This document provides guidance on screening for cholesterol levels in a community pharmacy setting. It defines cholesterol and hyperlipidemia, outlines who should be screened and how frequently. The summary describes the equipment needed for screening including a photometer, lancing device, test strips, and control solutions. Step-by-step instructions are given for calibrating the photometer, collecting a blood sample via finger prick, running the test strip, and interpreting results. Normal cholesterol ranges are provided along with factors that can influence accuracy.

1. Cholesterol screening
Dr Liesl Brown
Department of Pharmacy
University of Limpopo (Medunsa Campus)
Module 2.2: Cardiovascular Pharmacy
(2011)

2. Aim
How to screen for cholesterol in
Community Pharmacy setting

3. Objectives
After this practical experience, you will be able to provide the
answers to the following questions:
 WHAT is a cholesterol-screening test?
 WHO should have their cholesterol tested checked?
 HOW frequent should cholesterol be screened?
 WHAT is the importance of a cholesterol screening test?
 WHAT are the normal (reference) values of a cholesterol
screening test?
 WHAT are the precautions that need to be taken by a pharmacist
(operator) and by the subject (patient/volunteer)?
 HOW reliable are the results of a cholesterol screening test?
 WHAT factors can affect the screening results?

4. Hyperlipideamia (HLD)
Definition:
 Hyperlipideamia is a term used to describe all
conditions characterized by high cholesterol
levels
 Characterized by an increase in blood conc. of 1
/ > types of lipids (fats) in the blood (e.g.
cholesterol, cholesterol esters, triglycerides,
phospholipids)
 One of the main causes of:
 Atherosclerosis
 Coronary heart disease

5. Drugs that give rise to drug-
induced HLD
 Thiazide diuretics (LDL and total CHOL (TC)
increase)
 Certain β-blockers (TG increase and HDL decreases)
 Progestins (TC increases)
 Glucocorticoids (TC increases)
 Anabolic steroids (TC increases and HDL decreases)
 Cyclosporine (TG and LDL increases)
 Isotretinoin (TG increases and HDL decreases)
 Large amounts of alcohol (TG increases)
 Oestrogen in oral contraceptives

6. Other factors that give rise to HLD
 Very high KJ diet
 Diet rich in (unsaturated) fats
 Diet rich in cholesterol
 Very low fibre diet
 Lack of exercises
 Smoking
 Moderate / high alcohol abuse
 High androgen levels (men > premenopausal
women)

7. Determination & screening of
cholesterol
Determined in a:
 Clinical environment (e.g. blood taken and TG is
determined)
 Community Pharmacy (screening for CHOL)
Clinical environment
 Blood is drawn and lipoprotein / full lipogram (incl. TG)
be determined
 Blood drawn after 12 hrs of fasting and 24 hrs of
alcohol avoidance

8. Determination & screening of
cholesterol
Community pharmacy (Screening for CHOL)
 CHOL is screened
 Only total CHOL is determined
 Units: mmol/L; mg/100 ml/ mg/dl (1 mmol =
387 mg)
 Total CHOL represented as:
 Desired
 Moderately high
 Seriously high
 Above is linked to age

9. Determination & screening of
cholesterol
Other application locations:
 Doctor’s offices
 Medical clinics
 Homes
 Field Hospitals

10. Which persons’ total CHOL should be
tested?
 Patients with a personal history of CV disease
 Should there be a family history of CV disease – esp. in patients <
50 years
 Children, should there be a family history of hyperlipoproteinemia
 Should there be evidence of DM, hypertension, serious obesity (BMI
> 30), gout / smoking
 Women: 35-59 years of age with two/> risk factors* (*smoking,
hypertension, obesity, DM, family history of CV disease &
hypercholesterolemia)
 Men 35-59 years of age with one risk factor*
 Men: 20-34 years and 60-69 years of age, with 2/> risk factors*
 Adults > 20 years of age – non fasting CHOL screen done once
every 5 years

11. Patient factors which influence TC
levels
 Posture/position of patient
 Food and alcohol ingestion
 Physical activity
 Recent cardiac conditions
 Pregnancy
 Gender
 Age
 Trauma/infection
 Biological (‘time of the day’) variation

