Current management of dyslipidemia in two parts. First part for general doctors and second part for physicians.

1. CURRENT MANAGEMENT OF
DYSLIPIDEMIA
Dr Jayachandran Thejus MD DM
Specialist Interventional Cardiologist
Zulekha Hospital Sharjah

2. Part I
CURRENT MANAGEMENT OF
DYSLIPIDEMIA- BASICS

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

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

5. How to interpret lipid profile result?
• Total cholesterol
• LDL
• Triglyceride
• HDL
• LDL- most important.
• LDL measurement-
– Direct
– Indirect

6. 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”

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

8. Atheroscler
otic disease
Any value of
LDL is high
Diabetes
LDL > 70
mg%
Others
LDL 190 mg% or
more
or
10 yr risk 5% or
more
What is high
LDL?

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

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

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

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

13. Mobile app

14. Atherosclero
tic disease
Start statin
Diabetes
Start statin 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
Start statin
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 start statin…
• Check TSH.
• Check SGPT.
• Check CPK (total creatinine phosphokinase).
• Check S creatinine, urine proteins.
• Check HbA1C.

19. Before you start statin
• Ensure adequate lifestyle changes-
– Weight loss
– Diet change
– Exercise
• Avoid alcohol if SGPT is high.

20. How do you titrate 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 monitoring of SGPT & CPK
needed?
• SGPT.
• Muscle pain- do repeat CPK

23. When to stop statin?
• No recommendation to stop.

24. 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

25. Will statins produce diabetes?
• Very low incidence (high dose therapy will
cause diabetes in 1 in 500 patients.)

26. Will statins cause cancer?
• No

27. Will statins cause memory loss?
• May cause. Conflicting data.
• If a patient complains of memory loss or other
CNS symptom- prefer rosuvastatin to
atorvastatin.

28. Will statins cause renal 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 than 150 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 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

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.

37. END OF PART 1

38. Part II
CURRENT MANAGEMENT OF
DYSLIPIDEMIA- ADVANCED

39. CKD
• Automatically qualify for 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- very useful 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 (> 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

45. Lipid profile- fasting or not?
• First test- always fasting
• Further tests- if TG is not a concern, non
fasting is enough, except in diabetics.

46. Statin adherence
• Surprisingly low 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 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.

49. Omega 3 fatty acids
• 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
• LDL more 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 not needed solely for
• HF of non ischemic cause
• Aortic stenosis
• (Statins are useful for abdominal aortic
aneurysm)

55. End of Part II
Thank you