Chylomicrons

Transport Lipids

Triglycerides and Cholesterol from GI tract to the body.

Stored in Adipose Tissue

VLDLS

Very Low density Lipoproteins

These are the very bad lipids

Transport Triglycerides to adipose tissue and muscles

Play a big role in atherosclerosis

mainly composed of triglycerides

decrease triglycerides will decrease VLDL

Nicotinic Acid (Niacin) B3 lowers VLDL

IDL

Intermediate Density Lipoprotein

Bad lipid but not as bad as VLDL

Formed when VLDL loses some of its Triglyceride concentration

Gets converted to LDL in liver

High IDL increases your LDL

LDL

Low Density Lipoprotein

Very Very Bad Lipid

+ Risk factor for heart disease.

It transports Cholesterol EVERYWHERE

the more cholesterol you take in, the higher LDL goes.

YOU DO NOT WANT a high LDL

Management of LDL

Treatment Goals

If you have heart disease  < 70 mg/dl

If you have >2 risk factors < 100 (Diabetics)

If you have < 2 risk factors < 130

you are borderline if 130-160

You are high if 160-190

You are in serious trouble if > 190

Stop smoking, lose weight, eat healthy.

Lp (a) Lipoprotein

This is a bad lipid

Formed from LDL (bad) and a protein

It is associated with CAD

It is found in the athlerosclerotic plaques

It is associated with inflammatory conditions in the vessel

+ Risk Factor

HDL

High Density Lipoproteins

THIS IS HAPPY LIPID- IT IS GOOD

It goes and picks up cholesterol from your tissues and takes it back to liver so it cant be deposited in your vessels

Composed mostly of proteins

It is a negative risk factor for heart disease.

Levels increase with excercise, healthy eating

Decrease when you are lazy, smoke, drink

Cholesterol

Treatment Guidelines

You want your Cholesterol < 200 mg/dl

If > 240 you are in trouble- too high

It is a + risk factor for heart disease.

HDL

Treatment Guidelines

This is the Happy -Good Lipid

You want more of this one!

Women- you want it > 50 mg/dl

Men- you want it > 40

Excercise and healthy eating increase your HDL

It is a negative Risk Factor for Heart Disease

TRIGLYCERIDES

Treatment Guidelines

These are not good so you dont want much of them.

Your goal is > 120 mg/dl

A high level is > 200

Very High > 1,000 (usually genetic)

+ Risk Factor for Heart Disease

and

 pancreatitis

Decreasing sugar intake (wine) will help

TRIGLYCERIDES

Management of High levels

If your Triglycerides are > 400 but your LDL (Bad lipid) and HDL is OKAY

Then we just need to educate you on a good diet, stop smoking, watch your weight and excercise.

If your Triglycerides are > 400 and your LDL is also high and your HDL (good lipid) is low..

You need more teaching and we need to start you on medication today.

LDL

Management of the Bad Lipid

If your LDL is < 130 mg/dl and your HDL (good) is > 40

and you have < 2 risk factors

Repeat level every 5 years.

You need to be educated on a good diet- eat more vegetables, stop smoking, watch your weight and excercise.

If LDL 130-160 (Borderline) and HDL is > 40

Repeat level every 1-2 years

educate.

If your LDL > 160 and your HDL < 40

and you have more than 2 Risk Factors

You need to be started on Medication

Dietary Recommendations

in

Management of Hyperlipidemias

Your total fat intake should be < 30% of your calories

 Saturated fats and trans-fatty acids to < 7% of

Decrease intake of Cholesterol to < 200 mg/day

Use Poly-unsaturated fats or Monounsaturated fats

Increase your fruits and vegetables and whole grains: They 50-60% of your diet.

Decrease your sugar and wine intake if your

Triglycerides are > 200

Which foods are high

 in

Trans Fatty Acids

Fast Food

Snack foods (chips and crackers)

Fried Foods

Nondairy Creamers (Hazlenut coffee creamer )

Shortening for cooking

Baked Goods Prepackaged Cakes, pastries and cookies.

Which Foods are High

in

Cholesterol

Whole eggs

High Fat cut meats

Organ meats

duck

Packaged meats: bologna, ham, sausage, hot dog

Dairy products: whole milk, 2%, yogurts, cheese

partially hydrogenated oils

BILE ACID SEQUESTRANT RESINS

To treat Hypercholesterolemia and High LDL

Non-absorbable resin powders

Binds the bile acids in the intestines and prevents their reabsorption. This allows new bile acids to form that will absorb cholesterol and decreases LDL

Does not taste good.

