What management approach is recommended for a 66-year-old male with a history of hypertension, hyperglycemia, and hyperlipidemia, currently on Olmesartan (Olmesartan) 20mg + Amlodipine (Amlodipine) 5mg, Metformin (Metformin) 500mg, Rosuvastatin (Rosuvastatin) 5mg, and Vitamin B Complex, presenting with left lower buttock pain, decreased red blood cell count, increased mean corpuscular volume, and suspicion of glaucoma, with laboratory results showing hyperglycemia and hypercholesterolemia?

Management Approach for 66-Year-Old Male with Multiple Cardiovascular Risk Factors

Immediate Medication Optimization

Your patient requires intensification of his current regimen to address inadequately controlled hyperglycemia, hyperlipidemia, and cardiovascular risk, with specific attention to his glaucoma suspicion and macrocytic anemia.

Glycemic Control

• Increase Metformin to 1000mg twice daily (from current 500mg once daily) to achieve better glycemic control, as his glucose of 7.58 mmol/L (136 mg/dL) indicates inadequate diabetes management 1
• Target HbA1c should be <7% while avoiding hypoglycemia, using a patient-centered approach given his age and cardiovascular risk profile 1
• Recheck HbA1c in 3 months after medication adjustment to assess response 1

Lipid Management

• Increase Rosuvastatin from 5mg to 20mg daily given his ASCVD risk of 22.4% and borderline high cholesterol of 5.23 mmol/L (202 mg/dL), as high-intensity statin therapy is indicated for secondary prevention in high-risk patients 1
• However, exercise caution with rosuvastatin dose escalation given the recent evidence showing association between rosuvastatin use and increased glaucoma risk, particularly with longer duration of use 2
• Consider switching to pravastatin 40mg daily as an alternative, since it has minimal drug interactions and may have a more favorable safety profile regarding glaucoma risk 1, 3
• Recheck lipid panel in 6-8 weeks after statin adjustment 1

Cardiovascular Risk Reduction

• Restart low-dose aspirin 75-100mg daily for secondary prevention given his high ASCVD risk of 22.4%, unless there is a documented contraindication that led to discontinuation 7 months ago 1
• The combination of olmesartan/amlodipine with rosuvastatin has demonstrated efficacy and safety in patients with concomitant hypertension and dyslipidemia 4
• Continue current antihypertensive regimen (Olmesartan 20mg + Amlodipine 5mg) as blood pressure appears controlled 1

Macrocytic Anemia Workup

The combination of decreased RBC (4.28) and elevated MCV (103.0) requires immediate investigation:

• Order vitamin B12 and folate levels to evaluate for deficiency, as the patient is on Vitamin B Complex but may have malabsorption or inadequate supplementation 1
• Check thyroid function tests (TSH, free T4) as hypothyroidism can cause macrocytic anemia 1
• Obtain reticulocyte count to assess bone marrow response 1
• Review alcohol intake history despite no current smoking, as alcohol can cause macrocytosis 1
• If B12 deficiency is confirmed, initiate B12 1000mcg intramuscularly weekly for 4-8 weeks, then monthly, as oral supplementation may be inadequate if malabsorption is present 1

Buttock Pain Evaluation

The left lower buttock pain with specific aggravating/relieving factors suggests musculoskeletal or neurogenic origin:

• Perform straight leg raise test and FABER test to evaluate for lumbar radiculopathy or sacroiliac joint dysfunction 1
• Assess for piriformis syndrome given the pain pattern (relieved by movement, aggravated by rest) 1
• Consider lumbar spine X-ray if neurogenic claudication is suspected, particularly given his age and previous orthopedic surgery 1
• Trial of physical therapy with stretching exercises for piriformis and hip external rotators 1
• NSAIDs can be considered cautiously given his cardiovascular risk profile and potential need for aspirin 1

Glaucoma Management

• Urgent ophthalmology referral within 1-2 weeks for formal evaluation of increased cup-to-disc ratio of 0.6 1
• Note the potential protective effect of beta-1 selective blockers against glaucoma development, though this patient is not currently on beta-blockers 3
• Avoid adding oral beta-blockers solely for glaucoma prevention as blood pressure appears controlled on current regimen 1, 3
• Inform ophthalmologist about statin use, particularly rosuvastatin, given emerging evidence of association with increased glaucoma risk 2

Laboratory Monitoring Schedule

• Recheck fasting glucose and HbA1c in 3 months after metformin dose increase 1
• Lipid panel in 6-8 weeks after statin adjustment 1
• Complete blood count with B12/folate levels immediately to evaluate macrocytic anemia 1
• Comprehensive metabolic panel in 2-4 weeks after metformin increase to monitor renal function and electrolytes 1
• Creatine kinase if patient develops muscle symptoms given statin use 1

Lifestyle Modifications to Reinforce

• Sodium restriction to <2g/day for blood pressure and cardiovascular risk reduction 1
• Mediterranean diet pattern emphasizing vegetables, fruits, whole grains, and healthy fats for both diabetes and cardiovascular disease management 1
• Regular aerobic exercise 150 minutes per week (30 minutes most days) for glycemic control, blood pressure management, and cardiovascular risk reduction 1
• Weight management if BMI >25 kg/m² through caloric restriction and increased physical activity 1

Critical Pitfalls to Avoid

• Do not delay statin intensification despite glaucoma concerns, but choose the statin carefully and coordinate with ophthalmology 1, 2
• Do not ignore the macrocytic anemia as it may indicate B12 deficiency, which can worsen with metformin use and cause irreversible neurological damage if untreated 1
• Do not add a second RAS blocker (ACE inhibitor to olmesartan) as this increases adverse events without cardiovascular benefit 1
• Do not restart clopidogrel without understanding why it was stopped 7 months ago, as dual antiplatelet therapy increases bleeding risk without clear indication 1
• Do not attribute buttock pain to peripheral arterial disease without vascular assessment, as the pain pattern (relieved by movement) is atypical for claudication 1