Lipid disorders

Adults in the United States spent more on medications for diabetes and high cholesterol and other metabolic disorders than on any other class of medications in 2006. Expenditures for metabolic agents totaled $38.1 billion, or 18.3% of total outpatient drug expenditures for noninstitutionalized adults 18 years and older. In all, outpatient drug spending totaled $208.1 billion in 2006. Expenditures for the top 5 therapeutic classes accounted for $130.8 billion, or 62.9% of total expenditures. Findings are from the ongoing Medical Expenditure Panel Survey conducted by the Agency for Healthcare Research and Quality.

A 51-year-old man is admitted to the hospital with painful ulcers on both lower extremities, severe anemia, and a 45-kg (100-lb) weight loss over the past year. Pain from the ulcers prevents him from walking. The ulcers developed about 5 years earlier, as a result of his wearing high boots for work; they began as small sores and grew over time.

Generic drug utilization has reached its highest levels to date-60.4% for retail prescriptions and 49.3% for mail-service prescriptions (Cover Figure), while pharmacy reimbursement continues its downward trend.

Coronary artery disease (CAD), the most common form of cardiovascular disease in the United States, is the most costly type of cardiovascular condition to manage, according to the American Heart Association. Of the estimated $448.5 billion in total costs for cardiovascular diseases and stroke in 2008, CAD accounted for $156.4 billion, more than twice the cost of hypertension ($69.4 billion) and stroke ($65.5 billion) (Figure 1). Direct costs associated with CAD were $87.6 billion in 2008, of which prescription drug costs alone were $9.7 billion (Figure 2). Of the $68.8 billion in indirect costs for CAD in 2008, $58.6 billion were associated with lost productivity caused by increased mortality.

Use of AstraZeneca’s Crestor (rosuvastatin calcium) reduced the number of deaths, myocardial infarctions (MIs), and strokes as well as the need for bypass or angioplasty procedures by 45% in apparently healthy persons. Lead researcher Paul M. Ridker, MD, MPH, professor at Harvard Medical School, and director of the Center for Cardiovascular Disease Prevention, Brigham and Women's Hospital, Boston, and colleagues presented results of the AstraZeneca-funded JUPITER (the Justification for Use of Statins in Prevention: An Intervention Trial Evaluating Rosuvastatin) study at the 2008 Scientific Sessions of the American Heart Association held November 8 through 12 in New Orleans. Findings were published in the November 20 issue of the New England Journal of Medicine.

The federal government has less authority to set Medicare drug reimbursement prices than officials at the Centers for Medicare & Medicaid Services (CMS) had thought, according to a ruling by Judge Henry H. Kennedy Jr of the US District Court in Washington, DC, in a case (Hays v Leavitt [1:08-cv-01032-HHK]) filed by a person with chronic obstructive pulmonary disease. The patient, Ilene Hays, had received a prescription for DuoNeb, a combination inhalation drug made by Mylan’s Dey subsidiary.

During a routine physical examination, flesh-colored papules were noted on a 36-year-old man’s elbows, knees, and interphalangeal joints. The patient reported that they had been present for a long time, were nonpruritic, and had remained the same color and size. He had not self-treated with any over-the-counter medications. His only other concern was acid reflux for which he regularly took antacids. He had no significant medical or surgical history and no medication allergy. He smoked 1 pack of cigarettes per day, drank alcohol socially, and consumed caffeine-containing drinks daily.

Over the past 4 decades, our understanding of the role of elevated cholesterol in cardiovascular disease (CVD) has undergone radical change. During that time, we have moved from a belief that cholesterol does not matter and that atherosclerosis is an irreversible process to a strong conviction that treating elevated cholesterol, especially elevated low-density lipoprotein cholesterol (LDL-C), can slow and perhaps halt the progression of atherosclerosis. But it has been a slow process for several reasons. In the 1960s, the Framingham investigators demonstrated that elevated serum cholesterol is a risk factor for CVD.1

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Patients with newly diagnosed dyslipidemia often have difficulty remembering the difference between highdensity lipoprotein (HDL) and lowdensity lipoprotein (LDL) cholesterol.

