What is the best management plan for a patient with hyperlipidemia, hyperuricemia, chronic leg swelling, and a history of type 2 diabetes mellitus and hypertension?

Management of Hyperlipidemia in a Patient with Type 2 Diabetes and Hyperuricemia

Statin therapy is strongly recommended as first-line treatment for this 74-year-old patient with type 2 diabetes and elevated LDL cholesterol (3.5 mmol/L), given the patient's high cardiovascular risk profile. 1

Hyperlipidemia Management

Primary Intervention

• Start high-intensity statin therapy (atorvastatin 20-40mg or rosuvastatin 10-20mg daily) to achieve LDL-C target of <2.6 mmol/L (<100 mg/dL) for patients with diabetes 1
• The goal is to reduce LDL cholesterol by at least 30-50% from baseline, regardless of baseline LDL levels 1
• Statins have demonstrated significant reduction in cardiovascular events and mortality in patients with diabetes 1, 2
• Atorvastatin is FDA-approved for reducing the risk of MI and stroke in adults with type 2 diabetes with multiple risk factors for coronary heart disease 3

Monitoring and Follow-up

• Check lipid levels 8±4 weeks after starting statin therapy to assess efficacy 2
• Monitor liver function tests, given the patient's slightly elevated ALT (48) 3
• Reassess cardiovascular risk and adjust therapy as needed at follow-up visits 1

Hyperuricemia Management

• The patient's hyperuricemia (urate 0.45 mmol/L) is likely secondary to bendroflumethiazide therapy 4
• Consider modifying diuretic therapy as thiazides can increase uric acid levels 4
• The patient has previously experienced adverse effects with allopurinol (pruritis) and probenecid (hair loss), limiting urate-lowering therapy options 5
• For symptomatic hyperuricemia (toe paresthesias), consider:
  • Dietary modifications (reduce purine-rich foods, limit alcohol)
  • Hydration to promote uric acid excretion
  • Consultation with rheumatology for alternative urate-lowering therapy options 5, 4

Chronic Leg Swelling Management

• The patient's chronic leg swelling with redness and tenderness suggests venous insufficiency 1
• Refer for vascular assessment to confirm diagnosis 1
• Recommend compression stockings if venous insufficiency is confirmed 1
• Elevate legs when sitting or lying down 1
• Consider referral to vascular specialist for further management 1

Diabetes Management

• Current diabetes control is adequate with HbA1c of 53 mmol/mol 1
• Continue current diabetes medications (Galvomet) 1
• Podiatry referral is appropriate for diabetic foot assessment and toe symptoms 1
• Consider annual screening for other diabetes complications (retinopathy, nephropathy) 1

Comprehensive Cardiovascular Risk Management

• Address all modifiable cardiovascular risk factors 1:
  • Maintain blood pressure control (currently well-controlled at 122/80 mmHg)
  • Continue smoking cessation (patient is an ex-smoker)
  • Encourage regular physical activity appropriate for patient's mobility
  • Provide dietary counseling for both hyperlipidemia and hyperuricemia

Important Considerations and Pitfalls

• Statins may rarely cause myopathy or rhabdomyolysis; monitor for muscle pain, tenderness, or weakness 3
• Hydrophilic statins (pravastatin, fluvastatin) may have fewer drug interactions if patient is on multiple medications 1
• The combination of statins with fenofibrate may be considered if triglycerides remain elevated despite statin therapy, but requires careful monitoring for myositis 1
• Nicotinic acid can effectively increase HDL cholesterol but should be used with caution in diabetic patients as it may worsen hyperglycemia 1
• Regular monitoring of renal function is important, especially given the patient's eGFR of 60 (previously higher at 71,76) 1

Follow-up Plan

• Repeat lipid panel in 8-12 weeks to assess response to statin therapy 2
• Monitor liver enzymes and renal function 3
• Follow up on podiatry assessment for toe symptoms 1
• Reassess all cardiovascular risk factors at each visit 1