Dyslipidemia Flashcards
what is LDL goal for someone with DM?
<100mg/dl or 70mg/dl optional
what is the LDL goal for someone with CAD?
<100mg/dl or 70mg/dl optional
what is the evidence for primarily targeting LDL?
Total cholesterol has been found to be correlated with CHD. Most of total cholesterol is found in LDL. Studies have shown LDL is the most atherogenic lipoprotein. Atherogenesis of LDL is confirmed in genetic disroders in which LDL is high vs other risk factors, i.e. familial hypercholesterolemia
People with familial hypobetalipoprotenemia have documented longevity
Three studies: Framingham heart study, the Multiple Risk Factor Intervention Trial (MRFIT) and LIPID research clinics (LRC) trial . Direct relationship between LDL or TC and new onset CHD.
Populations with LDL levels <100 throughtout life, show near absesne of CHD
people with genetic hypercholesterolemia show premature CHD and atherosclerosis in the absence of other risk factors
12 Clinical trials have shown a reduced incidence of CHD and CHD mortality with LDL lowering (by statins)
what is the evidence fro primarily targeting HDL or triglycerides?
For targeting triglycerides: epidemiological studies found a correlation with TGs and incidence of CHD. However, multivariate analyses didnt find TG to be an independent risk factor for CHD. Other variables are linked such as High LDL, TC, HDL, obesity, DM , smoking etc So if high TG, still at higher risk even cannot be shown to be an independent risk factor. However now, New meta-analyses show some TG rich lipoproteins are atherogenic .
Data from the ACCORD Lipid trial suggest that adding fenofibrate to a low-dose statin does not further reduce the risk of cardiovascular events in people with diabetes, although a post-hoc analysis showed there may be benefit in those with high triglycerides (>200 mg/dL) and low HDL cholesterol (<35 mg/dL). This has been shown in post-hoc analyses of other trials as well.7,8 More data are needed to solidify any benefits of add-on therapy in this situation.
HDL: angiographc trials have shown that ppl with low HDL treated with fluvastatin, they have reduced progression of atherosclrosis (LCAS trial). The Post Coronary Artery Bypasss graft rial showe the satme thing with lovastatin.
Another piece of evidence was the VA-HIT study (see card below) . HDL increase partly repsonsible for dec major CHD events
PROVE-IT trial
Design: Randomized, double-blind, trial
Population: 4000 ACS patient (MI or UA) in 8 countries
I: aggressive lipid lowering vs. moderate therapy
C: Atorvastatin 80mg vs Pravastatin 40mg
O: Death composite ( Major CV events) , stroke, UA, revascularization,
LDL
Results: Atrovastatin 106 –> 62
Pravastatin 106 –> 95
Overall greater reduction in UA, MI, death composite in aggressive therapy vs. moderate therapy. All except stroke (low event rate)
Importance: sparked controversy regarding the equivalence of different statin forumulation and target levels of LDL. How low of LDL is too low? 100? is going low problematic? Aggressive therapy seems to have improved outcomes vs moderate therapy.
REVERSAL 2003
Design: Randomized, double-blind, MC trial
Population: 654 patients
I: aggressive lipid lowering vs. moderate therapy
C: Atorvastatin 80mg vs Pravastatin 40mg
O: % change in atheroma volume (follow up minus basline)
Results: Atrovastatin 150 –> 110
Pravastatin 150 –> 79
** significantly lower proegression rate of atheroma in atorvastatin group. Progression to atheroscleroisis in 2.7% pravastatin and 0.4% progresssion in atorvastatin group
Importance: Showed that you can essentially halt atherosclerosis progression to ~0. Although highest dose of lipitor necessary
HEART PROTECTION STUDY **
Design
P: 20,000 patients with coronary disease, DM or occlussive arterial disease (40-80 years old), with at least of a total cholesterol of 135
excluded: pts with chornic liver dsiease, >1.5 ULN for ALT, sever renal disease or cratinine > 200 mcg/l, evidence of muslce sisease, child bearing ptoential
I /C: simvastatin 40mg vs matched placebo
O: all cause mortaily
first events of nonfatal MI, coronary deat, fatal/non fatal strokes, coronary revascularization
Results: decrease in all the outcomes
Importance: lowering LDL with statin produces substanial reduction of major vascular disease. It has benefit in patients who already have coronary disease but also thos whtough diagonsed coronary disease who have cerebrovascular dsiease, peripherarl artherial disease or diabetes irrespective of what lipid concentrations pts had before treatment was initiated
study included older people and more women so that the study can be extrapolated more widely.