You get bloating and BAD FLATULENCE (fatty stools)

It interferes with absorption of other meds

Take coumadin, digoxin, BB or Cyclosporins 1 hour before you take this med

BILE ACID SEQUESTRANT RESINS

Used to bring down your Cholesterol and LDL levels

Questran-choleystyramine

                        Colestid- colestipol

                        Welchol- Colesevelam

Remember: These taste bad and they will give pt an upset stomach with bloating and flatulence. 

Must take coumadin, BB, cyclosporin, dig: 1 hour before or 3 hours or after taking this medication.

Nicotinic Acid

Niacin

Vitamin B3

Given to Lower Triglycerides, VLDL and LDL

(all the bad lipids)

Sig decrease in VLDL,Trig, LDL: 30-40%

Sig. decrease in cholesterol 20%

Increases the good lipid (HDL)

FLUSHING AND VASODILATION (Prostaglandins)

Take with aspirin

side effects diminish over time with use

Increased uric acid levels (DO NOT give in GOUT)

Monitor LFT and Uric Acid levels

Pregnancy Category C: but can be given in lower doses < 1000 mg.

Niacin or Nicotinic Acid-ER only OTC that works to decrease lipids.

Niaspan and Niacinamide or nicotinamide not effective in decreasing lipids.

"Flush free" Niacins do NOT decrease lipids.

STATINS

Are the Mainstay of Lipid Management

Used to Lower CHOLESTEROL levels

by

Inhibiting HMG-CoA reductace which is responbsible for the production of cholesterol in the liver.

HMG-CoA Reductase Inhibitors

To treat HIGH CHOLESTEROL and HIGH LDL

Will lower cholesterol and LDL

Drugs that inhibit HMG-CoA from synthesizing Cholesterol in the liver.

Used in some patients to prevent CAD

Should be taken at night when most cholesterol is being formed by liver

Pregnancy Category: X

DO NOT GIVE IN PREGNANCY

HMG-CoA Reductase Inhibitors

Medication Examples

"STATINS"

Lipitor- Atorvastatin

Lescol- Fluvastatin

Mevacor- Lovastatin

Pravachol- Pravastatin

Zocor- Simvastatin

Crestor- Rosuvastatin

Livalo- Pitavastatin- New: least complicating

Causes: bloating, flatulence, dyspepsia

Hepatotoxic: Must check LFT, SGOT levels

IF SGOT level triples: must stop

Rhabdomyolysis and Myalgia Risk: Check CPK.

(causes leg cramps)

If elevated: must stop

Labs: LFT,CPK baseline, Q 6 weeks, Q 3 mos/year

then simannually.

CHOLESTEROL ABSORPTION INHIBITORS

To Decrease Cholesterol

Inhibits Cholesterol absorption in small intestines

which decreases stores and reduces serum levels.

Give this if your patient is intolerant/ineffective STATIN

OR

Can also be given in combo with STATIN as

it is Synergistic (additive) w/Statin

Contraindicated in Liver disease (but does not cause liver damage)

Pregnancy Category C.

FIBRIC ACID DERIVATIVES

Used to treat High Triglyceride Levels

levels > 750 mg/dl

Decreases Lipolysis in Fat tissue

 Decreases free fatty acids required for synthesis of triglycerides

Decreases VLDL levels

Causes: Bloating, abdominal pain n/v/d

Hepatic: elevated LFT (monitor in 2 mos, 1 yr)

Gallbladder: Cholelithiasis and Choleycystitis

Leukopenia: Monitor CBC

Renal/Hepatic Disease: DO NOT GIVE

Pregnancy Category C: Do not give

FIBRIC ACID DERIVATIVES

MEDICATION EXAMPLES

Lopid: (Gemfibrozil)

Fenofibrate:  (Antara, Fenoglide, Lipofen, Lofibra

Tricor, Triglide)

Hepatic: elevated LFT (monitor in 2 mos, 1 yr)

Gallbladder: Cholelithiasis and Choleycystitis

Leukopenia: Monitor CBC

Renal/Hepatic Disease: DO NOT GIVE

Pregnancy Category C: Do not give

OMEGA 3-FATTY ACIDS

Give to decrease Triglycerides and Total Cholesterol

FISH OILS

Dyspepsia is the most common side effect

"bad smelling fish breath"

Can Decrease Platelet Aggregation and Increase Bleeding

Monitor: LFT and Bleeding times

Used for: High lipids (Trigs and Chol)

HTN

Prevent Stroke

Keep STENTS patent

Omega-3- Fatty Acids

Sources

and

Medication

To lower Cholesterol and Triglycerides

Cold Water fish

nuts, almonds, english walnuts

vegetables

flaxseed oils, canola oil, soybean oil

Lovaza: Contains EPA and DHA

Dose: 4 gm/day

Pregnancy Category: C