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Current management of dyslipidemia final
- 1. CURRENT MANAGEMENT OF DYSLIPIDEMIA DrJayachandran Thejus MD DM Specialist Interventional Cardiologist Zulekha Hospital Sharjah
- 2. Part I CURRENT MANAGEMENTOF DYSLIPIDEMIA- BASICS
- 3. How to interpretlipid profile result? • Total cholesterol • LDL • Triglyceride • HDL • VLDL
- 4. How to interpretlipid profile result? • Total cholesterol • LDL • Triglyceride • HDL • VLDL
- 5. How to interpretlipid profile result? • Total cholesterol • LDL • Triglyceride • HDL • LDL- most important. • LDL measurement- – Direct – Indirect
- 6. How to interpretlipid profile result? • Total cholesterol • LDL • Triglyceride • HDL • Prefer laboratories with direct LDL measurement. • Request for “Fasting lipid profile- direct LDL estimate please”
- 7. How to interpretlipid profile result? • Total cholesterol • LDL • Triglyceride • HDL • How to interpret LDL result?
- 8. Atheroscler otic disease Any valueof LDL is high Diabetes LDL > 70 mg% Others LDL 190 mg% or more or 10 yr risk 5% or more What is high LDL?
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- 14. Atherosclero tic disease Start statin Diabetes Startstatin if LDL is more than 70 mg% Others Start statin if LDL 190 mg% or more or 10 yr risk 5% or more
- 15. Atherosclerot ic disease Start statin Diabetes Startstatin unless LDL is less than 70 mg% Others Start statin if LDL 190 mg% or more or 10 yr risk 5% or more High intensity statin Moderate intensity statin
- 16. 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
- 17. 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
- 18. Before you startstatin… • Check TSH. • Check SGPT. • Check CPK (total creatinine phosphokinase). • Check S creatinine, urine proteins. • Check HbA1C.
- 19. Before you startstatin • Ensure adequate lifestyle changes- – Weight loss – Diet change – Exercise • Avoid alcohol if SGPT is high.
- 20. How do youtitrate statin dose? • Measure LDL initially every 6 weeks. Then at more lengthy intervals.
- 21. Co-prescription with statin •With atorvastatin- avoid- – Verapamil, diltiazem, amlodipine, amiodarone – Grapefruit juice • Rosuvastatin has less drug interactions.
- 22. Is repeat monitoringof SGPT & CPK needed? • SGPT. • Muscle pain- do repeat CPK
- 23. When to stopstatin? • No recommendation to stop.
- 24. Statin myopathy • Musclepain • 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
- 25. Will statins producediabetes? • Very low incidence (high dose therapy will cause diabetes in 1 in 500 patients.)
- 26. Will statins causecancer? • No
- 27. Will statins causememory loss? • May cause. Conflicting data. • If a patient complains of memory loss or other CNS symptom- prefer rosuvastatin to atorvastatin.
- 28. Will statins causerenal failure? • No. • (May cause benign proteinuria)
- 29. Ezetimibe • Decreases LDL •10 mg OD • Cholesterol absorption inhibitor • SGPT elevation • Add to statin/ alternative to statin.
- 30. PCSK9 inhibitor • Alirocumab(Praluent) • Self S/C injection every 2 weeks (75/150 mg) • For very high LDL (familial dyslipidemias).
- 31. Triglycerides • More than150 mg% is abnormal. • More than 200 mg%- CAD. • More than 500- 800mg%- pancreatitis.
- 32. • Secondary causes- –Obesity – Diabetes mellitus – Alcohol intake – Nephrotic syndrome – Hypothyroidism – Estrogen replacement therapy – Beta blocker – Steroid – Familial
- 33. • 200 to500 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
- 34. Low HDL • Definition –< 40 mg % in men – < 50 mg % in women • Lifestyle changes- – Exercise – Weight loss – Smoking cessation • No specific drug treatment is indicated.
- 35. 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.
- 36. 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.
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- 38. Part II CURRENT MANAGEMENTOF DYSLIPIDEMIA- ADVANCED
- 39. CKD • Automatically qualifyfor statin Rx- similar to atherosclerotic disease • In dialysis dependent persons, statins are not indicated.
- 40. Treatment goal Condition 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.
- 41. Risk scores • ACC/AHA-Pooled cohort equation • ESC- SCORE system- HDL is also taken into account
- 42. SCORE system- veryuseful relative risk estimator- can be shown to patient
- 43. 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.
- 44. Old (> 75yrs) • Scoring systems overestimate risk in elderly • After age 75 years, statin side effects are more- lower dose is advised- also titration up is advised
- 45. Lipid profile- fastingor not? • First test- always fasting • Further tests- if TG is not a concern, non fasting is enough, except in diabetics.
- 46. Statin adherence • Surprisinglylow in monitored studies • If LDL goal is not achieved, maintain a drug diary cross checked by a family member.
- 47. Lp (a) • Lp(a) is genetically determined. • Values more than 50 mg/dL increase risk of CAD.
- 48. Fibrates • Monitor CPKwhen 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.
- 49. Omega 3 fattyacids • 1 gm capsule • Dose- 3 capsules daily with meals • Risk of bleeding, especially with antiplatelets
- 50. 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%
- 51. 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
- 52. Familial dyslipidemia • LDLmore than 190 mg % is a strong indicator • Screen all first degree relatives (cascade screening) • Age from 5 yrs onwards
- 53. Type 1 DM •Supernormal lipid profile- deceptive • In spite of normal LDL, give statin if – Renal disease or – Microalbuminuria
- 54. Statins are notneeded solely for • HF of non ischemic cause • Aortic stenosis • (Statins are useful for abdominal aortic aneurysm)
- 55. End of PartII Thank you