What should be added to the regimen of a patient with type 2 diabetes mellitus when initial oral therapy no longer adequately controls glucose levels?

Selecting the most effective stroke prevention strategy for patients with cerebrovascular disease is an acknowledged challenge. In addition to decisions about the appropriateness of carotid surgery or angioplasty and stenting, there is the often tricky matter of designing the most effective medical regimen.

Patients appreciate-and often expect-notification of lab results. I have developed form letters to notify patients of cholesterol, bone density, and diabetes test results.

In their Consultations & Comments exchange, "Lipid Ratios and the Prediction of Atherothrombotic Risk" (CONSULTANT, January 2008), neither Dr William Kannel nor Dr William Feeman Jr discussed how measurements of high-sensitivity C-reactive protein (hsCRP) and lipoprotein-associated phospholipase A2 might help guide treatment decisions.

A 28-year-old woman presents with milky discharge in both breasts and throbbing occipital headaches of 4 months' duration. The headaches begin gradually, do not radiate, and have no apparent triggers or relieving factors.

As many as 10% of Americans older than 20 years have type 2 diabetes, and more than 20% of the total population has the metabolic syndrome. Type 2 diabetes will develop in many of those with the metabolic syndrome.

As the numbers of patients with diabetes continue to climb, physicians and health policy experts are devoting increasing attention to strategies that can improve care for these patients. One of the strategies frequently mentioned is the Chronic Care Model, developed in 1998 by the MacColl Institute for Healthcare Innovation.

Tea is the second most widely consumed drink in the world. There have been numerous studies of the relationship between tea consumption and vascular disease. Although most such studies have found a negative correlation between these two,1-4 some have shown no association,5 and 1 study has even suggested that increasing tea consumption is associated with greater risk of coronary artery disease.

In medicine, for far too long, men and women were lumped together into "one size fits all" algorithms or, worse, women were presumed to be smaller versions of their male counterparts.

Mortality data released by the CDC in January show that between 1999 and 2005, the age-adjusted death rate for coronary heart disease decreased by 25.8%, from 195 to 144 deaths per 100,000 persons per year. The new data also indicate that since 1999, the death rate for stroke has decreased by 24.4%, from 61 to 47 deaths per 100,000 persons per year. The reduction in mortality rates in 2005 resulted in approximately 160,000 fewer deaths from coronary heart disease and stroke, 2 of the 3 leading causes of death in the United States.

Consumer-directed health plans (CDHPs) are attracting new interest as a result of a ruling by the Internal Revenue Service (IRS) over what constitutes preventive services. CDHP benefit designs take various forms, but in general, these are low-premium, high-deductible plans that provide full or close to full coverage for enrollees once the deductible is met and are typically tied to a health savings account (HSA).

A proposal by the Centers for Medicare & Medicaid Services (CMS) published in the January 8 issue of the Federal Register would allow stand-alone Part D plans to offer reduced premiums to enrollees with limited incomes and resources-a rule intended to give such enrollees in each Medicare prescription drug benefit region at least 5 options with no monthly premium.

According to a survey published in January by the International Foundation of Employee Benefit Plans (IFEBP), Brook field, Wis (http://www.ifebp.org), US employers are increasingly covering alternative/complementary therapies and medical tourism as part of their health benefit cost-containment efforts. Currently, chiropractic care is covered by 80.5% of employers, and 33.5% of employers cover acupuncture or acupressure expenses. The IFEBP survey found that medical tourism-a practice in which US residents travel to other nations, such as India, Mexico,and Thailand, to obtain lower-cost treatment (Figure), including heart bypass surgery and hip or knee replacement surgery-is covered by 11% of employers. 

An obese 61-year-old man with a history of heroin abuse was brought to the hospital after he had fallen onto his buttocks on a sidewalk. He was able to stand initially, but weakness and numb-ness in his legs rendered him suddenly unable to walk or prevent himself from voiding. He denied abdominal or back pain. His medical history included asthma, chronic obstructive pulmonary disease, and hypertension.

The first step in the workup of a patient with a persistent asymptomatic alkaline phosphatase (ALP) elevation is to measure gamma-glutamyltranspeptidase to determine whether the elevation is liver-related or bone-related.