12. Patient factors which influence TC
levels
 Posture/position of patient
 TC increases in the standing position
 Determinations done in the same position (sitting)
 Sitting for at least 5 min. prior to test, so that the effect
can be stabilized
 Food and alcohol ingestion
 TC can be determined without patient fasting
 Dietary cholesterol will cause a small/insignificant
increase in TC
 Alcohol ingestion will give rise to a modest decrease in
TC
 Physical activity
 Strenuous physical activity 24 hrs prior to the
screening lowers TG levels
 Above influences TC levels

13. Patient factors which influence TC
levels
 Recent cardiac conditions
 TC levels decrease sign. following a MI (for various days, until
about 8 weeks)
 CHOL levels can also decrease following cardiac catheterization
 Pregnancy
 TC increases by 20 to 35%
 Gender
 After puberty: HDL levels are lower in men than women
TG and VLDL levels are higher in men than women
 After puberty: Oestrogen lowers LDL levels and increase HDL
(women)
Androgens increase LDL and decreases HDL (men)
 During menstruation: TC lower during luteal phase than other
stages of the menstrual cycle

14. Patient factors which influence TC
levels
 Age
 Birth to six months: plasma levels rise rapidly
Childhood: plasma CHOL levels stay reasonably
constant
After puberty: plasma CHOL rises
Adulthood: plasma CHOL reaches a peak:
 men: 50 to 60 yrs of age
 women: 60 to 70 yrs of age
 Trauma/infection
 Trauma: CHOL levels decrease by 40% and remain
lowered for 5 to 6 weeks after the event
 Infection (bacterial / viral)/bad pain/operation: CHOL
levels are lowered and remain lowered for 8 weeks
after such events

15. Patient factors which influence TC levels
 Biological (‘time of the day’) variation
 During the day: TC variation of 2 to 3% during
the day
 Seasonal variation: TC levels lower in summer
than winter

16. Cholesterol screening done in a
Community Pharmacy
Items needed:
 Reflex photometer (e.g. GCT meter)
 Finger pricking apparatus / lancing
device
 Lancets
 Reagent test strips (glucose,
cholesterol, triglycerides)
 Control solutions

17. Examples of different types of GTC-meters

18. Cholesterol screening done in a
Community Pharmacy
Calibration
 Calibration with a code strip serves to
adjust the meter to a specific characteristics
of the CHOL / GLUC / TG test strips used
 Code strips are wrapped individually in the
pack of test strips purchased
(!! Storage of the test strip in its wrapping
and not in the test-strip vial – print on the
code strip may impair the test strip quality
and lead to erroneous results !!)
 Calibration must take place when:
 The meter is switched on for the first
time
 Whenever new test strips are used

19. Cholesterol screening done in a
Community Pharmacy

20. Cholesterol screening done in a
Community Pharmacy

21. Cholesterol screening done in a
Community Pharmacy
Measurement procedures
 STEP 1: Wash and dry
hands thoroughly. Rinse with
clear water before
commencing measurement
(!! TG measurements – all
creams and many soap
products e.g. shower gels,
shampoos) contain fat –
leads to false results !!)
 STEP 2: Prepare lancing
device
 Select penetration depth
(e.g. ‘soft skin’ hands vs.
‘hard skin’ hands)

22. Cholesterol screening done in a
Community Pharmacy
Measurement procedures
 STEP 3: Switch on
apparatus
 Word CHOL / GLUC / TG
appears
 Corresponding code no.,
time, and date appears
 When word CODE
appears, the apparatus is
ready for measurements
 STEP 4: Remove the test
strip from its wrapping. Close
vial immediately

23. Cholesterol screening done in a
Community Pharmacy
Measurement procedures
 STEP 5: Cover flap and insert test
trip into slot in the direction of the
arrow making sure that it is inserted
as far as it can go
Test strip successfully read:
 two beeps
 name the test strip inserted e.g.
either CHOL or GLUC or TG will
be displayed
 CODE stops blinking and EV.0
begins to blink:
 Test strip incorrectly read:
Error messages appear e.g. E-1
, E-2 or OFF
 Act according to procedures
stipulated in the booklet

24. Cholesterol screening done in a
Community Pharmacy
 STEP 6: Open flap
 EV.O blinks on display together with
measurement time: 180 sec (max) for
TG (reaction time = 174 sec)
 STEP 7: Rub and kneed a fingertip to
facilitate the withdrawal and application
of blood
 STEP 8: Prick the massaged place on
the fingertip with the lancing device

