Transcript Slide 1

Ministry of Health
Family Practice Residency Training Program
MANAGMENMT OF HYPERLIPIDEMIA
Adopted from
The Third Report of the National
Cholesterol Education Program (NCEP)
Prepared by:
Dr. Ashwak Sabt
Dr. Amal Bu-Asali
Dr. M. Aljalahma
Revised By: Dr. Mariam AL-Jalahma
Dr. Dalal Al-Hashmi
Final Review: Dr. N. Das
FPRP……………………………………………….……………………………..2005
New Recommendation for Screening/Detection
Complete lipoprotein profile preferred
Fasting total cholesterol, LDL, HDL, triglycerides
after 12-14 h fasting
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•
Adults: > 20 years of age
· Every 5 years with no CAD risk
· Every 2 years if family history of premature CAD
•
Elderly patients > 75 years of age
· Evaluate only if multiple risk factors for CAD
•
Children > 2 years and adolescents <16 years with
family history of premature CAD or dyslipidemia, have
hypertension, or obesity, or DM or smoker.
· Once
•
For adolescents >16 years
· Once
ALGORITHM
FOR Treatment decision
based on LDL cholesterol
Assess total Fasting lipid profile
LDL > 2.6mmol/L
Rule out sec. causes***
Normal Profile
LDL <2.6mmol (100mg/dl)
Screen every 5 years
Patient with CHD
Or equivalent risk **
LDL Goal <2.6 mmol(100mg)
Assess risk factors*
Patient with multiple
risk factors +2
LDL goal
< 3.36 mmol (130mg)
A
Patient with 0 -1
risk factors
LDL goals
< 4.1mmol(160mg)
B
C
*Major Risk Factors (Exclusive of LDL
Cholesterol) That Modify LDL Goals
•
Cigarette smoking
•
Hypertension (BP  140/90 mmHg or on antihypertensive medication)
•
Low HDL cholesterol (<40 mg/dL or 1.03 mmol /L)
•
Family history of premature CHD
•
–
CHD in male first degree relative <55 years
–
CHD in female first degree relative <65 years
Age (men 45 years; women 55 years)
HDL cholesterol 60 mg/dL(1.554 mmol /L) counts as a “negative” risk factor; its
presence removes one risk factor from the total count.
Equivalent risk**
• DM- Atherosclerosis Ds.- Multiple risk factors that confer a 10 year risk
for CHD > 20%
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•If Triglycerides are higher than 5.6mmol(500mg/dl) first reduce triglycerides,
when triglycerides <5.6mmol, then treat LDL
A
Patient with CHD
Or equivalent risk (DM)
LDL Goal <2.6 mmol(100mg)
LDL< 2.6(100mg)
TLC &
follow up
6 months
Response
LDL 2.6-3.3 mmol
(100-129mg)
LDL >3.36 mmol (130mg)
TLC &
follow up
3 months
TLC &
Drug Therapy
No Response
B
Patient with multiple
risk factors +2
LDL goal
< 3.36 mmol (130mg)
Assess 10 year risk for CHD
< 10% 10 year risk
LDL
3.36-4.1mmo
130-160mgl
TLC &
follow up
6 months
>20% 10 year risk
Manage as CHD
equivalent risk
LDL
>4.1mmol
>160mg
Response
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TLC &
follow up
3 months
10-20% 10 year risk
LDL
>3.36mmol
>130mg
No Response
TLC &
follow up
3 months
Response
LDL
<3.36mmol
<130mg
TLC &
follow up
6 months
Drug
Therapy
Follow up with LDL
TLC: Therapeutic life style changes
C
Patient with 0 -1
risk factors
LDL goal < 4.1mmol(160mg)
LDL<4.1mmol
<160mg
LDL4.1-4.9mmol
160-189mg
LDL>4.9mmol
190mg
!!!Factors favoring
use of drugs****
TLC &
follow up
6 months
Response
TLC &
follow up
3 months
No Response
**** Factors favoring use of drugs
Drug
Therapy
In case of LDL4.1-4.9 mmol (160-189mg) the choice to start drug
therapy after TLC is favored according to the following:
• A severe single risk factor (heavy cigarette smoking, poorly
controlled hypertension, strong family history of premature CHD, or
very low HDL cholesterol};
• Multiple life-habit risk factors and emerging risk factors (if measured)
• 10-year risk approaching 10%
***Ruling out Secondary Causes
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TLC: Therapeutic life style changes
Management of Specific Dyslipidemia
Elevated Triglycerides
150-199mg/dL
1.64-2.26mmol
primary target LDL goal
•Weight reduction
•Increase physical
activity
> 500 mg/dL
>5.64mmol
200-499mg/dL
2.26-5.63mmol
Monitor non -HDL cholesterol*
Primary target is
Triglycerides lowering
•Weight reduction
•Increase physical activity
• Drug therapy
In high risk patients
( Triglycerides lowering drugs, or
Intensify LDL lowering drugs
•Very low fat diet
•Weight reduction
•Increase physical
activity
•Triglycerides
Lowering drugs
The ATPIII encourages a more aggressive approach to hypertriglyceridemia.
The major lipid component of VLDL is the triglycerides. The NCEP mentions
VLDL level as part of a secondary treatment goal in patients with hypertriglyceridemia
Termed as the non-HDL cholesterol ( total cholesterol minus HDL) see table 2
Table1 ATP III classification of triglycerides
*Table 2 non-HDL cholesterol
Normal triglycerides
<1.69 mmol <150mg/dl
Border line-high TG
1.69-2.26 mmol 150-199mg/dl
< 2.6
< 3.36
2.26- 5.63 mmol 200- 499mg/dl
< 3.36
< 4.1
> 5.64mmol >500 mg/dl
< 4.1
< 4.9
High TG
Very high TG
Low HDL Cholesterol
•No specific goal for raising HDL, no specific drug therapy,
•Target should be to lower LDL cholesterol, weight reduction and increased physical activity.
•Drug therapy is mostly reserved for patients with CHD & CHD risk equivalent.
•In patients with low HDL & high triglycerides ( 2.26-5.63 mmol), monitor non-HDL cholesterol.
Management of Very high LDL cholesterol p-190 mg/dL).
Persons with very high LDL cholesterol usually have genetic forms of hypercholesterolemia:
monogenic familial hypercholesterolemia, familial defective apolipoprotein B, and polygenic
hypercholesterolemia. Early detection of these disorders through cholesterol testing in young
adults is needed to prevent premature CHD. Family investigation is important to identify similar
affected relatives.
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Metabolic Syndrome
The diagnosis of metabolic syndrome is made when three or more of the following risk
determinants are present:
(1.7 mmol)
(1.05 mmol)
(1.3 mmol)
( treatment of hypertension, use of Aspirin, treatment of elevated Triglycerides
and low HDL cholesterol)
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TLC: Therapeutic life style changes
• Reduced intakes of saturated fats «7% of total calories) and cholesterol
«200 mg per day) (see Table 6 for overall composition of the TLC Diet)
• Therapeutic options for enhancing LDL lowering such as plant
stanols/sterols (2 g/day) and increased viscous (soluble) fiber (10-25 g/day)
• Weight reduction
• Increased physical activity
Nutrient composition of TLC diet
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* Lovastatin (20-80 mg), pravastatin (20-40 mg), simvastatin (20-80 mg), fIuvastatin
(20-80 mg), atorvastatin (10-80 mg), cerivastatin (0.4-0.8 mg).
t Cyclosporine, macrolide antibiotics, various antifungal agents and cytochrome P-450
inhibitors (fibrates and niacin should be used with appropriate caution).
+ Cholestyramine (4-16 g), colestipol (5-20 g), colesevelam (2.6-3.8 g).
¥ Immediate release (crystalline) nicotinic add (1.5-3 g). extended release nicotinic acid
(Niaspan @) (1-2 g). sustained release
nicotinic add (1-2 g).
Drug Therapy follow up steps
Lipid lowering agents available in the local health centers
Drugs Class
Statins
Fluvastatin (Lescol)
Dose &
Administrati
on
Contraindic
ation
Initially 2040mg HS up
to 40mg BD.
Liver
diseases
Pregnancy
and lactation
Pravastatin
Sodium (Lipostat)
Usual range
10-40 mg HS
Simvstatin (Zocor)*
Usual range
10-80 mg HS.
Atoravastatin (Lipitor)*
Fibrate
Bezafibrate (bezallip
retard)
10
Usual range
10-40 mg OD
up to max.
80mg at any
time of the
day with or
without food
400mg od in
the morning
or evening
with or after
meal
Renal
impairment
Liver
diseases
Pregnancy
and lactation
Caution
•
Liver function test should be carried out
before and within 1-3 months of starting treatment
then at 6 month interval thereafter 1 year.
Discontinue. If serum transaminases raises to 3
times the upper limit.

