1.  DM

2.  Peripheral Artery Dz

3.  Abdominal Aortic Aneurysm

4.  Symptomatic carotid artery dz

5.  multiple risk factors conferring a 10yr risk for coronary heart dz greater than 20%

Major CHD risk factors

(use for Framingham)

current cigarette smoking

HTN (BP ≥140/90 or if on anti-HTN)

Low HDL

fam hx (males less than 55, females less than 65)

male  ≥45

female  ≥55 or premature menopause w/out ERT

*if HDL  ≥60 you can subtract one risk factor!

1.  DM

2.  hypothyroidism

3.  obstructive liver dz

4.  chronic renal failure

5.  drugs that increase LDL and decrease HDL

(steroids, corticosteroids, EtOH, BB, protease inhibitors (for HIV tx), isotretinoin, progestins, thiazide diuretics)

TLC steps

(healthy diet, weight reduction, increased physical activity)

Visit 1:  begin TLC

                                              6wks later

Visit 2:  eval LDL response- if goal not reached intensify LDL-lowering therapy (consider adding plant stanols/sterols and fiber)

                                             6wks later

Visit 3:  eval LDL response- if goal not reached consider adding drug tx

6wks again to next visit, once goal reached every 4-6mo

HMG Co A Reductase Inhibitors

"statins"

all end in "astatin"

-atorvastatin (lipitor):  best at lowering TG, also very good at dec LDL

10-100mg qday

non-linear dose relationship

taken in evening usu greater effect on LDLs

decreases CV morbidity/mortality (simva- and prava-)

decreases stroke incidence

MC!  myopathy:  1 in 10 pt report myalgia, myositis, rhabdomyloysis; inc with high dose of simvastatin

hepatic toxicity:  elevated transaminases

neuropathy

-pregnancy (X) and lactation

-active/chronic liver dz

-concomitant use of CSA, gemfibrozil, niacin

*increases risk of myositis

reports of myopathy with:  CSA, gemfibrozil, clofibrate, niacin, azole, antifungal, erythromycin, nefazodone, protease inhiitors

-may potentiate oral anti-coag

-increased effect/toxicity of levothyroxine

from most to least drug intrxn

Lova-,Simva- > Atorva- > Fluva-, Pitava-, Prava-, Rosuva-

cholestyramine

colestipol

colesevelam

not as good as statins, may actually inc TGs via inc hepatic VLDL production

-good for people with moderately high LDLs

-works well with statins, can be used with niacin and fibric acids

-strong safety and efficacy record (not absorbed in GI so no systemic toxicity)

GI:  constipation, belching, flatulence, abdominal distension, nausea, heartburn

-start with lower dose and titrate up or increase fluid and fiber intake

basically assume decreases absorption of everything until proven otherwise

*take other meds 1 hour before or 4-6hours after!

decreases bioavailability of statins

pt w/ hx of dysbetalipoproteinemia

pt w/ hx of severe constipation

not for use as monotherapy in pt with TGs > 500 

Fenofibrate (Tricor), Gemfibrozil

really good at lowering TG and comparable with statins at increasing HDL

good for combined dyslipidemia

decreases major coronary events but NO significant decrease in mortality

AE:

-GI MC!

-can increase bile lithogenicity

drug intrxns:

-may potentiate warfarin (anti-coag)

-avoid with statins (increased risk of myositis)

Niacor and Niaspan 1-2g tid

favorable effects on all lipids/lipoproteins:  best at increasing HDL and ties fibric acids at decreasing TG

start slow, go slow, monitor for hepatic toxicity

decrease major coronary events and CHD deaths

AE:

-flushing MC!

-may cause glucose intolerance and increase uric acid

-older versions have caused fulminant hepatitis (Niaspan better tolerated)

CONTRAINDICATIONS:

-liver dz!

-DM2

-gout

-hyperuricemia

decreased effect of oral hypoglycemics

may inhibit uricosuric effects of sulfinphyrazone and probenecid (inhibits uric acid elimination)

increased toxicity (myopathy) with lovastatin and possibly other statins

may potentiate anti-HTN meds

Ezetimibe (Zetia)

AE:  monotherapy:  fatigue, abdominal pain, diarrhea, arthralgia, back pain

with statin:  above + HA and myalgia

contraindications:  do not combo with statins in active liver dz or in pt w/ persistent LFT elevations

drug intrxns:  decreased absorption when given w/ cholestyramine (bile acid);

-give 2hr before or 4hr after cholestyramine

-Ezetimibe levels may increase when taken with gemfibrozil, cyclosporine

-combo-ed with statins works well

plant stanol esters

fish oils (omega-3 fatty acids), EPA, DHA over AHA

other therapies:

blond psyllium

oat bran

statin (or BAR or nicotinic acid)

                                                 6wks later

if goal not met:  consider increasing statin dose or add BAR/nicotinic acid

                                                 6wks later

still not met:  intensify therapy or refer to lipid specialist

if goal met:  treat other lipid risk factors and follow up every 4-6 months

baseline ALT

ALT, fasting lipid profile 6-12wks after dose change

q6-12mo thereafter

CK prn myositis

baseline ALT and baseline alk phos

ALT, alk phos 6-12wks X 2, q12 mo thereafter

fasting lipid profile 6-12mo after dose change, q12 mo there after

CK prn myositis

baseline ALT, alk phos.

ALT, alk phos 6-12wks, q12mo thereafter

after stable dose achieved X 2mo- fasting lipid profile, uric acid, and glucose,

fasting lipid profile q12mo thereafter

CK prn myositis