What is the recommended management for a patient with hyperglycemia, elevated Blood Urea Nitrogen (BUN), and high Low-Density Lipoprotein (LDL) cholesterol levels, along with slightly elevated Thyroid-Stimulating Hormone (TSH) and abnormal lymphocyte and basophil counts?

Management of Hyperglycemia, Elevated BUN, High LDL Cholesterol, and Abnormal Lymphocyte/Basophil Counts

Initiate metformin for the hyperglycemia (fasting glucose 128 mg/dL), start a statin for the elevated LDL cholesterol (101 mg/dL), and implement aggressive lifestyle modifications including weight loss and dietary changes to address the metabolic syndrome pattern evident in these labs. 1

Immediate Priorities: Address the Hyperglycemia

• Start metformin as first-line therapy for the fasting glucose of 128 mg/dL, which indicates diabetes mellitus (diagnostic threshold ≥126 mg/dL). 2
• Metformin reduces fasting plasma glucose by approximately 53 mg/dL and HbA1c by 1.4% based on clinical trials, and also provides modest weight loss benefits (1-2 lbs). 2
• The eGFR of 69 mL/min is adequate for metformin use (contraindicated only if eGFR <30 mL/min), though dose adjustment may be needed if renal function declines further. 2
• Target HbA1c <7% to improve not only glucose control but also triglyceride levels, as poor glycemic control is a major driver of dyslipidemia in diabetes. 3, 4, 5

Lipid Management: Prioritize LDL Cholesterol Reduction

• Initiate moderate-to-high intensity statin therapy (atorvastatin 20-40 mg or rosuvastatin 10-20 mg daily) for the LDL cholesterol of 101 mg/dL, which exceeds the goal of <100 mg/dL for diabetic patients. 1
• The American Diabetes Association recommends statin therapy for all diabetic patients aged 40-75 years regardless of baseline LDL levels, as diabetes itself confers high cardiovascular risk. 1
• Statins provide proven cardiovascular event reduction and will also lower triglycerides by 10-30% in a dose-dependent manner, addressing the borderline triglycerides (88 mg/dL is acceptable but could be optimized). 1, 3
• The HDL cholesterol of 51 mg/dL is adequate (goal >40 mg/dL for men, >50 mg/dL for women), so HDL-raising therapy is not immediately necessary. 1

Lifestyle Modifications: Foundation of Treatment

• Prescribe medical nutrition therapy with reduction of saturated fat to <7% of total calories, elimination of trans fats, and restriction of dietary cholesterol to <200 mg/day. 1
• Target 5-10% body weight reduction through caloric restriction, which can lower triglycerides by 20% and improve insulin sensitivity. 1, 3
• Recommend at least 150 minutes per week of moderate-intensity aerobic activity, which reduces triglycerides by approximately 11% and improves glycemic control. 1, 3
• Increase soluble fiber intake to 10-25 g/day, which lowers LDL cholesterol by approximately 2.2 mg/dL per gram of soluble fiber. 1
• Consider adding plant stanols/sterols (2 g/day), which can lower LDL cholesterol by 8-29 mg/dL. 1

Elevated BUN: Assess for Underlying Causes

• The BUN of 24 mg/dL (elevated, reference range 6-20 mg/dL) with creatinine 1.21 mg/dL and eGFR 69 mL/min indicates mild chronic kidney disease (CKD Stage G2). 1
• The BUN/creatinine ratio of 19.8 is within normal range (10-28), suggesting the elevation is likely related to early diabetic nephropathy rather than prerenal azotemia. 1
• Optimize blood pressure control and consider ACE inhibitor or ARB therapy if blood pressure is elevated or if microalbuminuria develops, as these agents slow progression of diabetic nephropathy. 1
• Monitor renal function every 3-6 months given the diabetes diagnosis and borderline eGFR. 1

Abnormal Lymphocyte and Basophil Counts: Clinical Context

• The absolute lymphocyte count of 3.59 x10³/uL (elevated, reference range 0.80-3.00) and basophil percentage of 1.3% (elevated, reference range 0.0-1.0%) are mild elevations that are likely reactive rather than indicative of primary hematologic disease. 1
• These findings can be seen in the context of metabolic syndrome, chronic inflammation, or recent viral illness. 1
• No immediate hematologic workup is needed unless the patient develops constitutional symptoms (fever, night sweats, weight loss), progressive lymphocytosis, or other concerning features. 1
• Recheck CBC in 3-6 months to ensure these abnormalities resolve with metabolic optimization. 1

Monitoring Strategy

• Recheck fasting lipid panel 4-12 weeks after initiating statin therapy to assess LDL cholesterol response and ensure goal of <100 mg/dL is achieved. 1
• Obtain HbA1c in 3 months to assess glycemic control on metformin, with target <7%. 1, 3
• Monitor renal function (creatinine, eGFR) every 3-6 months given the diabetes and borderline kidney function. 1
• Reassess CBC in 3-6 months to ensure lymphocyte and basophil counts normalize. 1
• Monitor liver function tests (AST, ALT) at baseline and periodically on statin therapy, though the current values (AST 35, ALT 35) are normal. 1

Critical Pitfalls to Avoid

• Do not delay statin therapy while attempting lifestyle modifications alone—diabetic patients require pharmacological lipid management regardless of baseline LDL levels due to high cardiovascular risk. 1
• Do not overlook the importance of glycemic control in managing the overall metabolic profile, as improved glucose control will beneficially impact triglycerides and potentially slow progression of nephropathy. 1, 3, 4, 5
• Do not initiate fibrate therapy at this time, as triglycerides are not elevated (88 mg/dL is normal, <150 mg/dL) and LDL cholesterol is the primary target. 1, 3
• Do not pursue extensive hematologic workup for the mild lymphocytosis and basophilia unless these persist or worsen on repeat testing, or if concerning clinical features develop. 1