Myositis:Reversiblemyositis is a rare but
significant side effect.i t may be increased in those with
renal impairment ,hypothyrodism, concomitant use of
cyclosporine. concomitant treatment with fibrate and
statins ass. With increased risk of myositis.

Advise patient to report promptly unexplained
muscle pain,tend,erness,weakness.Check CPK if
markedly elevated (>10 times upper limit of
normal)discontinue treatment.
Baseline serum creatinine or creatinine clearance.
If Serum creatinine>1.5 mg/dl or135mmol/l bezalip
retard must not be used .Instead Bezalip tab 200mg can
be used
Baseline LFT (same as above)
* These drugs available for referred patients only
Special Considerations for different population groups
Middle aged men (35 – 65 years): with relatively high risk for CHD need intensive
LDL – Lowering therapy.
Women ages (45 – 75 years) with multiple risk factors & metabolic syndrome
cholesterol lowering drugs are preferable to hormone replacement therapy for CHD risk
reduction.
Older adults (men ≥ 65 & women ≥ 75 years).
For primary prevention TLC is first line of therapy. LDL lowering drugs are considered
for older persons with multiple risk factors or advanced sub clinical atherosclerosis.
Younger adults (men 20 –35 years, women 20 – 45 years).
CHD is rare except in those with severe risk factors (familial hypercholesterolemia,
heavy smoking, DM). The following table show management of LDL cholesterol in
young adults.
LDL
≥ 130 mg
TLC
Drug
+
<
< 3.36 mmol
160 – 189mg
+
±
+
+
4.1- 4.9 mmol
190 mg
4.9 mmol
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