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How would you manage the following 26 yr old  M with no sig PMH. No Rx meds. 

In for checkup, fam hx of t2dm and wants to be checked. 

The following labs were drawn after a very strict  fast . Pt does intermittent fasting and had been > 12 hours with only h20 at time of labs. 

Lipids:

Total: 288

Trigs: 236

HDL: 52

VLDL: 47

LDL: 188

Dutch lipid criteria negative for familial hypercholesterolemia. Father on XOL medicine, but otherwise no known family history of ASCVD.  Normotensive, no smoking, no DM, normal BMI. 

BGL: 127 , follow up a1c 5.1% 

     Find this to be interesting BGL with that a1c..  Pt EXTREMELY nervous about the blood draw and nearly passed out. Elevated glucose from stress response? 

 

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How would you manage the following 26 yr old  M with no sig PMH. No Rx meds. 
In for checkup, fam hx of t2dm and wants to be checked. 
The following labs were drawn after a very strict  fast . Pt does intermittent fasting and had been > 12 hours with only h20 at time of labs. 
Lipids:
Total: 288
Trigs: 236
HDL: 52
VLDL: 47
LDL: 188
Dutch lipid criteria negative for familial hypercholesterolemia. Father on XOL medicine, but otherwise no known family history of ASCVD.  Normotensive, no smoking, no DM, normal BMI. 
BGL: 127 , follow up a1c 5.1% 
     Find this to be interesting BGL with that a1c..  Pt EXTREMELY nervous about the blood draw and nearly passed out. Elevated glucose from stress response? 
 
Could be stress response; I'd believe the a1c. I would probably try some education and diet changes for his lipids before considering meds. Given his reaction with the blood draw, he might be motivated to not eat like he's 10 feet tall and bulletproof.

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Sounds like a statin in order 

 

BMI is what?  <25?

 

Plug the numbers in online calculator    Review guidelines   

 

Honestly would consider OGT test if they were really concerned with DM   

 

Open honest discussion with patient   TC 288 and LDL 188 both stink and likely familial  

 

send for nutrition consult   Encourage 39+ min aerobic exercise daily   Zero trans fats  

eat well

 

recheck in 3-4 months   

 

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Do you think glucose could be from fasting for more than 12 hours?  Something about the liver keeping us alive... probably enhanced by cortisol,  acting on the liver for gluconeogenesis.  I don't put much stock in random glucoses, especially because people get so crazy with the fasting.

He's 26 with a normal bmi.  Tell him to relax and stop trying to find problems, they'll come soon enough.  Regular exercise and water.  Don't do drugs.  Stay in school.  Wear sunscreen.

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I changed my mind somewhat.  The 12+ hours for fasting might be skewing the results; 8 hours is the norm.  Check with your facility.

Fpnotebook puts it a bit more clearly (not that utd was confusing):

  1. Screening Indications (repeat every 3 years)
    1. See Risk Factors above
    2. Body Mass Index >25 kg/m2 (>23 kg/m2 in asian patients)
    3. Family History of Diabetes Mellitus
    4. Prior history of Gestational Diabetes
    5. Age over 45 years
    6. HDL Cholesterol <35 mg/dl
    7. Serum Triglycerides >250 mg/dl
    8. Polycystic Ovary Syndrome
    9. Hypertension
  2. Impaired Glucose Metabolism
    1. Hemoglobin A1C 5.7 to 6.4%
    2. Fasting Glucose: 100 to 125 mg/dl
      1. Known as Impaired Fasting Glucose
      2. New guidelines suggest bottom cut-off of 100 mg/dl
      3. Metabolic Syndrome defined as 110 mg/dl or higher
    3. Two hour Glucose Tolerance Test (75 g): 140-199 mg/dl
      1. Known as Impaired Glucose Tolerance
  3. Lipid Profile
    1. Serum Triglycerides >150 mg/dl
    2. Serum very Low Density Lipoprotein(VLDL) increased
    3. Serum HDL Cholesterol decreased
      1. Men <40 mg/dl
      2. Women <50 mg/dl
  4. Best lab markers for Insulin Resistance
    1. Plasma Insulin level (or Glucose to Insulin Ratio)
    2. Plasma Triglyceride levels
    3. Triglyceride to HDL ratio
    4. McLaughlin (2003) Ann Intern Med 139:802-9 [PubMed

In your scenario, routine screening for diabetes not really recommended until you saw the aberrant lipids, d/t age and lack of family hx or any symptoms, then a1c would be obtained, which is present.

You have somewhat discordant results- the glucose spells trouble but the a1c traditionally doesn't (not above 6.0). However, at this point, think of insulin resistance of some sort, with the elevated glucose and resistant type a1c based on the fpnotebook info.

You mentioned "intermittently" fasting- most people fast when they sleep, how much longer does he fast?  Does he have sleep apnea?

I would recheck after a fast of 8 hours, and include a UDS, based on your description of jitters and not eating.  Usually people who don't eat due to substance issues have a1c's much lower, like around 4 from what I've seen.

 

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OK, let’s break this down into two questions; FBS and lipids. FBS is FBS. Two or more independent readings while fasting of 125 mg/dL or greater is diagnostic for DM (there are four ways to make the dx). Yes, excessive cortisol levels can elevate BS. The fact that the HbA1c is at that level tells me that this person probably doesn’t have consistent hyperglycemia.

 

Lipid levels with an LDL 190 mg/dL> is automatic for statin tx. Elevated HDL for mild/low moderate LDL values can be a negating factor for statin tx. Reportedly, the best one can hope for with dietary modification is a 15% drop in LDL, though I’ve seen greater reductions in years past. Bottom line, either of these two discussions comes back to the same common denominator which is CV risk reduction, in addition to renal/ocular disease for DM. Trig levels more prone to sudden dietary changes than cholesterol. Values >400 mg/dL warrant more concern for pancreatitis than anything else.

 

Me? Discuss statin therapy and leave option to pt. There’s a difference in risk reduction for primary and secondary CV risk reduction (more bang for the buck with latter by far). Check a second fasting blood sugar and if greater than 124 mg/dL then discuss Metformin option. I’d trust the HbA1c/GTT more than borderline two separate FBS values.

 

 

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