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Hyperlipidemia

Hyperlipidemia. Done by: Mohannad A. AL-Shibani Pharm.D intern. Main points. Pathophsiology Management Case. Pathophsiology. Definition : an increase plasma level of cholesterol and / or triglyceride

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Hyperlipidemia

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  1. Hyperlipidemia Done by: Mohannad A. AL-Shibani Pharm.D intern

  2. Main points • Pathophsiology • Management • Case

  3. Pathophsiology Definition: an increase plasma level of cholesterol and / or triglyceride • Hyperlipidemia may be secondary to disorder like DM , hypothyroidism, nephrotic syndrome , obesity, high alcohol intake and some drugs Prevalence: 20.6 million children and adults – 12.0 % of the population -- have hyperlipedemia

  4. Pathophsiology • Diagnosed: 14.6 million people • Undiagnosed: 6.0 million people • In KSA 22% of population have an increase in cholesterol and /or triglyceride • A leading risk factor for CV disease

  5. Pathophsiology Etiology: • Primary causes(genetic): single or multiple gene mutations that result in either overproduction or defective clearance of TG and LDL cholesterol, or in underproduction or excessive clearance of HDL • Secondary causes(lifestyle &others): xss. dietary intake of saturated fat, cholesterol, and trans fats. Like polyunsaturated or monounsaturated fatty acids , diabetes mellitus, alcohol over use,CKD, hypothyroidism, biliary cirrhosis and drugs, such as thiazides, β-blockers , estrogen and progestins

  6. Pathophsiology Risk factor: • Non – modifiable: • Age >45 for male , >55 for female • Male sex (at risk 4-5 times more than female) • Family history of premature CHD (1st-degree relative) • Genetic susceptibility

  7. Pathophsiology Risk factor: • Modifiable • HTN(> 140/90 mmHg ) • DM • Obesity • Inactivity • Low HDL(<40 mg/dl) • Smoking • Chronic kidney disease

  8. higher Cholesterol Levels Associated With CHD Risk higher 150 125 100 75 CHD Incidence per 1000 50 25 0 265-294  204 205-234 235-264  295 Serum Cholesterol (mg/100 mL)

  9. Pathophsiology Complication: • Fatty streaks: its reversible process while atherosclerosis (plaque) irreversible • Corneal xanthelasma: accumulation of yellow plaque underneath skin ,eyelid(irreversible) • Planar exanthema: appear on hand,Knee,&elbow (irreversible) • Irruptive exanthema : rashes due increase TG (reversible)

  10. Pathophsiology Characteristic of plasma lipoprotein:

  11. Pathophsiology Classification: 1-phenotypic (Fredrickson classification)

  12. Pathophsiology Classification: 2-(Genetic classification)

  13. Pathophsiology Diagnosis: measureSerum lipid profile after 12 hr. fasting like • total cholesterol • TG • HDL-cholesterol • calculated LDL-cholesterol and VLDL) VLDL= ( TGL / 5 ) LDL= {Total cholesterol – (HDL +VLDL)}

  14. Pathophsiology Normal level of lipoprotein: National Cholesterol Education Program Adult Treatment Panel III Screening: A fasting lipid profile should be repeated every 5 yr. Lipid measurement should be accompanied by assessment of other cardiovascular risk factors

  15. II-Managment

  16. managment • Life style modification • Drug therapy like: • Bile acid sequestrants • Nicotinic acid derivative • Fibric acid derivative • HMG-CoA reductase inhibitor • Cholesterol absorption inhibitors

  17. managment Life style modification: • decreasing intake of saturated fats and cholesterol; increasing fiber, complex carbohydrates; stop smoking and maintaining IBW. Referral to a dietitian is often useful, • Drugs are the next step when lifestyle changes are not effective after 3-4 month. However, for patients with extremely elevated LDL-cholesterol (> 200 mg/dL [> 5.2 mmol/L]) and those at high cardiovascular risk, drug should accompany with diet and exercise from the start

  18. PHARMACOTHERAPEUTIC OPTIONS cholesterol-lowering medications may be considered in addition to lifestyle changes.

  19. managment Drug therapy: 1) Bile acid sequestrants • M.O.A:block intestinal bile acid reabsorption, forcing up-regulation of hepatic LDL receptors to recruit circulating cholesterol for bile synthesis

  20. managment • usually used with statins or with nicotinic acid to augment LDL-cholesterol reduction • their use is limited by adverse effects of bloating, nausea, cramping, and constipation. They may also increase TGL so use only in type 2A • Example: cholestyramine ,and colestipol

  21. managment • Cholestyramine available in powder form so can mix with orange drink or juice to minimize gritty texture • Dose: 4 g QID • Colestipol have better adherence b/z its odorless and tasteless, available in tablet form • Dose: 2 to 16 grams/day once or in divided doses

  22. managment 2-Nicotinic acid derivative: • M.O.A.: alters lipid profiles has not been well defined. It may inhibition of release of free fatty acids from adiposetissue, and increased lipoprotein lipase activity, which may increase the rate of chylomicron triglyceride removal from plasma • the most effective drug for increasing HDL • Principle use in type 2B as first line and second line in type 2A,may used as first line or alternative in type4&5

  23. managment S.E.: hyperglycemia , hyperurecemia ,itching and cutaneous flushing may restrict its use but…. Dose: 500mg at within meal or after to reduce the incidence and side effects which may occur and titrated dose to 2000 mg/d

  24. managment 3-fibric acid derivative: M.O.A.: • increases lipolysis and elimination of triglyceride-rich particles from plasma by activating lipoprotein lipase and reducing production of apoprotein C-III (an inhibitor of lipoprotein lipase activity). • Drug of choice in type 4 and may used in 2B and in decrease HDL alone

