Archive for lipids

Extreme Lipids II

Posted in Diabetes, Heart Disease with tags , , , , , on September 23, 2008 by Dr. CJ

There aren’t many lipid panels that stun me, which is probably a bad sign – that we are becoming more tolerant of slothen behavior and excessive hyperlipidemia, knowing that there are medications to rescue one from years of lousy self-care.

This gentleman had a most impressive lipid panel, perhaps forcing you to ask how he is even alive.

Total Cholesterol    1248  (normal < 200)

LDL                         n/a  (normal < 130)

– invalid when Triglycerides > 300

HDL                        n/a  (normal >39)

– invalid when Triglycerides > 1200

Triglycerides          8062  (normal <150)

This very nice 40-something gentleman presented to me in clinic in DKA (Diabetes KetoAcidosis) – his first doctor visit in 10+ years.  He was continually thirsty (polydipsia), continually urinating large amounts (polyuria), and had lost 40 pounds over the past 3 months . . . unintentionally.

He knew that he had Diabetes Mellitus, for he had witnessed the disease in nearly all of his family members and recognized these classic symptoms.  Unfortunately, he waited to the point that he developed DKA. 

DKA is a complicated process – briefly, the body is so overwhelmed with high glucose in the bloodstream that it is no longer able to utilize glucose in the tissues (muscle, brain, etc.) and the pancreas is exhausted from pumping out so much insulin that it stops doing so.  The result is that the body cannot utilize glucose as a fuel source and must resort to breaking down fat (hence the weight loss) to provide fuel for the tissues.  This process creates a toxic acidic environment in the bloodstream, potentially deadly.

I admitted him to the hospital, and we achieved control over his diabetes.  It appears that he does, in fact, have Type 2 Diabetes Mellitus (DM) – formerly known as Adult-Onset Diabetes Mellitus.  DKA is far more common in Type 1 DM, but occasionally does occur in Type 2 DM.

But, about those lipids . . . there a couple notable findings:

  • the person who drew his blood immediately noticed how fatty the blood appeared
  • he had Xanthomas (cholesterol deposits) on his elbows
  • the in-house glucose machine misread his glucose as normal (the true serum test drawn at the same time was markedly elevated)
  • he had no problems with his pancreas – he dodged a bullet.  When the triglycerides are above 500, one is at risk for pancreatitis.  At 8000, it’s a miracle he didn’t kill off his pancreas (or maybe he did, and that’s why he’s not making insulin – regardless he didn’t have any lab evidence of pancreatitis)

  The quickest and easiest treatment for such severe hyperlipidemia and hypertriglyceridemia in a person with diabetes is correction of the diabetes.  I’m anxiously looking forward to rechecking those numbers, now that he is on a treatment regimen.  I’ll post an update.

Extreme Lipids I

Posted in Heart Disease, Preventive Medicine with tags , , , , , on September 22, 2008 by Dr. CJ

I saw a woman a few months ago who had concerns about a strange sensation in her chest.  She had had her cholesterol panel checked a few months prior by her gynecologist at her yearly female exam.  The gynecologist communicated to her that her total cholesterol was too high at 240 and that she should follow-up with my clinic.

Sure, 240 is high for a total cholesterol is high, but the details of the individual lipid measurements are far more telling than a “total”.  This woman’s lipid panel is a perfect case in point.

  Here’s the panel – refer to this post for details on the significance of each value.

Total Cholesterol    240  (normal < 200)

LDL                         111  (normal < 130)

HDL                        117  (normal >39)

Triglycerides            61  (normal <150)

So what?  This panel achieves one of my fantasy goals for cholesterol numbers – an HDL greater than the LDL [without cholesterol medication].  There was one other patient who came close.

Her total cholesterol is high in part due to the very high HDL cholesterol, but if you’re going to have a high total cholesterol, this is the way to do it.

Why is a high HDL a good thing?  HDL protects the heart and brain by it’s “scavenger” effects on plaque in blood vessels.

That’s no easy task, although favorable genetics certainly help.  The hightest HDL’s I’ve seen are generally in alcoholics – unfortunately, the HDL-raising benefits of alcohol are outweighted by its deleterious effects.

The best way to raise the HDL is through regular, intense exercise.  There was a study from years ago that analyzed HDL’s in runners: the more miles they ran in a week, the higher their HDL.

Is simvastatin still a good drug?

Posted in Heart Disease with tags , , , on January 22, 2008 by Dr. CJ

There was a report released recently about simvastatin being less effective than one of the more experienced statins at reducing certain measures of cardiovascular risk, despite its ability to lower the LDL cholesterol (the “bad” cholesterol) levels. 

My first word of caution regarding this: the study was performed in a very select group of individuals, people with a genetic disorder contributing to markedly elevated cholesterol levels that affects less than 1% of the population.  Right off the bat, you would be hard-pressed to apply the results of this study to the larger population (not sure why they even bothered).

It very well may not be as effective at reducing cardiac risk as we once thought, but until there is a more clear answer it shouldn’t be shunned quite yet.  As a generic drug, it is cheap and most often quite effective at lowering the LDL.  I expect there will be more detailed outcome studies comparing simvastatin with other statins.