When to Screen and When to Treat
Transcript of When to Screen and When to Treat
Dyslipidemia
When to Screen and When to Treat
RISK FACTORS FOR
CORONARY ARTERY DISEASE
High Cholesterol
Smoking
Obesity
Male Gender
Female Gender
• > 55 years of age or
postmenopausal
without estrogen
replacement
Hypertension
Diabetes
Low HDL < 35
Family History of CAD,
stroke, peripheral
vascular disease,
sudden death (< 55
yrs in men or < 65 yrs
in females)
Screening of Children
American Academy of Pediatrics , July, 2008
Recommendations:
All children with family history of high
cholesterol, early atherosclerosis,
unknown family history and personal risk
factors i.e. diabetes, hypertension , obesity
and metabolic syndrome
Screening of Children (part2)
Screen at 2 years of age and repeat every two to three years.
Statin Drugs should be among the first line agents.
Statin Drugs should be started at 8 to 10 years of age in children with F H , diabetics with LDL>130 mg and be considered in metabolic syndrome & obesity.
TARGET Lipid Profile for Children
TC < 170
LDL < 110
TG < 150
HDL > 45 for boys
HDL > 55 for girls
Cholesterol Particles
Screening Tests
1. Fasting Lipid Profile: TC, LDL, HDL and TG
2. Thyroid Functions
3. Liver Functions
4. Hgb A1c, glucose, insulin particularly in
Metabolic syndrome
Familial Hypercholesterolemia
1. Family History
2. TC: 250-350, LDL : 150-250
3. HDL & TG are usually normal
4. Goals are to reduce LDL to 100 and TC to
170
Metabolic Syndrome
1. Overweight:BMI >25 or >85%
Obese:BMI >30 or > 97%
2. Hypertension
3. Diabetes Mellitus,type 2
4. Acanthosis nigricans
5. Fatty liver: NASH
6. Sleep apnea
7. Endocrine abnormalities: polycystic ovary disease, gynecomastia
8. Blount disease
Metabolic Syndrome
1. Atherogenic Lipid Profile: elevated TG > 150
normal or elevated LDL & decreased HDL < 40
2. Enhanced hepatic VLDL synthesis with increase
in small LDL particle i.e. Lpa, the most atherogenic
form of LDL
3. Peripheral tissue lipprotein lipase resistance
with increase in TG
4. Goals are to reduce TG,Lpa and increase HDL
Therapeutic Lifestyle Change
Reduce sat.fat to <10% of calories
Reduce Cholesterol intake to <300 mg /day
Add in dietary adjuncts:
• Plant Stanol/sterols
• Viscous fiber
Reduce Weight
Increase physical exercise
Diet Therapy: 5% reduction LDL
Low fat/low cholesterol
Increase water soluble fibers: soya,
psyllium, cereals
Fruits/vegetable : bannanas, berries, citrus,
broccoli, brussels, sprouts, beans, peas
Oils: unsaturated, polyunsaturated, omega
3, nuts
Aerobic Exercise: 1 hour daily
Increase in HDL : 15%
Decrease in TG : 20%
Increase in lean muscle mass
Decrease in body fat
Improvement in cardiovascular fitness
Over the counter medications
A. Niacin: most effective way to increase
HDL, decrease TG & decrease Lpa
B. Plant Sterol/Stanol Esters: reduce LDL
C. Water Soluble Fiber : reduce LDL
D. Omega 3/Omega 6 Oils : reduce TG
E. Natural Statins: Red Yeast Rice
F. Aspirin: 81 mgm over 12 years
NIACIN/B3
ACTIONS- Increase HDL 20-30%,
Decrease TG 20-25%,
Decrease LpA 10-25%
Forms of Niacin/B3
1. B complex-50mg under 12 yrs, B-complex-100
over 12 yrs.
2. Liquid B complex: 20 mgm/ml, orange flavored:
dose: 2 ½ ml<12 yrs, 5 ml>12 yrs.
3. Crystalline Niacin: 100, 250 & 500 mgm
4. Sustained release Niacin: 250 & 500 mgm
5. Niaspan (prescription) : 500,750 &1000 mgm,
maximum dose: 2000 mgm
NIACIN SIDE EFFECTS/TOXICITY
Effects are related to increasing dose
(1.5-3mg)• Cutaneous Effects: flushing, pruritus, rash
• GI Effects: nausea, vomiting, diarrhea, anorexia
• Metabolic Effects: glucose, uric acid (gout) and hepatic enzymes
(> 2 gm daily)
Precautions:• Should always be taken with or after a meal
• Prophylactic salicylates and avoidance of hot beverages or soups
or strenuous exercise will help to mitigate any adverse symptoms
EFFECTS OF NIACIN
Effect on Triglycerides
• Diurnal variation in plasma triglycerides (higher at night)
• Decreases lipolysis of adipose tissue fatty acids which leads to a
release of free fatty acids for use as food
•
• Perhaps acts on hormone sensitive lipase therefore smaller
quantities of fatty acids are transported to the liver with a
resultant decrease of triglycerides, VLDL, LDL, Lpa, and total
cholesterol
EFFECTS OF NIACIN
Effect on HDL
• Scavenger receptor (SR-BI) selectively
removes cholesterol ester
• Catabolic pathway involves a “holoparticle
uptake” of HDL (Apo A1)
• Niacin increases Apo A1 and HDL by decreasing
hepatic catabolism without effecting
cholesterol ester elimination
ACTION OF NIACIN TO ELEVATE HDL
LIPID PROFILE RESPONSE
PLACEBO VS NIASPAN
RELATIONSHIP OF HDL-C LEVELS
AND CORONARY ARTERY DISEASE
PLANT STANOL/STEROL ESTERS
Benecol, Take Control Margarine(1.5-3 grams daily)
• Developed in Finland
• Combined with Canola Oil and soy in a margarine
• Lowers LDL by 10-20% without reducing HDL!
