once a week. He states that he knows he can do better with his diet and is determined to do so.