Treat the results or the patient?

My patient is a 63-year-old woman on multiple medications for treatment of abnormal lab results. A few months ago she was hospitalized for a week with a campylobacter infection from which she has fully recovered.

My involvement in her care is management of osteoporosis manifest by low bone mineral density without fracture. Her therapy is risedronate 35 mg weekly together with supplemental calcium and vitamin D. She also has been diagnosed in the distant past as having hypothyroidism and is taking thyroxine 75 mg orally daily. She has not tolerated attempts to wean off of thyroxine and she is clinically euthyroid.

She peaked my interest when she presented her lipid profile results ordered by her cardiologist:

LP(a)
HDL-2 (large, buoyant)
Total HDL-C direct
LDL-C
HDL-3 (small, dense)
Total VLDL-direct
Real-LDL-C
VLDL-3 (remnant lipo)
Sum total cholesterol
Sum total LDL-C
Triglycerides-direct
Total non-HDL-C (LDL+VLDL)
Remnant lipo (IDL+VLDL3)
Real-LDL size pattern

There is good literature evidence to support a role for abnormalities in each of these tests in the pathogenesis of atherosclerosis but their role in individual patient care is not yet established. National Cholesterol Education Program guidelines do not yet recommend most of these and there is a lot of homework still to be done both in the lab and the clinic. This lab profiling is expensive and in most clinical circumstances is best avoided.

Based on more real world lipid profiling her total cholesterol was 187; HDL was 43; LDL, 116; and triglycerides, 158. She was placed on three lipid-lowering medications and at repeat study done three months later, total cholesterol was 207; HDL, 46; LDL, 140; and triglyceride, 106. Omega-3 therapy was added to her list (reason unclear).

For completeness her gynecologist has her on conjugated equine estrogen 0.45 mg, and her cardiologist also has her on irbesartan (angiotensin receptor blocker) for treatment of hypertension. Her BP in the clinic was 130 mm Hg/75 mm Hg.

She is now on eight prescription medications and six over-the-counter medications for management of asymptomatic conditions. Her likelihood of being compliant with therapy is low.

As a profession we find ourselves in the situation of having identified an increasing number of measurable risk factors for conditions with potentially disastrous outcomes if not prevented. We also have an increasing array of very effective preventive therapies. What is missing is a measure of what is the most likely adverse health outcome in an individual patient. My patient faces the possibility of a hip fracture, acute myocardial infarction, congestive heart failure or stroke. The more of these we try and prevent with medications, the less likely the patient is to take them as prescribed.

It won’t be too long before more items on the increasingly complex lipid profile listed above will give rise to more specific guidelines and therapy. Then what?