EXAM - Dyslipidemia

Question 1

What resources might you use for managing dyslipidemia?

Answer 1

RxFiles: Pg. 2 = screening, Pg. 27 = drugs

CPS: Dyslipidemias

Canadian Cardiovascular Society Guidelines for Dyslipidemia

CVD risk estimators

Diabetes quick reference page 5

Question 2

Use the Framingham risk tools to calculate CVD risk for:

Hermione, 62 year old female. HDL 1.1, Cholesterol 5.2, BP 152/89. On no medications

Answer 2

Total points: 17

Risk level intermediate – 18.51% 10-year CVD risk

Question 3

Would you suggest a statin for Hermione?

Answer 3

I would say yes – as per the Framingham document, consider for women 60 and older with one other risk factor (HTN in this case)

Question 4

Hermione reports increased stress over recent years caring for her aging parents, physical inactivity and is overweight. What are some nonpharmacological options for dyslipidemia?

Answer 4

Diet

Weight loss and reduction of abdominal obesity

Physical activity

Stress management

Others:

Smoking cessation

Sufficient sleep

Question 5

Remember.. Hermione, 62 year old female. HDL 1.1, Cholesterol 5.2, BP 152/89. On no medications

What else do we need to look into for Hermione?

Answer 5

Diagnosis and possible management of HTN

Question 6

Ronald is a 45 year-old who has had T2DM for the past two years. Does he need a statin?

Answer 6

Yes, statins are recommended for patients age ≥ 40 with T2DM

(page 5 of diabetes quick reference)

Question 7

What are other statin – indicated conditions?

Answer 7

Clinical Atherosclerosis

AAA

DM (age ≥ 40, DM ≥ 15 years for age ≥30, microvascular disease)

CKD (age ≥ 50 and GFR < 60 or ACR >3mg/mmol)

LDL ≥ 5 mmol/L

Question 8

What would you prescribe Ronald?

Answer 8

Ex. Atorvastatin 10 mg po hs

(page 27 RxFiles)

Question 9

What would be involved in monitoring related to prescribing Ronald a statin?

Answer 9

LDL: initial non-fasting, then as indicated

Fasting lipids: 4-12 weeks after initiation/dose adjustments, then q3-12 months

Routine LFTs not indicated unless high dose or at risk

(RxFiles page 27)

Question 10

Ginny is 67 years old, has an HDL of 1, LDL 4, cholesterol of 6 and SBP of 120. She is a smoker. What is her CVD risk estimation?

Answer 10

This gives her a Framingham risk score (FRS) of 18 – high risk

Question 11

What intensity of statin is indicated for her? What dose range will be an appropriate target for her?

Answer 11

high-risk requires a high-potency statin.

One option is Atorvastatin 40-80 mg – although I would start low and titrate up as indicated/tolerated

(Rx Files pg.27 - top right)

Question 12

Harry scored 16 points on his Framingham risk score, giving him a 25.3% 10-year CVD risk. Harry is otherwise healthy aside from being overweight and having abnormal lipids. What do you do?

Answer 12

Discuss health behavior modifications – CPS states to trial 3 months of dietary changes prior to initiation of drugs when considering primary prevention. But for secondary prevention and high-risk individuals, statins should be started concurrently with dietary changes. (CPS – Therapeutic Choices). However, the Dyslipidemia guideline shows going to health behavior modification first even for high risk. I think either may be acceptable.

Question 13

You decide to initiate a statin (Atorvastatin 10mg daily) and recommend healthy lifestyle changes. Following the recommendations in your RxFiles book, you recheck Harry’s lipids after 4-12 weeks. His LDL-C is 3.8. What do you do?

Answer 13

Advance statin dose, I would increase to 20 mg Atorvastatin daily

Check adherence, check in with lifestyle changes, possibly connect with dietician if you haven’t already

Question 14

After another 4-12 weeks of therapy Harry’s LDL-C is now 2.8. What next?

Answer 14

As Harry was high risk, a high-potency statin is indicated. According to RxFiles atorvastatin 40-80mg is the high intensity dose for this drug. You could continue to titrate the dose up

Question 15

You increased Harry’s atorvastatin again to 40mg daily, at his next follow-up his LDL is 2.4, but he is reporting generalized muscle pain that is compromising his quality of life. What do you asses?

Answer 15

Figure 3 in CPS: Diagnosis and Management of Statin-induced Myopathy

For patients with muscle-related symptoms do history, physical exam and check creatine kinase.

Question 16

Harry’s creatine kinase came back normal. No other causes of his muscle pain are identified in his history or exam. What do you diagnose and what is your treatment response?

Answer 16

I would call this a statin-induced myalgia. Options are to continue, reduce dose or stop the statin, or could use an alternate statin. (Figure 3 – CPS)

Question 17

You decide to reduce the dose back to atorvastatin 20 mg, as Harry did not experience myalgia symptoms on this dose. At 4-12 week follow-up his muscle symptoms have resolved and his LDL is 2.6. What now?

Answer 17

The CCS Dyslipidemia guideline (p.5) states that if LDL ≥ 2 on maximally tolerated statin-dose then add-on therapy should be discussed with the patient.

Question 18

What would you prescribe for add-on therapy for Harry?

Answer 18

First line add on treatment of Ezetimibe is suggested (CCS Dyslipidemia p.5)

Ezetimibe 10 mg daily (rx files)

Question 19

Draco had an MI 6 months ago and is new to your care. Initial lab workup shows LDL-C of 2. He is already taking atorvastatin 20mg daily. What’s next?

Answer 19

This is not a situation of primary prevention, as Draco already has ASCVD as demonstrated by his MI. According to figure 2 (page 6 of the CCS Dyslipidemia guideline), intensification of statin should be discussed for LDL-C ≥ 1.8.

If you reach maximally tolerated statin dose and are not at target then see figure 3 for add-on therapy in patients with ASCVD (p.13)

Question 20

Lily is 32 years old and is prescribed a statin to manage dyslipidemia. She comes to your office stating that she is considering trying to become pregnant soon and is wondering if she can stay on her medication during pregnancy and breastfeeding?

Answer 20

Nopers. Statins are a no go during pregnancy and breastfeeding and should be stopped 1 month prior to stopping contraception.

Interrupting therapy during this time is low-risk for most – monitoring is not required during pregnancy except for patients with the genetic dylipidemias Familial hypercholesterolemia (FH) or Familial chylomicronemia syndrome (FCS)

Question 21

Additional cases

Answer 21

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