Cholestoff, tablet / capsule• One to four a day
STRUCTURE OF PLANT
STEROLS/CHOLESTEROL
Omega 3/Omega 6 Oils
Effect: 30-50% decrease in TG
Dose: 1-3 grams daily
Forms:
1. Capsule
2. liquid
3. Gel: coromga 2gm/package
4. Eggs & Milk
5. Flaxseed fiber
6. Cold water fish
7. Chocolate Omega Truffles: 2.5 gm
Natural Statin
1. Red Yeast Rice: fermented rice similar to
Mevacor in action. Produces 20-30%
reduction in LDL
2. Advantages: well tolerated, inexpensive,
OTC
3. Dose: 600-1200 mgm daily
Prescription Medications
1. Statin Drugs: reduce LDL
2. Bile Acid Sequestrants : reduce LDL
3. Fibrates: reduce TG & increase HDL
4. Cholesterol Absorption Inhibitors: Zetia
HMG Coa REDUCTASE INHIBITORS
20-60% decrease in LDL
Action: inhibits LDL production in the liver
Products
• Fluvastatin: Lescol
• Lovastatin: Mevacor
• Pravastin: Pravachol
• Simvastatin: Zocor
• Atorvastatin: Lipitor
• Rosuvastatin: Crestor
• Liver toxicity (must check liver functions periodically)
• At increasing doses may produce rhabdomyalysis, insomnia
( switching to a more powerful statin is more cost effective than
increasing the dose of the same medication)
Statin Drugs: 20-60% decrease in
LDL
Lovastatin: Mevacor: 10, 20, 40 mg: generic
Pravastatin: Pravachol: 10, 20, 40, 80 mg:
generic
Simvastatin: Zocor: 5, 10, 20, 40, 80 mg:
generic
Statin Drugs : cont.
Atorvastatin: Lipitor: 10, 20, 40, 80 mg. no
generic.
Rosouvastatin: Crestor: 5, 10, 20, 40 mg. no
generic. Increases HDL 8-12%.
Red Yeast Rice: 600 mg. OTC. Natural statin
START WITH SMALLEST DOSE & TITRATE TO
DESIRED LDL 100-110.
BILE ACID SEQUESTRANTS
Cholestyramine: Questran
Colestipol: Colestid
Colesevelam: Welchol
Binds cholesterol in the intestinal tract with a
decrease in LDL of 10-15%
Needs to be taken 2-3 times daily
May cause bloating, constipation, flatulence
Fibric Acids
Action: reduces triglycerides 30% ,LDL
10% and increases HDL 20%.
Product:
• Gemfibrozil: Lopid : 600 mgm
• Fenofibrate: Tricor : 48 & 145 mgm
Should be used cautiously in combination
with Statins.
Cholesterol Absorption Inhibitor:
Zetia
Decreases LDL 18-20%
Is metabolized in small intestine & liver
with primary biliary excretion
No pharmacologic differences in
adolescents & adults
Effective in Homozygous Familial
Hypercholesterolemia & Sitosterolemia
COMBINATION MEDICATIONS
VYTORIN: Zocor & Zetia: triples the effect of
the statin without side effects:
10/10,10/20,10/40& 10/80
Simcor: Zocor & Niaspan: 500/20, 1000/20&
2000/20
Advicor: Mevacor & Niaspan: 500/20, 750/
20, 1000/20& 1000/40
TREATMENT RECOMMENDATIONS
FOR PROFILE # 1
PROFILE
• Total cholesterol = 235
• Triglycerides = 90
• HDL = 46
• LDL = 173
TREATMENT PLAN
• Dietary Fiber
• Plant Stanol Esters
• Statin
TREATMENT RECOMMENDATIONS
FOR PROFILE #2
PROFILE
• Total cholesterol = 255
• Triglycerides = 316
• HDL = 27
• LDL = 165
TREATMENT PLAN
• Dietary Fiber
• Plant Stanol Esters
• Niacin
• Omega 3/6
• Fibrate
• statin
Vytorin: Zocor & Zetia
Advantage: use smaller dose of statin drug
with the effect of tripling the dose of the
statin
Dosage: 10/10, 10/20, 10/40, 10/80
TREATMENT RECOMMENDATIONS
FOR PROFILE #3
PROFILE
• Total cholesterol = 304
• Triglycerides = 109
• HDL = 39
• LDL = 243
TREATMENT PLAN
• Dietary Fiber
• Plant Stanol Esters
• Niacin
• Statin
TREATMENT RECOMMENDATIONS
FOR PROFILE #4
PROFILE
• Total cholesterol = 250
• Triglycerides = 750
• HDL = 34
• LDL = NC
TREATMENT PLAN
• Dietary fiber
• Plant Stanol Esters
• Niacin
• Omega 3/6
• Fibrates
• statin
Personal Favorites
Benecol or Cholestoff
Balanced B complex 50 or 100
Omega 3/6 oils
Water soluble fiber: psyllium
Red Yeast Rice
Zocor/ Pravachol
Fenofibrates