CURRENT MANAGEMENT OF DYSLIPIDEMIA

Dr Jayachandran Thejus MD DMSpecialist Interventional Cardiologist

Zulekha Hospital Sharjah

Part I

CURRENT MANAGEMENT OF DYSLIPIDEMIA- BASICS

How to interpret lipid profile result?• Total cholesterol• LDL• Triglyceride• HDL• VLDL

How to interpret lipid profile result?• Total cholesterol• LDL• Triglyceride• HDL• VLDL

How to interpret lipid profile result?• Total cholesterol• LDL• Triglyceride• HDL

• LDL- most important.• LDL measurement-– Direct– Indirect

How to interpret lipid profile result?• Total cholesterol• LDL• Triglyceride• HDL

• Prefer laboratories with direct LDL measurement.

• Request for “Fasting lipid profile- direct LDL estimate please”

How to interpret lipid profile result?• Total cholesterol• LDL• Triglyceride• HDL

• How to interpret LDL result?

Atherosclerotic disease

Any value of LDL is

high

Diabetes

LDL > 70 mg%

Others

LDL 190 mg% or more

or10 yr risk 5% or

more

What is high LDL?

http://cvdrisk.nhlbi.nih.gov/

http://cvdrisk.nhlbi.nih.gov/

http://cvdrisk.nhlbi.nih.gov/

http://cvdrisk.nhlbi.nih.gov/

Mobile app

Atherosclerotic disease

Start statin

Diabetes

Start statin if LDL is more

than 70 mg%

Others

Start statin if LDL 190 mg% or

moreor

10 yr risk 5% or more

Atherosclerotic disease

Start statin

Diabetes

Start statin unless LDL is less than 70

mg%

Others

Start statin if LDL 190 mg% or more

or10 yr risk 5% or more

High intensity statin

Moderate intensity statin

Statins• Atorvastatin• Rosuvastatin• Simvastatin• Pitavastatin• Fluvastatin

• 10 20 40 80 mg• 5 10 20 40 mg• 10 20 40 mg• Levazo 2mg 4 mg• Lescol-XL 80 mg

Statins• Atorvastatin• Rosuvastatin• Simvastatin• Pitavastatin• Fluvastatin

• 10 20 40 80 mg• 5 10 20 40 mg• 10 20 40 mg• Levazo 2mg 4 mg• Lescol-XL 80 mg

Before you start statin…• Check TSH.• Check SGPT.• Check CPK (total creatinine phosphokinase).• Check S creatinine, urine proteins.• Check HbA1C.

Before you start statin• Ensure adequate lifestyle changes- – Weight loss– Diet change– Exercise

• Avoid alcohol if SGPT is high.

How do you titrate statin dose?• Measure LDL initially every 6 weeks. Then at

more lengthy intervals.

Co-prescription with statin• With atorvastatin- avoid-– Verapamil, diltiazem, amlodipine, amiodarone– Grapefruit juice

• Rosuvastatin has less drug interactions.

Is repeat monitoring of SGPT & CPK needed?

• SGPT.• Muscle pain- do repeat CPK

When to stop statin?• No recommendation to stop.

Statin myopathy• Muscle pain• Increased CPK• Check for Vit D deficiency & hypothyroidism- correct• Atorvastatin (& simvastatin)- stop coexistent calcium channel

blockers and amiodarone.• Reduce dose of statin• Try alternate day therapy• Change from atorvastatin to rosuvastatin- low dose, alternate

day.• (Shift to fluvastatin)• Ezetimibe

Will statins produce diabetes?• Very low incidence (high dose therapy will

cause diabetes in 1 in 500 patients.)

Will statins cause cancer?• No

Will statins cause memory loss?• May cause. Conflicting data.• If a patient complains of memory loss or other

CNS symptom- prefer rosuvastatin to atorvastatin.

Will statins cause renal failure?• No.• (May cause benign proteinuria)

Ezetimibe • Decreases LDL• 10 mg OD • Cholesterol absorption inhibitor• SGPT elevation• Add to statin/ alternative to statin.

PCSK9 inhibitor • Alirocumab (Praluent)• Self S/C injection every 2 weeks (75/150 mg)• For very high LDL (familial dyslipidemias).

Triglycerides• More than 150 mg% is abnormal.• More than 200 mg%- CAD.• More than 500- 800mg%- pancreatitis.