  25. managment Example: 1)gemfibrozil(lopid) dose:600 mg BID Cost: 55 SR , 2)fenofibrate(lipanthyl) dose:200 mg OD Cost: 49 SR Other: 3) clofibrate(use restricted due high mortality) 4) benzofibrate(use restricted due stone formation) • S.E: muscle cramps and stiffness

  26. managment 4-HMG-CoA reductase inhibitor: • M.O.A: inhibit hydroxymethylglutaryl CoA reductase, a key enzyme in cholesterol synthesis, leading to up-regulation of LDL receptors and increased LDL clearance. They reduce LDL-cholesterol by up to 60% • Not only have statins improved lipid profiles, but they have in turn reduced cardiovascular morbidity and mortality

  27. managment • Drug of choice in type 2A & 2B b/z it mainly act on LDL • S.E: 1)Mylagia 2)increase liver function test Example: 1-atorvastatin(lipitor) 2-simvastatin(zocor) 3-pravastatin(lipostat) 4-fluvastatin(lescol) 5-rosuvastatin(crestor)

  28. managment

  29. managment

  30. managment 5-cholesterol absorption inhibitor: • M.O.A: inhibit intestinal absorption of biliary and dietry cholesterol • Decrease LDL by 15-20% • Increase HDL by 2.5-5% • Decrease TGL by 0-2% • can be used as monotherapy in patients intolerant to statins or added to statins for patients on maximum doses with persistent LDL-cholesterol elevation

  31. managment • Doesn’t influence the activity of CYP-450 • S.E.: abdomain pain ,fatigue , diarrhea • Example: Ezetemibe (Ezetrol) cost:225 SR • Dose: 10 mg OD approved in Oct.2002

  32. managment • New combination of ezetemibe and simvastatin in saudi market called (INGEY) or (Vytorin) • Dose : - 10/20 mg cost: 273 SR -10/40 mg cost:296 SR

  33. managment Guidelines for treatment according NCEP: 1- Initiate LDL-lowering drug therapy with a statin, or bile acid sequestrant, or nicotinic acid. 2- In 6 weeks, evaluate if LDL goal is achieved. If not,Consider higher dose of statin or add bile acid sequestrant or nicotinic acid or ezetemibe

  34. managment 3-In 6 weeks, evaluate if LDL goal is achieved. If not, intensify drug therapy. If LDL goal is achieved, treat other lipid risk factors 4-Every 4 - 6 months, monitor response and adherence to therapy • IF TGL high alone used first niacin or fibrate • IF HDL low alone consider first niacin

  35. Take Home points: • LDL is the primary target of lower cholesterol & better predictor of CHD • NCEP recommend full lipid panel every 5 years • Dietry therapy should consider first line in tratment • Drug therapy should combined with Life style modification • Selection of drug is based on efficiacy ,side effect &cost

  36. III-case study

  37. Case study File no.:552020 HPI:68 years Yemenian female, 82 kg, with known case of type 2DM, and dyslipidemia . She came to family clinic complaining of fatigue ,palpitation and dyspnea Vital signs: Wt : 82 Kg HR: 20 mm/hr Temp: 37.2 c BP: 119/77 mm Hg CC: generalized fatigue from any activity , difficult in breathing and increase in its heart rate with sweating Physical examination: HEENT: normal Chest: clear CVS: S1 + S2+O Abd: normal and soft • Extremities: normal

  38. Case study Past medical history: 1) Hyperlipidemia from 2 years treated by: Atorvastatin (lipitor) 10 mg OD then changed …… 2)Type 2 DM from 4 years treated by: metformin (glucophage) 500 mg BID glibenclamide(daonil) 5 mg BID • She took ASA 81 mg OD • Patient note non compliance to drug due financial reason .and not adherence to her diet

  39. Case study Family history: Her mother with DM type II Social history: married, non smoker , poor education and financial proplem Lab result: 1-Glycated haemoglobin level is 7.5% 2- LDL=4.03mmol/l (<3.3mmol/l) 3- HDL=1.32 mmol/l (>1.03mmol/l) 4-TGL=1.91 mmol/l (<3.3mmol/l) 5- chol=5.5mmol/l (<5.17mmol/l) 6- FBS= 6.1mmol/l (<7 mmol/l) 7- 2hr= 11.4mmol/l (<11.0 mmol/l)

  40. Case study

  41. Case study Plan: • The most common cause of therapy failure is: 1) the wrong medication, 2) the wrong dose, 3) patient non-compliance • On 5/5/2008………………….

  42. Case study atorvastatin 10 mg equivalent to 20 mg simvastatin • In case of DM : 1)advice to increase dose of glibenclamide to 5mg TID • In case of hyperlipidemia: 1)Advice to increase dose of simvastatin to 20 mg OD

  43. Recommendation: • Educate the patient about his medication uses and administration • Advise patient to take the medication regularly to avoid the complication in future • Illustrate to the patient importance of diet • Try to help the socioeconomic proplem of the patient by shown him the cheapiest alternative of his medication availble in market

  44. ,

  45. Refrences • Marry A. Kimble.Handbook of Applied Therapuetics.Lippincott Williams and Wilkins, MD.8th Ed, 2007; Chapter 12, page:127-143 • Grundy SM, et al. Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. Circulation 2004; 110: 227-239 • Stone NJ, Blum CB, Winslow E. Management of lipids in clinical practice. 5th ed. Caddo, OK, Professional Communications, Inc., 2005.

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