definite reduction in the reduction of ischemic stroke and transient ischemic attacks. Reduced needd for revascularization
*** this study demosnstarted that lowering LDL from below 116 to below 77mg/dl reduces vascular diease risk by ~25%. People who were even below 100mg/dl had benefit (surprising) if they lowered their LDL
ENHANCE 2010
Design: Randomized, double-blind, 24 month trial
Population:720 pts with familial hypercholesterolemia
I:
C: Simvastatin 80mg + Placebo/ Simvastatin 80mg + 10mg ezetemibe
O: Atherosclerosis: change in media intima thickness in caroteid aretieres, bulbs, internal carotid arteries
Results: no difference in mean mediate thicnkess between intervetion group vs no intervention
decerase in LDL greater with ezetemibe
decreases TG and CRP
Safety profile about the same
Importance: ezetimibe has been shown to lower LD 15% but hans not been shown to improve clinical outcomes (atherosclerosis)
ppl had assumed that it would improve clinical outcomes because it decreases LDL but not the case in this trial.
JUPITER
Design:
Population: 17,800 patients with LDL < 130 and CRP > 2mg/dl
I:
C: Rosuvastatin 20mg vs placebo
O: combined MI, Stroke, arterial revascularization, hopsitalization for UA, or death from CV cause
Results: LDL decrease 50% vs placebo
dec CRP by 37% vs placeboy
decrease in MI, stroke , revasculariazation, etc for rosuvastatin vs placebo
Importance: Healthy people with low LDL but high CRB can have decreased risk of CV events
CRP contributes to CV disease
Controversial: One pointed out that JUPITER did not tease out the real importance of CRP levels, or whether lowering those levels is useful. Because of its design, it could not (and did not) tell us whether the beneficial outcome is specific to Crestor, or is a class effect of all statins (which seems very likely). It did not tell us whether reducing CRP levels is itself beneficial, or even whether using CRP as a screening tool is actually helpful.
VA-HIT 2001
Design: MC, Randomized , DB, placebo controlled trial
Population: 2000 men with history of CHD and low HLD (mean 32)
I: Fibrate vs placebo
C: Gembfibrozil 1200mg QD or Placebo
O: Lipid levels at baseline and @ 18 months
incidence of CHD death
incidence of non-fatal MI
Results: inverse relationship for HDL and incidence of CHD events ( inc HDL 5mg/dl = dec 11 % CHD events)
TG and LDL levels did not predict CHD events incidence.
Importance: It’s the first lipid intervention trial to show that raising HDL-C concentrations in persons with established CHD and both a low HDL-C and a low LDL-C level will significantly reduce the incidence of major coronary events. it showed that it can be independent of LDL levels and TG levels.
what is the evidence for each for heart attacks and strokes?
HMG COA reductase inhibitors : do dec MI risk inc first heart attacks in ppl without HLD or heart disease (crestor 20) used in studies
fibrates Only statins shown to reduce risk of stroke.. all the others not
niacin when given with simvastatin vs simvastatin, no change in cardiovascular events. So questionalbe. In fact slight increase in ischemic stroke (AIM-HIGH trial) In COronary drug project study showed decrease in stroke risk .
