Hyperlipidemia

Question 1

Treatment Target Groups for Statins

Answer 1

Patients with clinical ASCVD
Patients with LDL 190 or more
Patients with diabetes, 40-75 years old with LCL >70
Patients 40-75 with 10 year ASCVD risk of 7.5% or more

Question 2

Normal Ranges of Lipids

Answer 2

Total Cholesterol <200
LDL <100
HDL >60
Triglycerides <150

Question 3

Lipid Screening Recommendation

Answer 3

Fasting Lipids every 5 years for adults over 20

Estimate ASCVD risk every 4-6 years

Question 4

After starting statins

Answer 4

Second lipid panel in 4-12 weeks, then again every year at least
A1C and Glucose as statins, especially high dose, increase risk of DM

Question 5

Before starting lipids

Answer 5

Obtain a liver function panel, CK

Obtain Thyroid and A1C/Fast Glucose to rule out thyroid/DM

Question 6

Xanthomas

Answer 6

Severe high cholesterol sign of cholesterol buildup on eyelids

Question 7

Dietary Fat effects

Answer 7

Saturated fats = increase cholestrol, goal is to reduce this by half
Mono-saturated Fats = preserve HDL
Poly-unsaturated fats = essential fatty acids like Omega-3, may lower total cholesterol
Trans-fatty acids = very bad, should avoid all of them

Question 8

Key Part of Lipid Management

Answer 8

Lifestyle changes

Heart healthy diet, exercise, smoking cessation,

Question 9

Non-dietary lipid changes

Answer 9

Starvation such as anorexia can cause elevation
Alcohol abuse can elevate
Thiazides can elevate
Hypothyroid and Diabetes can elevate

Question 10

Statin Teaching Points

Answer 10

Asians may have increased response to high dose statins
Avoid grapefruit juice
Report muscle pain / weakness
Avoid alcohol

Question 11

Medium Lowering Statins

Answer 11

Lower TC and LDL by 20-30% average, small Trig reduction
Lovastatin, Pravastatin, Simvastatin, Fluvastatin

Lovastatin is usually best tolerated and can be taken at evening meal
Simvastatin is dangerous in patients on cardiac rhythm drugs and has highest risk of complications

Question 12

High lowering statins

Answer 12

Lower TC and LDL by 30-50% average, modest Trig reduction
Atorvastatin, Rosuvastatin (Really Aggressive)

Avoid grapefruit, Asians should start on lower dose

Rosuvastain may have no effect on total cholesterol directly

Question 13

Typical Starting Doses

Answer 13

Medium
Lovastatin 20mg / day
Simvastatin 5 mg/day

High
Atorvastatin 10mg/day
Rosuvastatin 5mg/day

Question 14

Triglyceride Lowering Agents

Answer 14

Fibric Acids such as gemfibrozil and fenofibrate
Usually only needed if Trigs are >400 and pancreatitis is present

Cannot be given to patients with hepatic or renal issues

Question 15

Bile Acid Sequestrants

Answer 15

May be used as monotherapy to lower LDL or as combo with statin
Cholestyramine

Safer for liver

Question 16

Muscle pain in patient on statin

Answer 16

Check CK, if elevated stop the statin and monitor renal function. May restart if liver is normal and once muscle pain clears. If episode repeats, discontinue statin.

Question 17

A patient who is taking a statin drug to treat dyslipidemia has begun a diet and exercise program. The patient reports new onset of muscle pain several weeks after beginning therapy.
What is the initial action by the primary care provider?

Prescribe acetaminophen or ibuprofen

Recommend reducing exercise intensity

Reduce the dose of the statin drug

Order a creatine kinase (CK) level

Answer 17

A potential serious side effect of statin drugs is drug-induced myopathy. Patients who report new-onset muscle pain should have CK levels evaluated. If this is elevated, the statin drug should be stopped and renal function should be evaluated.