Dyslipidemia Practice Exam: Diabetes Chapter 25

Dyslipidemia is one of the most significant modifiable risk factors for cardiovascular disease in people with diabetes. The 2018 Clinical Practice Guidelines simplify the management approach by focusing on statin therapy for high-risk individuals and establishing clear, aggressive targets for Low-Density Lipoprotein Cholesterol (LDL-C).

This practice exam tests your ability to identify who requires statin therapy, when to intensify treatment with second-line agents, and how to manage hypertriglyceridemia safely.

Key Concepts Covered in This Exam:

Indications for Statin Therapy: Identifying the broad criteria for treatment initiation, including age $\ge$ 40, duration of diabetes >15 years, or the presence of microvascular complications.
Therapeutic Targets: Mastering the primary goal of therapy: achieving an LDL-C consistently <2.0 mmol/L or a >50% reduction from baseline.
Intensification: Knowing when to add ezetimibe or PCSK9 inhibitors for patients who do not reach targets despite maximally tolerated statin therapy.
Hypertriglyceridemia: Understanding that fibrates are generally used to prevent pancreatitis when triglycerides are >10.0 mmol/L, rather than for primary CVD prevention.
Screening Intervals: Recalling the recommendation to screen lipid profiles at diagnosis and annually (or every 3 to 6 months after starting treatment).

1. A patient with type 2 diabetes and established CVD is on high-intensity statin therapy but has an LDL-C of 2.8 mmol/L. Which therapy may be considered to further reduce CV events?

Add colesevelam

Add extended-release niacin

Add gemfibrozil

Add ezetimibe or consider a PCSK9 inhibitor

2. What is the most common lipid pattern in people with type 2 diabetes?

Isolated low HDL-C with normal TG and LDL-C

Elevated LDL-C, normal TG, normal HDL-C

Elevated total cholesterol with normal lipid subfractions

Hypertriglyceridemia, low HDL-C, relatively normal LDL-C

3. Case: A 42-year-old man with obesity and metabolic syndrome (no diabetes yet) is found to be prediabetic during statin therapy. He asks if he should stop his statin. What is the most appropriate advice?

Continue statin therapy

Discontinue statin immediately as it caused the prediabetes

Switch to fibrate therapy

Discontinue all lipid therapy and focus only on lifestyle

4. Case: A patient with type 2 diabetes is intolerant to statins. What second-line therapy should be considered to achieve LDL-C goals?

Gemfibrozil as monotherapy

High-dose niacin

No alternative therapy is available

Ezetimibe, bile acid sequestrants, or PCSK9 inhibitors

5. According to Diabetes Canada, at what fasting triglyceride level should a fibrate be used to reduce the risk of pancreatitis?

>4.5 mmol/L

>6.0 mmol/L

>10.0 mmol/L

>8.0 mmol/L

6. A patient with impaired glucose tolerance (IGT) and metabolic syndrome asks about their cardiovascular risk and whether lipid treatment is warranted. What is the most evidence-based response?

IGT with metabolic syndrome carries significant CV risk; aggressive management of dyslipidemia to similar targets as diabetes is reasonable

Focus only on glucose management

Only treat after progression to diabetes

IGT does not increase CV risk; treatment is unnecessary

7. Case: A patient with familial hypercholesterolemia and type 2 diabetes is not achieving LDL-C goals despite maximally tolerated statin therapy. What additional therapy should be considered?

Niacin

Ezetimibe or PCSK9 inhibitor

Bile acid sequestrant only

Gemfibrozil

8. What is the alternative apolipoprotein B (apo B) target for people with diabetes?

<0.9 g/L

<0.8 g/L

<0.7 g/L

<0.6 g/L

9. Case: A patient with type 2 diabetes is on maximum-tolerated statin therapy but has an LDL-C of 2.4 mmol/L (baseline was 4.0 mmol/L). According to the guidelines, what should be considered next?

Discontinue statin and switch to fibrate

No further therapy needed as >50% reduction achieved

Add niacin for additional LDL-C lowering

Add ezetimibe to achieve LDL-C goal

10. Case: A 35-year-old man with type 2 diabetes has had diabetes for 18 years and has microalbuminuria. His LDL-C is 2.8 mmol/L. Should he be considered for statin therapy?

Only if his LDL-C exceeds 3.5 mmol/L

Only after a formal cardiovascular risk calculation

No, he is too young for statin therapy

Yes, because he is >30 years with diabetes duration >15 years and microvascular disease

11. A patient with type 2 diabetes is concerned about statin-induced diabetes. According to the guidelines, what should you counsel them?

Statins significantly increase diabetes risk and should be avoided

There is a small overall increase in diabetes risk

Only pravastatin is safe from this risk

Statin-induced diabetes is a myth with no supporting evidence

12.

According to the guidelines, at what TG level is LDL-C systematically underestimated even when it can still be calculated?

4.5-6.0 mmol/L

>6.0 mmol/L

1.5-4.5 mmol/L

0.5-1.5 mmol/L

13. Diabetes is associated with how much greater risk of vascular disease compared to individuals without diabetes?

8- to 10-fold greater

2- to 4-fold greater

5- to 7-fold greater

1.5-fold greater

14. Case: A healthcare team is developing a lipid screening protocol for their diabetes clinic. Based on the guidelines, which statement best reflects appropriate screening frequency?