25. Cholesterol screening done in a
Community Pharmacy

26. Cholesterol screening done in a
Community Pharmacy
 STEP 9:
 Cover yellow test field completely
with blood (otherwise falsely low
results will be measured)
 If too little blood is applied, do
not rub it in or apply second drip,
repeat the measurement with a
fresh test strip
 Allow hanging blood drop to form
without applying too much
pressure
 Carefully drop blood to yellow
test field on top of strip without
touching top of strip

27. Cholesterol screening done in a
Community Pharmacy
 STEP 9 (cont.):
 If too little blood is applied, do not rub it in or apply second drip,
repeat the measurement with a fresh test strip

28. Cholesterol screening done in a
Community Pharmacy
 STEP 10: Close the flap
after applying the drop

29. Cholesterol screening done in a
Community Pharmacy
 STEP 11: Meter counts down in seconds to 0.
Last four sec is heard at the end of the
measurement followed by a long beep
 Measured value (in mg/dl or mmol/l)
appears on the display and EV.O blinks
 Measured values only within certain
ranges:
 CHOL 150 – 300 mg/dl (3.88 - 7.76
mmol/l)
 Blood GLC 20 – 600 mg/dl (1.1 – 33.3
mmol/l)
 TG 70 – 600 mg/dl (0.80 – 6.86
mmol/l)
 Above the ranges : HI shown
 Below the ranges: LO shown (also
when too little blood is used)
 Open flap. Remove test strip
 Close flap and switch meter off

30. Cholesterol screening done in a
Community Pharmacy

31. Cholesterol Action Limits

32. Heart Foundation recommendations
SA Heart Foundation recommends the following classification
for TC levels:
 <5.0 mmol/L – Desirable
 5-6.5 mmol/L – Moderate risk
 6.5-7.8 mmol/L – High Risk
 >7.8 mmol/L – Very high risk
 Recommended that > 1 test be done for confirmation
(esp. moderate/high TC)
 TC screening can be done – fasting/non-fasting
conditions

33. Factors influencing the accuracy of
results
Factors influencing the accuracy of results
 Instrumental factors
 Sampling
 Quality control procedures
 Instrumental factors
 Apparatus of Community Pharmacies compare well with
apparatus in Clinical environments
 Comparing results: variation from 1 to 5% (Community Pharmacy
results lower than standard operating laboratories results

34. Factors influencing the accuracy of
results
 Sampling
 Has a strong influence on the accuracy of results
 Personnel have to be trained in the correct procedures
 Results of finger pricking sample vary about 4% from the
venous puncture sample
 !! Finger should not be ‘milked’ at all – blood will then
mix with the ECF and result in giving falsely low
CHOL levels
 Capillary tube should not be pushed into the finger

35. Factors influencing the accuracy of
results
 Quality control procedures
 Standing correct quality SOP should be adhered to at all
times
 Accuracy of the sample should be evaluated through the
test of std solutions with a known CHOL level
 Should be done weekly / after 100 tests (which ever
comes first)
 Records should be kept of the results and carefully
studied
 Analyzers that do not comply with ≈ 5% or < standard
precision, should be removed from service until repaired
 Comparing: venous puncture sample of same patient
(screen test done in a Community Pharmacy) vs.
laboratory (clinical setting)
 Optical system of the apparatus should be cleaned with
70% alcohol
 Should not be used within 15 min. after the cleaning
procedure
 Instruction manual should be strictly adhered to

36. References
 Davies, A, Blakeley, AGH and Kidd, C. Human Physiology. McGraw-
Hill:Boston, Massachusetts
 Griesel, MS. Primary screening and monitoring services for
pharmacists. PSSA Publications: Potchefstroom, Chapter 2, pp. 48-61
 Internet resources:
 http://www.diavant.com/diavant/CMSFront.html?pgid=3,1,5,0
 http://www.diavant.com/diavant/CMSFront.html?pgid=1,3,9,1
 http://www.roche-diagnostics.com/products_services/accutrend_gct.html
 SAMF, 9h edition, Section on Serum lipid-modifying agents

37. Hands on screening of cholesterol levels in
blood plasma using photometers

38. Hands on screening of cholesterol levels in
blood plasma using photometers
DE 519 CE S522
CE
302B
TA N309
VA
520C