Hyperlipidemia


CAD Equivalents
Peripheral Arterial Disease (PAD)
Abdominal Aortic Aneurysm
Symptomatic CAD*
Diabetes Mellitus

 

“ATP IV” Basics: Statin Intensity
High-intensity
(> 50% LDL-C reduction)
Moderate-intensity
(30% to < 50% LDL-C reduction)
Atorvastatin 40-80 mg
Rosuvastatin 20 mg
Atorvastatin 10-20 mg
Rosuvastatin 5-10 mg
Simvastatin 20-40 mg
Pravastatin 40-80 mg
Lovastatin 40 mg
Fluvastatin 40 mg bid

New Lipid Guidelines (2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol)
1. Individuals with clinical ASCVD
– Age < 75 y High-intensity
– Age > 75 y Moderate-intensity
 
2. With primary elevations of LDL-C > 190 mg/dL High-intensity
3. Age 40-75 yrs with diabetes and LDL-C 70-189
– Estimated 10-y ASCVD risk > 7.5%: High-intensity
– Estimated 10-y ASCVD risk < 7.5%: Moderate-intensityy
4. Without clinical ASCVD or diabetes
     age 40-75
     LDL-C 70- 189 and
     estimated 10-year ASCVD risk of 7.5% or higher

Moderate-to-high intensity
5. In most cases these are people with familial hypercholesterolemia. Moderate-to-high intensity
6. Most of these people will have had a myocardial infarction (heart attack), angina, peripheral artery disease, or a stroke. High-intensity

New Lipid Guidelines (2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol)
Individuals with clinical ASCVD, Age < 75 y High-intensity
 
With primary elevations of LDL-C > 190 mg/dL
Age 40-75 yrs with:
 - Diabetes

 - LDL-C 70-189,
-  Estimated 10-y ASCVD risk > 7.5%
Most of these people will have had
 - Myocardial infarction (heart attack)
 - Angina
 - Peripheral artery disease or
 - Stroke.
 

Individuals with clinical ASCVD, Age > 75 y
Moderate-to-high intensity
Age 40-75 yrs with:
 - Diabetes

 - LDL-C 70-189,
-  Estimated 10-y ASCVD risk < 7.5%
Without clinical ASCVD or diabetes
     Age 40-75
     LDL-C 70- 189 and
     estimated 10-year ASCVD risk of > 7.5%
In most cases these are people with familial hypercholesterolemia.

 
TGL Management
> 500 < 500
Risk of Pancreatitis
Q = Was the pt fasting?
LDL ?

Start:
TRICOR 145mg po qd 


>100

<100

-Statin
Atorvastain 80mg po qhs
??
Diet and Exercist.

Causes of Hyperlipidemia

Causes of secondary dyslipidemia:

  •  Diabetes mellitus
  • Hypothyroidism
  • Obstructive liver disease
  • Chronic renal failure
  • Some medication

Labs/Work-up

  • CBC, CMP
  • TSH
  • A1c
  • Check Renal function (CMP)
  • Check Liver Function (CMP, PT/INR)

Follow-up Labs

Lipid Panel (NEW GUIDELINES)

  • DO NOT follow serial lipid panel.
  • Just pick HIGH/MODERATE intensity based on risk factors.
     

Lipid Panel (OLD GUIDELINES)

When to Re-check lipid panel after starting -statin?: 6 weeks

  • If satisfactory lipid control and no evidence of SE: Review again at 4-6 months, then 6-12 monthly
  • If unsatisfactory lipid control: Repeat 6 weeks after dosage adjustments are made until the desired lipid concentrations are achieved
  • However NICE state that LFTs only need to be measured on three occasions:
    • Baseline LFT should be measured before starting a statin. Liver function (transaminases) should be measured within 3 months of starting treatment and at 12 months, but not again unless clinically indicated.
    • People who have liver enzymes (transaminases) that are raised but are < 3 times the upper limit of normal should not be routinely excluded from statin therapy.
    • Treatment should be discontinued if serum transaminase concentrations rise to, and persist at, 3x normal range

Liver Enzymes

-Statin Therapy Start ↑↑ AST, ALT
(but < 3x normal)
Asymptomatic CONTINUE -STATIN
Symptomatic STOP
 
 

-Statin Side Effects

  • Statin-related muscle complaints include
    • statin myopathy (any muscle complaints related to these drugs),
    • Myalgia (muscle complaints without serum CK elevations),
    • Myositis (muscle complaints with serum creatine kinase [CK] elevations), and
    • Rhabdomyolysis (markedly ↑↑ CK levels, creatinine, and pigment-induced nephropathy).
  • Muscle symptoms with demonstrable weakness and histopathologic findings of myopathy can occur in patients on statins, despite normal serum CK levels.
  • The risk of rhabdomyolysis and other adverse effects related to statin use can be exacerbated by several factors, including compromised hepatic and renal function, hypothyroidism, diabetes mellitus, and concomitant medication use.
     
  • Simvastatin, atorvastatin, and lovastatin are primarily metabolized by the cytochrome P-450 (CYP) 3A4 system; medications that inhibit CYP 3A4, such as macrolide antibiotics, azole antifungals, and cyclosporine, increase the serum concentrations of these statins and therefore the risk of statin-associated myopathy.
  • Other medications that can increase the risk of statin-associated myopathy include fibric acid derivatives such as gemfibrozil, niacin, HIV protease inhibitors, nefazodone, verapamil, diltiazem, and amiodarone.
  • The consumption of more than a quart of grapefruit juice a day has also been associated with statin myopathy.
  • Combination therapy with ezetimibe has not been shown to increase the risk of myopathy.
     
  • Although some experts recommend baseline serum CK measurements prior to the start of statin therapy, routine monitoring of CK levels is not required.
  • There is no need to discontinue statin therapy in asymptomatic patients unless CK levels are more than 10 times higher than the upper limits of normal.

 

2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol

Major recommendations for statin therapy for ASCVD prevention

Initiating statin therapy in individuals with clinical ASCVD

Initiating statin therapy in individuals without clinical ASCVD

1

Statin Therapy_Monitoring therapeutic response and adherence



 

 


Drugs

% LDL
reduction
< 24% 25-32% 31-39% 37-45% 48-52% 55-60% 60-63%
Fluvastatin
(Lescol)
20 40 80 - - - -
Lovastatin
(mevacor)
10 20 40 80 - - -
Pravastatin
(pravachol)
10 20 40 80 - - -
Simvastatin
(zocor)
5 10 20 40 80 - -
Atrovastatin
(lipitor)
- - 10 20 40 80 -
Rosuvastatin
(crestor)
- - - 5 10 20 40
Ezetimibe/Simvastatin
(Vytorin)
- - - 10/10 10/20 10/40 10/80
 

 

ITE 2013, Q#186.

A 53-year-old male with hypertension, hyperlipidemia, and nonalcoholic fatty liver disease began taking atorvastatin (Lipitor) 3 months ago. His LDL-cholesterol level is now at goal, but he has developed an asymptomatic elevation of his hepatic transaminases to twice-normal levels. Which one of the following is the most appropriate course of action?

A) Continue the atorvastatin at the current dosage
B) Reduce the dosage of atorvastatin by half
C) Discontinue atorvastatin and switch to another statin
D) Discontinue atorvastatin and switch to an antihyperlipidemic agent from a different class
E) Order hepatic ultrasonography

ANSWER: A