Therapeutics of Dyslipidemia Flashcards
What is the goal for treating primary prevention of ASCVD?
reducing risk of initial CV event
What is the goal for treating secondary prevention of ASCVD?
patient has had at least one CV event; goal is to reduce risk of repeated event
risk of very high triglycerides
pancreatitis
therapeutic lifestyle changes that can improve dyslipidemia
- Heart-healthy lifestyle and habits recommended for all
- Reduced intake of saturated fats and cholesterol
- Weight reduction
- Increased physical activity
- Smoking cessation – lowers ASCVD risk
- Substitute unhealthy foods
- Low fat, low cholesterol diet
- Achieve ideal body weight
- Dietary options to reduce LDL
What are the dietary options to reduce LDL?
- Fiber: 10-15g/d of psyllium seed reduced total and LDL cholesterol by 5-20%; MOA: binds cholesterol in the gut and reduces hepatic production and clearance
- Plant sterols and plant stanols: 2-3 g/day lowers LDL by 6-15%
How long should a patient be on TLC’s before going to drug therapy?
3 months unless patient is at very high risk
What are the the 4 statin benefit groups (as defined by the 2013 ACC/AHA Guideline)?
- Secondary prevention in patients with clinical ASCVD
- Primary prevention in patients with LDL > 190
- Primary prevention in patients with diabetes, 40-75 years of age, and LDL 70-189
- Primary prevention in patients without diabetes, 40-75 years of age, LDL 70-189, and 10-year ASCVD risk of > 7.5%
Therapy for Secondary prevention in patients with clinical ASCVD
- High intensity statin if < 75 yrs and no safety concerns
- Moderate intensity statin if > 75 years and safety concerns
Therapy for Primary prevention in patients with LDL > 190
- High intensity statin if > 21 years
- Target 50% LDL reduction, add non-statin LDL lowering drug if needed
Therapy Primary prevention in patients with diabetes, 40-75 years of age, and LDL 70-189
- Moderate intensity statin
- Consider high intensity if 10-year ASCVD risk > 7.5%
Therapy Primary prevention in patients without diabetes, 40-75 years of age, LDL 70-189, and 10-year ASCVD risk of > 7.5%
- Moderate or high intensity statin if 10-year ASCVD risk > 7.5%
- Consider moderate intensity statin if 10-year ASCVD risk 5-7.5%
When would the goals be for LDL < 70 mg/dL and non-HDL < 100 mg/dL?
if it’s secondary prevention in patients with clinical ASCVD comorbidities:
- DM
- recent ASCVD event
- poorly controlled ASCVD risk factors
When would the goals be for LDL <100 mg/dL and non-HDL < 130 mg/dL?
- Secondary prevention in patients with clinical ASCVD without comorbidities
- Primary prevention in patients with LDL ≥ 190
- Primary prevention in patients with diabetes, 40-75 years of age, and LDL 70-189
- Primary prevention in patients without diabetes, 40-75 years of age, LDL 70-189, and 10-year ASCVD risk of ≥ 7.5%
What do you do if patient is experiencing myopathy?
- Check CK, SCr, and myoglobinuria
- Take patient off statin; if ADR resolves, re-challenge with lower dose or lower class (usually pravastatin)
symptoms of hepatotoxicity
- fatigue
- loss of appetite
- abdominal pain
- dark urine
- yellow of skin
What do you do if patient is experiencing hepatotoxicity?
- immediately take patient off medication
- measure LFT’s (AST/ALT) immediately
What do you do for patients who are intolerant to statins?
- Optimize diet and exercise + a non statin agent
- Preferred agents: Ezetimibe (low intensity) or PCKS9 inhibitors (high intensity)
- Non-preferred: bile acid sequestrants (if TG < 300)
If patient does not fall under the 4 statin benefit groups, why would patient need to be treated?
- have ASCVD risk
- hypertriglyceridemia (TG ≥ 500 mg/dL)
- patients with low HDL (HDL < 40 mg/dL is a risk factor for CHD)
How do you treat patients that have ASCVD risk but does not fall under the 4 statin benefit groups?
- First line: statin therapy with intensity tailored based on patient factors
- Second line: Ezetimibe (low intensity) or PCKS9 inhibitors (high intensity), or non-preferred: bile acid sequestrants (if TG < 300)
How do you treat patients that have hypertriglyceridemia (TG ≥ 500 mg/dL) but does not fall under the 4 statin benefit groups?
- TLC’s
- Drug therapy: high potency statin, niacin, fibrates, omega-3 fatty acids
How do you treat patients that have low HDL (HDL < 40 mg/dL) but does not fall under the 4 statin benefit groups?
- TLC’s
- Drug therapy: niacin, fibrates
Dyslipidemia therapy with pregnancy
- Discontinue therapy for the duration of the pregnancy
- Statins are category X
Dyslipidemia therapy with children
- Therapy not recommended until patient is at least 8
- TLC’s s
- Drug therapy: Bile acid sequestrants and statins
Collect
- Patient characteristics
- Patients medical and family history
- Current medications and prior lipid-lowering medication use
- Socioeconomic factors
- Lifestyle assessment
- Symptoms indicative of ischemic injury
- Objective data: vitals, FLP, liver and renal function, glucose
Assess
- Rule out secondary causes
- Assess groups with special considerations such as pregnancy, children
- Dyslipidemia-related complications (e.g., MI, stroke)
- 10-year atherosclerotic cardiovascular disease (ASCVD) risk assessment
- Current medications that may contribute to dyslipidemia
- LDL-C reduction based on statin benefit group, if applicable to patient
- Appropriateness and effectiveness of current lipid-lowering therapy (if any)
Plan
- Tailored therapeutic lifestyle changes
- Lipid-lowering medication regimen
- Monitoring plan to assess efficacy and safety: Every 6-12 weeks after drug initiation or titration; Every 6-12 month intervals once at goal
- Patient education
- Self-monitoring of weight, exercise, diet, drug adherence/AE
- Referrals to other providers when appropriate for coordination of care
Implement
- Provide patient education regarding all elements of treatment plan, including self-management training
- Use motivational interviewing and coaching strategies to maximize adherence
- Schedule follow-up and timeframe to achieve goals of therapy
Monitor and Evaluate
- Determine response to lipid-lowering therapy
weight-loss goals (weight, BMI) - Presence of medication-induced adverse effects
- Occurrence of CV events
- If secondary prevention, ASCVD symptoms may improve over months to years
- If xanthomas present, lesions should regress with therapy
- Patient adherence to treatment plan using multiple sources of information
