Dyslipidaemia

Question 1

Established facts

Answer 1

Major risk factors for CAD include:

–↑ LDL cholesterol + ↓ HDL cholesterol

–ratio LDLC/HDLC >4

Risk increases with increasing total cholesterol (TC) levels

TG levels >10 mmol/L increases risk of pancreatitis

Management should be correlated with risk factors

10% reduction in total cholesterol gives 20% ↓ in CAD after 3 yrs

1 mmol/L reduction in LDL (using a statin) reduces risk of CVS events by 20–25%

Question 2

Investigations

Answer 2

Serum triglyceride

Serum cholesterol and HDLC and LDLC

TFTs if hypothyroidism suspected

Question 3

Appropriate treatment goals

Answer 3

Treat all risk factors.

total cholesterol <4.0 (esp. if high risk)

LDLC <2.0 m mol/L (<1.8 in high-risk patients)

HDLC >1.0 m mol/L

non-HDLC <2.5 mmol/L

triglycerides <2.0 mmol/L

Question 4

Dietary measures:

Answer 4

–Keep to ideal weight. Follow low carbohydrate diet (avoid sugar).

–Reduce fat intake, esp. dairy products and meat. Healthy fats ok.

–Avoid ‘fast’ foods and deep-fried foods

–Replace saturated fats with mono- or polyunsaturated fats

–Always trim fat off meat, remove skin from chicken

–Avoid biscuits and cakes between meals

–Introduce plant sterol-enriched milk, margarine or cheeses

–Ensure a high-fibre diet, esp. fruit and vegetables

–Keep alcohol intake to 0–2 standard drinks/d

–Drink more water

–Use approved cooking methods, e.g. steaming, grilling

Question 5

Other Non-pharmacological measures

Answer 5

Regular exercise

Cessation of smoking

Cooperation of family is essential

Exclude secondary causes e.g.

• hypothyroidism
• type 2 diabetes
• nephrotic syndrome
• obesity
• alcohol excess
• esp. ↑ TG
• specific diuretics

Question 6

Checkpoints

Answer 6

Diet therapy effective (TG ↓, LDLC ↓) within 6–8 wks

Continue at least 6 mths before consider drug therapy in all but the highest-risk category

Question 7

Patients requiring treatment (PBS guidelines)

Answer 7

Risk category /

• Initiate drug therapy if lipid level (mmol/L) is

Pts with existing symptomatic CHD, PVD and cerebrovascular disease

• Any level

Pts with diabetes plus one of microalbuminuria; age >60; Aboriginal or Torres Strait Islander

• Any level

FHX of CHD (one first-degree relative <45 years of age, or two <55 years)

• Any level

Aboriginal and Torres Strait Islander pts with hypertension

FHx of CHD (one first-degree relative <60 years of age, or one second-degree relative <50 years)

• Cholesterol >6.5 mmol/L or
• Cholesterol >5.5 mmol/L and
• HDL <1 mmol/L

Pts with HDL <1 mmol/L

• Cholesterol >6.5 mmol/L

Pts not eligible under the above:

1. men 35–75 years
2. postmenopausal women up to 75 years

• Cholesterol >7.5 mmol/L or
• Triglyceride >4 mmol/L

Patients not otherwise included in the above

• Cholesterol >9 mmol/L or
• Triglyceride >8 mmol/L

Question 8

Pharmacological measures

Statins

Answer 8

Use these agents in addition to diet.

Hypercholesterolaemia Rx should start with a statin esp. if ↑ LDLC.

Options: Choose one of the following:

HMG CoA reductase inhibitors (‘statins’): first line

–simvastatin or pravastatin or atorvastatin 10 mg (o) nocte, ↑ to max. 40–80 mg/d or

–fluvastatin 20 mg (o) nocte, increase to max. 80 mg/d or

–rosuvastatin 5–40 mg/d

Adverse effects:

• GIT side-effects
• myalgia
• abnormal liver function

Monitor:

• Measure LFTs (ALT and CPK) and CK as baseline
• Repeat LFTs after 4–8 wks

Question 9

Other agents

Answer 9

If LDLC target levels not reached on a maximally tolerated statin dose, add:

• one of ezetimibe
• bile acid binding resin
• nicotinic acid.

Ezetimibe: 10 mg/d

• Adverse effects: arthralgia, myalgia, myositis, liver dysfunction

Bile acid binding resins, e.g. cholestyramine 4 g/d in fruit juice increasing to max. tolerated dose

• Adverse effects: GIT side-effects (e.g. constipation, offensive wind)

Nicotinic acid 250 mg (o) bd with food daily increase to max. 1000 mg tds

• Adverse effects: flushing, gastric irritation, gout
• Minimise with gradual introduction, take with food

Fish oils (n-3 fatty acids): 6 g/d

PCSK9 inhibitors, e.g. alirocumab, evolocumab; new second-line agents given by injection

Question 10

Resistant LDLC elevation

Answer 10

Combined ‘statin’ and resin, e.g.

• cholestyramine 4–8 g (o) mane + a ‘statin’ to max dose

or

Combined ezetimibe + statin

Question 11

Moderate to severe (isolated) TG elevation

Answer 11

Gemfibrozil 600 mg (o) bd

or

Fenofibrate 145 mg (o)/d

Note: Slow response monitor LFTs predisposes to gallstones and myopathy

Alternatives:

• nicotinic acid or
• n-3 fish oil concentrate 6 g (o) daily in divided doses to max. 15 g/d

Note: Reduction in alcohol intake is important.