BABRs
ezetemibe. Reduce LDL but no reduction in clinical outcomes
OMEG 3 lowers TG but no evidence with CHD
waht non medication factors increase the risk for myopathy?
renal impairment (acute or chronic renal failure)
hypothyroidism
age >65
-obstructive liver disease
discuss use of statins in patients with muscle symptoms (dose limitations, precautions?)
if patients have muscle symptoms they need to be seen immediately and order a CPK
discuss use of statins in patients with Liver/ALT elvation (fatty liver) (dose limitations, precautions?)
Contraindicated if active liver disease
Need to look at AST and ALT levels and stop medications if they rise >3 ULN
-if patient has baseline elevated liver enzymes due to fatty liver or hepatic steatosis, can still use statins. Studies showed no significant difference in increase in liver enzyme elevation. Just have to monitor patients for symptoms of liver damage PMID 15131789
ok to use in nonalcoholic fatty liver or chronic liver disease
-avoid in patients with acute liver failure or decompensated liver cihrrosis (evidence level C (expert opinion) PMID: 16581333
-pravastatin and pitivastatin and crestor not sig metabolism by cyp450 enzymes
discuss use of statins in patients with elevated CPK (dose limitations, precautions?)
If a patient has symptoms of muscle damage like soreness, pain etc. get a CK level. If level is >10 x upper limit of normal, DC the statin. IF patient previously had rhabdomyolysis do not retry a statin
Name some drugs (lipid and non-lipid ) that increase the risk of rhabdomyolysis with statins?
Fibrates
Niacin
CYP3A4 inhibitors like voriconaole, itraconazole, erythomycin, protease inhibitors, cyclosporine verapamil, diltiazem
what is the max rec dose of lovstatin with drugs that inc rhabdomyolysis
do not exceed 20mg if used with verapamil/diltiazem/danazol
do not exceed 40mg if used with amiodarone and dronedarone
Contraindicated with lovastatin: Itraconazole Ketoconazole Posaconazole Erythromycin Clarithromycin Telithromycin HIV protease inhibitors Boceprevir Telaprevir Nefazodone
Avoid large quantities of GFJ
max dose of simvastatin that inc risk of rhabdo
80mg dose (not be used unless patient has been on it for a year and no signs of muscle damage
max dose of atrovastatin in these combiantions
do not exceed atrovastatin 20mg with itraconazole or clarithromycing
highlight the 2012 changes in statin labeling
- Removed the requirement for routine monitoring of liver enzymes. Measure liver enzymes before starting statin therapy then as clinically necessary afterwards. Stop therapy if liver damage symptoms are present
- statins increase blood sugar and A1c (minor) Benefits>risks
- Memory loss and confusion added to side effects(cognitive side effects)
what are statin equivalent doses?
simvastatin 20mg lovastatin 40mg pravastatin 40mg atorvastatin 10mg rosuvastatin 5mg
how does one raise HDL?
Weight reduction 5-20%inc Exercise 5-30% inc smoking cessation 5% Statins (reduces CHD risk) 5-10% niacin 5-30% inc fibrates 5-15% inc
at what level should TG be treated ?
If greater than >500 treat TG first
If LDL goal achieved then try to lower TG levels below 150mg/dl
with what medications to treat high TG?
150-199 : lfestyle changes, dec bw, exercise, smokin cessation, dec alcohol, avoid high car intake
200-499: achieve ldl goal first. Then achieve non-HDL goal: statins to lower LDL and VLDL
Fibrates: lower VLDL TG, and VLDL -C
nicotinic acid lowers VLDL TG and VLDL C
at > 500: low fat diet
fish oils
fibrates
niocitinic acid
BABRs contraindicated cuz tend to raise TGs
statins not very effective at lowering TGs
discuss safety and effectivenes of Garlic
MOA: contains Aliin, which is converted to allicin by body enzyemes. Then broken down to other constituents that are thought to inhibit HMG coa reductase etc.
Effectiveness: Controversial . In 1990s many studies showed garlic was effective in lowering LDL but studies were small, inconsistent, and flawed. low . Showed dec in LDL, TC, and TG. Some studies show that it has no sig effect in dec cholesterol. Some analyses find when you pool all garlic studies there is a benefit. But if you pool only the higher quality studies, no benefit.
