I am pleased to announce that, as of October 2018, I am a certified clinical lipidologist, accredited by the American Board of Clinical Lipidology (ABCL). The role of the lipidologist is to diagnose, treat, and manage patients with elevated cholesterol or triglyceride levels. Currently, there are approximately 700 certified lipidologists in the U.S.
Dyslipidemia is a major public health concern. Elevated cholesterol levels, particularly what’s called the “bad” cholesterol (LDLc) or non-HDL cholesterol are major risk factors for atherosclerotic cardiovascular disease leading to heart attack and stroke. World Health Organization estimates that globally, 45% of people have elevated total cholesterol.
Dyslipidemia could be monogenic, polygenic or due to comorbidities such as metabolic syndrome, insulin resistance, diabetes mellitus, chronic kidney disease, nephrotic syndrome, weight gain, lack of exercise, or use of other medications.
According to ABCL, I am 1 of 3 physicians in the U.S. who is certified in all three specialties; endocrinology/diabetes, hypertension and dyslipidemia. This allows me to provide comprehensive and detailed care to endocrine patients, particularly those with diabetes.
I am happy to contribute to the editorial by Lisa Eramo published in Medical Economics, January 2018. The article is important as it raises physician awareness of Merit-based Incentive Payment System (MIPS) under which hypertension management falls. MIPS, part of 2015 MACRA, will go into effect in 2019.
Normal BP: <120/80 mmHg
Elevated BP “Pre HTN”: 120-130/<80
Stage 1 HTN: 130-140/80-90
Stage 2 HTN: >140/90
New targets for treatment:
If ASCVD 10-year-risk is <10%, then target BP <140/90
If ASCVD 10-year-risk is ≥10%, then target BP <130/80
AGE>65 and “healthy”
Primary hypoparathyroidism (PHPT) is a rare endocrine condition defined by hypocalcemia and deficient parathyroid hormone (PTH). It is primarily managed with high dose oral calcium and vitamin D supplementation instead of targeting the root cause of deficient PTH.
Conventional treatment is difficult to manage and often inadequate at controlling symptoms and preventing complications. RhPTH (1-84) is a recombinant form of PTH that acts as a direct substitute to the native hormone. It is a novel therapy that allows significant dose reductions in calcium and vitamin D supplementation, while achieving improved serum calcium, phosphate and calcium-phosphate product levels.
These biochemical advantages over the conventional therapy can translate to significant clinical benefits: reduced adverse events and improved quality of life. Our patient experienced just that with PTH replacement therapy. We propose a simple and practical protocol of how to initiate and titrate PHPT treatment. We emphasize the need for RhPTH(1-84) in all patients with resistant or refractory hypoparathyroidism.
EZ, IB, GT
Recent literature suggests that early metformin use could help reduce CVD progression and outcomes in patients with prediabetes and type 2 diabetes beyond glycemic control. It is important to discuss this information with individuals who are in the prediabetic or early diabetic stages of the disease, A1c 5.7-7.0%. Benefits should be weighed against metformin adverse effects, polypharmacy, life expectancy and comorbidities, particularly in the setting of cardiac, renal or hepatic pathology. Individualized patient discussion and clinical decision would be pivotal to proper medical care.
I am pleased to announce that, as of June 2016, I am a certified hypertension specialist, accredited by the American Society of Hypertension. Currently, there are about 1600 certified specialists in the U.S. and Canada.
Hypertension is a major public health concern. About 30% of Americans have elevated blood pressure. It is a main contributor to poor cardiovascular outcomes, leading to heart failure, myocardial infarction, peripheral vascular disease, stroke, vascular dementia and chronic kidney disease.
Hypertension is commonly seen in various endocrinological conditions such as diabetes mellitus, metabolic syndrome, adrenal, thyroid, parathyroid anomalies.
Type 2 diabetes is prevalent and a common cause of other conditions such as kidney failure (nephropathy), nerve damage (neuropathy), eye disease (retinopathy), bone infection (osteomyelitis) and heart illness (coronary artery disease). It is primarily due to excessive body weight. So it is natural to look for medications that can help not only with glucose control but also targeting the root problem, obesity.
In the diabetes world, there are two such drug classes, ‘GLP-1 agonists’ and ‘SGLT-2 inhibitors’. Both can assist patients in losing significant body weight. These medications could be expensive, but if covered by health insurance, would be viable options for type 2 diabetes. Of course, side effects and contraindications need to be discussed with the physician.
Blood pressure (BP) control is a critical part of managing patients with type 2 diabetes. Perhaps it is the single most important aspect of diabetes care, which unlike hyperglycemia and dyslipidemia can reduce both micro- and macrovascular complications. Hypertension is more prevalent in individuals with diabetes than general population, and in most cases its treatment requires two or more pharmacological agents (about 30% of individuals with diabetes need 3 or more medications to control BP).
In this article we describe the key evidence that has contributed to our understanding that reduced BP translates into positive micro- and macrovascular outcomes. We review the data supporting current recommendation for BP target < 130/80 mmHg. Two studies suggest that a lower BP goal could be even more beneficial. We also present the comparative benefits of various antihypertensive drugs in reducing diabetes-related micro- and macrovascular complications.
Finally we propose an evidence-based algorithm of how to initiate and titrate antihypertensive pharmacotherapy in affected individuals. Overall, achieving BP < 130/80 mmHg is more important than searching for the “best” antihypertensive agent in patients with diabetes.
In LEAD-6 trial, about 500 patients with type 2 diabetes were followed for 26 weeks. Participants were randomized to receive either Victoza 1.8 mg once daily or Byetta 10 mcg twice daily. Results indicated relative superiority of Victoza over Byetta as shown by improved A1c (-Δ1.1% vs -Δ0.8%) and better convenience and tolerability.