Screen only at diabetes diagnosis and never repeat

Lipid profile at diagnosis; if treatment not warranted, repeat annually or as indicated

Screen every 5 years regardless of treatment status

Only screen if symptoms of CVD develop

15. Which healthy behaviour intervention components are recommended to improve the lipid profile in people with diabetes?

Only aerobic exercise

Weight management, physical activity, dietary changes (low saturated/trans fats), smoking cessation, and moderate alcohol

Only smoking cessation

Only dietary modifications

16. According to Diabetes Canada, what is the primary LDL-cholesterol target for people with diabetes who have indications for lipid-lowering therapy?

<2.0 mmol/L

<2.5 mmol/L

<1.8 mmol/L

<1.5 mmol/L

17. What percentage of Canadians with type 2 diabetes for 15 years also have dyslipidemia according to a national cross-sectional chart audit?

66%

45%

75%

55%

18. Which lipid-lowering medication has an ancillary effect of lowering A1C in people with type 2 diabetes?

Colesevelam

Ezetimibe

Fenofibrate

Atorvastatin

19. Case: A 55-year-old woman with type 2 diabetes has elevated TG (3.8 mmol/L) and her calculated LDL-C appears lower than expected. What should be considered?

LDL-C may be underestimated; consider using non-HDL-C or apo B

LDL-C is accurate and no further action needed

Repeat the LDL-C test in 6 months

TG level is not relevant to LDL-C calculation

20. Case: A 60-year-old man with type 2 diabetes requires a lipid profile. He takes long-acting basal insulin at bedtime. What is the recommendation regarding fasting for lipid testing?

A fast of >8 hours may be inappropriate; nonfasting with non-HDL-C or apo B is valid

Insulin patients should never have fasting lipids measured

Only random lipids should be measured

Always require a 12-hour fast regardless of insulin

21. A clinician is evaluating a patient’s lipid results and considering whether to use apo B or non-HDL-C as an alternative target. What is the relationship between apo B of 0.8 g/L and non-HDL-C?

Apo B 0.8 g/L is approximately equal to non-HDL-C of 2.6 mmol/L

Apo B 0.8 g/L is approximately equal to non-HDL-C of 2.0 mmol/L

Apo B 0.8 g/L is approximately equal to non-HDL-C of 3.4 mmol/L

There is no correlation between apo B and non-HDL-C

22. Which statin should NOT be used in combination with gemfibrozil due to increased risk of myopathy and rhabdomyolysis?

Only rosuvastatin

Any statin

Only atorvastatin

Only simvastatin

23. According to the guidelines, laboratories will not report calculated LDL-C when triglycerides are at what level?

≥2.5 mmol/L

≥5.5 mmol/L

≥3.5 mmol/L

≥4.5 mmol/L

24. What is the alternative non-HDL-cholesterol target for people with diabetes?

<2.6 mmol/L

<3.0 mmol/L

<2.0 mmol/L

<3.4 mmol/L

25. Case: A 45-year-old woman with type 2 diabetes has fasting TG of 12.5 mmol/L despite good glycemic control and dietary modifications. What is the most appropriate pharmacological intervention?

Fibrate therapy to reduce pancreatitis risk

PCSK9 inhibitor therapy

Ezetimibe therapy

High-intensity statin therapy

26. Case: A team is reviewing factors that increase the risk of statin-induced myopathy. Which combination of risk factors warrants the most caution?

Age >80 years, female, small body frame

Young female with no comorbidities

Middle-aged male on monotherapy

Young male with normal renal function

27. A patient with type 2 diabetes has TG of 2.8 mmol/L and asks about the optimal TG level. Although TG is not a target of therapy for CV risk reduction, what level is considered optimal?

<1.0 mmol/L

<2.0 mmol/L

<1.5 mmol/L

<2.5 mmol/L

28. Case: A 52-year-old man with type 2 diabetes has an LDL-C of 3.2 mmol/L. He has no known CVD but has hypertension and microalbuminuria. He is not currently on lipid-lowering therapy. What is the most appropriate first-line treatment?

Niacin therapy

Statin therapy

Fibrate therapy

Ezetimibe monotherapy

29. Case: A 48-year-old woman with type 2 diabetes has achieved LDL-C of 1.9 mmol/L on statin therapy. Her TG is 2.4 mmol/L and HDL-C is 1.0 mmol/L. She asks about adding fenofibrate to further reduce her CV risk. Based on current evidence, what is the most appropriate response?

Add fenofibrate as it will significantly reduce CV events

Fibrates should not be routinely added in patients at LDL-C goal as there is no additional CV benefit

Add both fenofibrate and niacin for maximum effect

Fenofibrate is contraindicated with statins

30. What is the mechanistic explanation for why LDL particles are more atherogenic in people with type 2 diabetes even when LDL-C appears normal?

LDL particles are less susceptible to oxidation in diabetes

LDL particles are typically small and dense

There is no difference in LDL atherogenicity in diabetes

LDL particles in diabetes are larger and more buoyant

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