Safety:Drug interactions are the main concern since some preparation have been shown to induce CYP3A4 enzymes. Be wary of cyp3A4 substrates. Garlic also has an antiplatelet effect so be are if patient is taking anticoagulants or antiplatelet agents
discuss safety and effectivenes of red rice yeast
MOA: extracts of rice that has been grown on the Monascus purpureus strain of red yeast. They have monacolins that have some HMG coa reductase inhibition activity
Effectiveness: since they have active ingredient, shown to be effective in a prospective double-blind study PMID9989685
they have monacolin K which = lovastatin but only 0.2% in red yeast rice. Daily dose = 2.4 g which equally 4.8mg of lovastatin. Thats super low dose. Also, FDA considers these products illegal. Ppl can get them from the internet or other places. Mfg may not indicate how much active ingredient there is. Also, may have variable amounts of active ingredient since not regulated (no mfg standards set )
Safety: Can have same Side effects as statins: i.e hepatotoxicity and risk of myopathy.
Also some have shown to have contaminants that could damage kidneys
discuss safety and effectivenes of omega 3
MOA: inhibit synthesis of VLDL (and TGs)
Effectiveness: Clinical research shows that taking fish oil in doses of up to 1-5 grams/day can reduce triglycerides by as much as 20% to 50%. does not lower LDL or TC. May in fact increase LDL . slight increase in HDL
Lovaza is most has EPA and DHA and has 840 mg /capsule. Closest to what has been studied. lowers tg ~45%.
No evidence that actually improves cardiovascular outcomes, just that it lowers TGs
Safety: high doses can inhibit platelet aggregation but not as much as aspirin. Patients should be cautious if also taking other antiplatet or anticoagulant agents
Can have Fishy burp or GI side effects. Take with food
discuss safety and effectivenes of cholestoff
MOA: prevent cholesterol from being incorporated into fat micelles, thus decreasing cholesterol absorption
One serving of Nature Made CholestOff® supplies 900 mg of plant sterols and stanols per serving for a daily intake of 1800 mg. 200 mg expected for average person diet
Effectiveness:
More recently there is a recommendation to include 2 g per day of plant sterols into the diet for those with elevated serum LDL-C (NCEP 2001) ATP III guidelines also recommend it as a dietary option (2 grams per day)
-have been shown to reduce cholesterol by 6-15% but have not been shown to decrease risk of CHD
such as decreasing heart attacks etc .
sterols and stanols are considered comparable .
No effect on HDL
Safety: High serum plant sterols have been linked to increased risk of heart disease. They may decrease cholesterol levels but might actually increase risk of cardivascular disease. Plant sterols have been found in atherosclerotic plaques. More research is needed. because of this some people recommend only plant stanols such as in benecol
dose
titration
common side effects
and management of common side effects for Slo-niacin
Dosing: 250, 500, 700 mg po QD
start low dose and increase to desired response
can increase BG, check BG after starting therapy
SE: flusihg, itching, diarrhea, gi distress, hypercglycemia, hyperuriciemia (gout) OT hypo, hepatotoxicity
management of flushing: goes away with time. However, can take ASA 325mg (or IBU 200) 30 min before niacin dose to prevent the symptoms from happening
avoid using alcohol, hot bevrages or eating spicy food around time of takign med to reduce flushing
If any signs of liver damage, see doctor right away
discuss the different formulations of niacin that are available
Formulations are not interchangeable
Niacor OTC immediate release
take with food
-poor tolerability with ethichng flushing
Niaspan Extended release niacin
- take at bedtime with lowfat snack
- FDA approved to use with simvastatin and lovastatin but inc risk of myipathy and rhabdo
- approved with any of the resins
- more expensive
- less itching and flushing
- no inc risk of liver damage
Slo-niacin Sustained Release
take with food , once daily
-less itching and flushing
-more hepatotoxicity
