Next month, the Endocrine Society’s Clinical Endocrinology Update will kick off in Miami, during which attendees will hear about the latest breakthroughs in patient care, as well as those cases that may prove difficult for clinicians.
One such session is Lisa Tannock’s Meet-the-Professor presentation on Thursday, September 5, titled “Challenging Cases in Lipid Management.” Cardiovascular disease (CVD) remains the leading cause of mortality in the U.S. and lipids have been are a key contributor to cardiovascular disease risk ; thus, tailoring the correct lipid-lowering therapies for patients is crucial, although that’s not always so simple.
Endocrine News caught up with Tannock, MD, an endocrinologist and lipidologist at the University of Kentucky in Lexington, to talk about her presentation, difficult cases she’s seen, and why she welcomes disagreement from the audience.
Endocrine News: First off, can you give me a little background on your presentation, as well as an overview of what attendees can expect?
Lisa Tannock: During CEU, I will be discussing the latest lipid guidelines in my first talk, then presenting a series of real cases from my practice that represent the types of challenges many providers will see. I like to use the audience response system to assess the various approaches the audience would consider after the case is presented, then I will briefly review the evidence to help guide the audience. I think a key thing for learners to understand is that when we get into these types of difficult cases, often there is no set correct answer, as each individual patient may need a different option depending on their concurrent medical issues or prior medication use history. My goal is to help the providers in the audience think through different options.
Patients reporting intolerance to statins are unfortunately common and it becomes a significant challenge for the provider to know how to help them.
I am the current chair of ESAP, and one thing to point out is that in ESAP (and the board exam) there is always only a single best answer; however in the ‘real world’ that is not the case, and so in this Meet-the-Professor presentation, we will discuss various alternative approaches that a provider can try with each patient.
EN: The title of the session is “Challenging Cases in Lipid Management.” Can you give an example or a preview of a case you’ll cover in the session?
LT: The most common case I get asked to address is that of a patient at high risk for CVD or with known CVD who presents with statin intolerance, and so I will discuss a case of this. Patients reporting intolerance to statins are unfortunately common and it becomes a significant challenge for the provider to know how to help them. However, I will also talk about a few other challenging cases that providers may see, such as CVD risk in patients with chronic kidney disease or use of combination lipid-lowering therapies in patients at particularly high risk for CVD.
EN: Why is it important for physicians to be aware of these challenging cases?
LT: Because we all see these patients, especially endocrinologists (and cardiologists) will see a disproportionate share because primary care physicians are generally really good at initiating statin therapy per guidelines so the patients that are fairly straightforward may never be referred to a specialist. However, patients for whom a primary care physician does not know what to do (statin intolerant, for example, or when the guidelines for management are not very clear, or when combination therapy may be indicated) tend to be referred to endocrinologists. Thus, it is critical for the specialist to have insight and understanding of various approaches.
I find that often there are a few people in the audience who have strong beliefs in something I recommend against – like the use of coenzyme Q-10 in statin intolerant patients, for example – who may push back against my recommendations.
EN: How controversial is this topic? Do you expect some pushback or questions from attendees?
LT: There is always some disagreement in part as the guidelines are not 100% clear on management of these types of challenging patients; I find that often there are a few people in the audience who have strong beliefs in something I recommend against – like the use of coenzyme Q-10 in statin intolerant patients, for example – who may push back against my recommendations. I actually enjoy this; as a big part of how well a therapy may be tolerated by a patient in part depends on how much the provider can convince the patient that the therapy will be effective.
Having some debate and discussion over different opinions is a great way to demonstrate to other members of the audience that there is not one single best option for every patient, but that it should be a dialogue between provider and patient. For most lipid-lowering therapy options there is no real evidence of harm, but several different options that may be right. So it is good for providers to be aware of these different options.
EN: What should attendees take away from your presentation?
LT: Hopefully that they have the ability to manage these challenging cases and don’t necessarily need to refer them on, and that there is often more than one right answer, and the correct choice will vary between each provider and patient.