• Secondary causes-– Obesity– Diabetes mellitus– Alcohol intake– Nephrotic syndrome– Hypothyroidism– Estrogen replacement therapy– Beta blocker– Steroid– Familial

• 200 to 500 mg%-– Most important- address secondary cause.– Aim of treatment is reduction of CAD risk, not reduction of

pancreatitis risk– Treat only if patient is otherwise a candidate for statin based on LDL

guidelines– Statin alone

• More than 500 mg%-– Aim of treatment is reduction of pancreatitis risk.– Fenofibrate 145 mg– Omega 3 fatty acids– Rosuvastatin 5-10 mg may be added to fenofibrate

Low HDL• Definition– < 40 mg % in men– < 50 mg % in women

• Lifestyle changes-– Exercise– Weight loss– Smoking cessation

• No specific drug treatment is indicated.

Take home messages• LDL more than 70 mg% in diabetics & any LDL

in CAD patients needs to be treated.• LDL 190 mg % or more in others needs to be

treated. • If LDL is less than 190 mg %, find 10 year

cardiac risk and treat if it is more than 5%.• Statin is preferred.

Take home messages• Take SGPT & CPK before treatment.• For hypertriglyceridemia more than 500 mg %

fenofibrate or omega 3.• Low HDL alone does not need treatment.

END OF PART 1

Part II

CURRENT MANAGEMENT OF DYSLIPIDEMIA- ADVANCED

CKD• Automatically qualify for statin Rx- similar to

atherosclerotic disease• In dialysis dependent persons, statins are not

indicated.

Treatment goalCondition Targets (both should be met)

Atherosclerotic disease LDL < 70 mg/dL and 50% reduction in LDL

Diabetes LDL < 70 mg/dL and 50% reduction in LDL

CKD LDL < 70 mg/dL and 50% reduction in LDL

Others

LDL > 190 mg/dL LDL < 100 mg/dL and 50% reduction in LDL

LDL < 190 mg/dL, but 10 yr risk > 5% LDL < 115 mg/dL and 30% reduction in LDL

After LDL goal is met, non HDL goal should be met- goal is 30 mg% + LDL goal.

Risk scores• ACC/AHA- Pooled cohort equation• ESC- SCORE system- HDL is also taken into

account

SCORE system- very useful relative risk estimator- can be shown to patient

Young (age < 40 yrs)• Statin for primary prevention is only for 40

years or more unless LDL is very high (>190mg%).

• Younger patients- take decision in individual case.

Old (> 75 yrs)• Scoring systems overestimate risk in elderly• After age 75 years, statin side effects are

more- lower dose is advised- also titration up is advised

Lipid profile- fasting or not?• First test- always fasting• Further tests- if TG is not a concern, non

fasting is enough, except in diabetics.

Statin adherence• Surprisingly low in monitored studies• If LDL goal is not achieved, maintain a drug

diary cross checked by a family member.

Lp (a)• Lp (a) is genetically determined. • Values more than 50 mg/dL increase risk of

CAD.

Fibrates• Monitor CPK when giving with statin.• If statin is co-prescribed, rosuvastatin at low dose

(5-10 mg).• Liver enzyme elevation can occur-monitor SGPT• Pancreatitis risk increases when given for

moderate TG- so avoid if TG less than 500 mg%• DVT may occur- watch. • Creatinine may increase- monitor frequently

during treatment.

Omega 3 fatty acids• 1 gm capsule• Dose- 3 capsules daily with meals• Risk of bleeding, especially with antiplatelets

Pregnancy and lactation• Avoid statins during pregnancy and lactation• In ladies of child bearing age, preferably avoid

statin- if needed, avoid pregnancy.• Phytosterol tabs, isphagula powder.• OC should be avoided if LDL > 160 mg%

Alcohol in dyslipidemia• High TG- avoid alcohol• Statin given to patient with elevated SGPT-

avoid alcohol• CAD protection from low alcohol consumption

is only for Western population- not for South Asians

Familial dyslipidemia• LDL more than 190 mg % is a strong indicator• Screen all first degree relatives (cascade

screening) • Age from 5 yrs onwards

Type 1 DM• Supernormal lipid profile- deceptive• In spite of normal LDL, give statin if – Renal disease or– Microalbuminuria

Statins are not needed solely for• HF of non ischemic cause• Aortic stenosis• (Statins are useful for abdominal aortic

aneurysm)

End of Part II

Thank you