Diagnosis and Treatment Diagnosis and Treatment of Dyslipidemiaof Dyslipidemia

New guidelines are based on the New guidelines are based on the “Adult “Adult Treatment Plan III (ATP III)”Treatment Plan III (ATP III)” 2004 2004

Focus = multiple risk factor assessment to Focus = multiple risk factor assessment to determine those individuals at highest absolute determine those individuals at highest absolute Coronary Heart Disease (CHD) riskCoronary Heart Disease (CHD) risk

Diabetes is identified as being a Diabetes is identified as being a CHD risk CHD risk equivalentequivalent - in other words, a person with - in other words, a person with Diabetes is considered at the Diabetes is considered at the same risk of same risk of CHDCHD as a person with a previous hx of CHD as a person with a previous hx of CHD

Assessing CHD RiskAssessing CHD Risk

Framingham Risk ScoreFramingham Risk Score - Projects - Projects potential for 10 year absolute CHD Risk potential for 10 year absolute CHD Risk (ranges from < 10% to > 20%) (ranges from < 10% to > 20%)

Use in patients Use in patients withoutwithout CHD or CHD CHD or CHD Risk EquivalentsRisk Equivalents

Lipid EvaluationLipid Evaluation

Done after a Done after a 9 – 12 hour9 – 12 hour fast to ensure fast to ensure an adequate evaluation of all an adequate evaluation of all components of a lipid profilecomponents of a lipid profile

If Triglycerides are extremely elevated, If Triglycerides are extremely elevated, calculation of the LDL can be difficult calculation of the LDL can be difficult

Non-fasting samples should not be used Non-fasting samples should not be used for diagnosis for diagnosis

LDL GoalsLDL GoalsRisk CategoryRisk Category LDL-C GoalLDL-C Goal Initiate Lifestyle Initiate Lifestyle

ChangeChangeConsider Drug Consider Drug

TreatmentTreatment

High Risk (High Risk (20%)20%)

CHD or CHD CHD or CHD equivequiv

< 100mg/dl< 100mg/dl 100mg/dl100mg/dl 100mg/dl100mg/dl

Moderately High Moderately High Risk Risk 2 risk 2 risk

factors (10-20%)factors (10-20%)

< 130mg/dl< 130mg/dl 130mg/dl130mg/dl 130mg/dl130mg/dl

Moderate RiskModerate Risk

2 risk factors 2 risk factors (10%)(10%)

< 130mg/dl< 130mg/dl 130mg/dl130mg/dl 160mg/dl160mg/dl

Low RiskLow Risk

0-1 risk factors0-1 risk factors

< 160mg/dl< 160mg/dl 160mg/dl160mg/dl 190mg/dl190mg/dl

Medications for Medications for Treatment of Treatment of DyslipidemiaDyslipidemia

New Recommendations in TherapeuticsNew Recommendations in Therapeutics - - Combination therapyCombination therapy is recommended is recommended

for selected high risk patientsfor selected high risk patients

- Despite success of the statins as a- Despite success of the statins as a group, coronary event rates remain highgroup, coronary event rates remain high

- Combination therapy may be as efficacious - Combination therapy may be as efficacious as single therapy with less side effects as single therapy with less side effects

- Side effects and toxicity of statins increase- Side effects and toxicity of statins increase with each dosage increment with each dosage increment

Types of MedicationsTypes of Medications Drugs that Affect Hepatic Lipoprotein Drugs that Affect Hepatic Lipoprotein

Metabolism Metabolism

1) 1) HMG-CoA Reductase InhibitorsHMG-CoA Reductase Inhibitors (statins)(statins) - - Lovastatin, pravastatin, simvastatin, fluvastatin Lovastatin, pravastatin, simvastatin, fluvastatin

2) 2) Nicotinic AcidNicotinic Acid - - Immediate releaseImmediate release

(IR), sustained release (SR), extended release (ER)(IR), sustained release (SR), extended release (ER)

3) 3) FibratesFibrates - - Gemfibrozil, fenofibrate, clofibrate Gemfibrozil, fenofibrate, clofibrate

Types of MedicationsTypes of Medications Drugs that Affect Intestinal Drugs that Affect Intestinal

Metabolism of Cholesterol Metabolism of Cholesterol 1) 1) Bile Acid SequestrantsBile Acid Sequestrants - - Cholestyramine, Cholestyramine,

colestipon, colesevelamcolestipon, colesevelam

2) 2) Inhibitors of cholesterol absorptionInhibitors of cholesterol absorption (vegetable derived) (vegetable derived) - Sterol/stanol esters - Sterol/stanol esters (available (available in dietary margarine – BeneChol®) in dietary margarine – BeneChol®)

3) 3) Selective Cholesterol Absorption Selective Cholesterol Absorption Inhibitor (CAI) - Inhibitor (CAI) - Ezetimibe Ezetimibe NEW CLASS NEW CLASS

Lifestyle Treatment of Lifestyle Treatment of DyslipidemiaDyslipidemia

Lifestyle Changes Still Recommended for all Lifestyle Changes Still Recommended for all patients patients

Physical ActivityPhysical Activity Smoking cessationSmoking cessation Weight LossWeight Loss Dietary modificationDietary modification

Reduce saturated and “trans” fatsReduce saturated and “trans” fats Increase fiber (25g/day)Increase fiber (25g/day) Consider plant sterols/stanols (2-3 servings/day)Consider plant sterols/stanols (2-3 servings/day)