Approach to Hyperlipidemia

8/9/2019 Approach to Hyperlipidemia

1/30

OMAR M AL NOZHA

Assistant Prof. of Medicine

Taibah University


2/30

Introduction

y What to do wit a patient who has hyperlipidemia?

yWhy Rx?

y Who to treat ?

y When to start Rx?

y How should Rx?


3/30

Case 1y 41 Y.O M

y Type 2 diabetes

y TG of12.6 mmol/L on routine lipid evaluation

y Total cholesterol (6.0) mmol/L, HDL (0.9) mmol/L

y Fasting Glucose (9.6) mmol/L , A1c (8.9%)

y LDL ???y TG > 4 XX


4/30

Case 2

y 28 years old girl

y

Fashion student at McgillyAnnual checkup

y Lipid profile as follow

y TG (3.0) mmol/L, T.C (7.0) mmol/L

y HDL (0.8) mmol/L, LDL 4.8 mmol/L


5/30

Case 3

y 45Y.O M buss driver

y Smokes 15 cig/day

y HTN


y TG( 1.5) mmol/L , T.C ( 5.2 ) mmol/L,y HDL(0.9) mmol/L, LDL( 3.6) mmol/L


6/30

Secondary dyslipidemia

Importance ??

y Type 2 diabetes mellitus

y Cholestatic liver diseases

y Nephrotic syndrome

y Chronic renal failure

y

Hypothyroidismy Cigarette smoking

y Obesity

y Drugs (e.g. HAART, olanzapine)


7/30

ATPIII guidelines


8/30


9/30

Approach steps !

y Proper Targeted Hx

y Proper Targeted physical Exam

y

Framingham risk scoring system

y None pharmacological measures

y Pharmacotherapy


10/30

Important History points:y For Risk assessment:

y Co-morbidities ( e.g.)

y Previous cardiovascular episodes

( TIA, IHD, Stroke , PVD)

y FH ( Lipid, premature CAD)

y

Important for management:y Diet

y ROS to R/O secondary etiology ( e.g.)

y Contraindication to pharmacotherapy (e.g.)


11/30

Physical exa check i ts

y

Signs of hyperlipidemia:y Xanthomas and

xanthelasmas

y Arcus senilis

y Insulin resistance:y Acanthosis nigricans

y

Dyslipidemia complications:y Major and Peripheral pulses

y Secondary etiologies:

y

Peripheral neuropathyy Thyroid status

y LL Oedema


12/30


13/30

Framingham / Risk assessment:y Scoring card system

y Hand-held devices software

y Website designed

y Modified Framingham system

y Other risk scoring systems ( UK, Reynolds)


14/30

Managementy None pharmacotherapy :

y Diet ( e.g for each ^ HDL / affecting TG, LDL )

y Life style improving Risk for CAD

( examples)

y Correct secondary causes ( e.g.)

y Pharmacotherapy ( targeted Rx)


15/30

Pharmacotherapy options:yyAlready on the market:Already on the market:

yStatins

yFibrates

yResins

yCholestrol Uptake inhibitors

yNiacin

yFish Oil


16/30


17/30

HMGCo-A Reductase Inhibitors

y Fluvastatin

y Lovastatin = Pravastatiny Simvastatin

y Atorvastatin

y Rosuvastatin

y Pitavastatin not in N Americay Cerivastatin withdrawn


18/30

Statin Effect hepatocyte

http://www.med.unibs.it/~marchesi/cholest.html#synthesis


19/30

Statin effecty Inhibits endogenous cholesterol production by

hepatocytes

y Leading to Increases uptake of cholesterol from bloodby hepatocytes

y Leading eventually to reduced circulating cholesterol


20/30

Fibric Acid Derivatives

y

Gemfibrozily Fenofibrate

y Bezafibrate

y Ciprofibrate - not in N America

y Clofibrate - withdrawn


21/30

Fibrateseffect

yActivate PPAR-Ey Increase production of LPL

y lowers TG

y Indirectly raise HDLyEnhance reverse cholesterol transport to

HDL


22/30

Binding resins

y Cholestyramine

y Colestipol

y Colesevelam not in Canada


23/30

Effect f esi s

( Bile aci i ers)

y Bind to Bile acids non-re-absorbable

y Liver must convert more CholBile acidsy Liver must provide more Cholesterol

y Increase HMG Co-A reductase

y Increase LDL receptors to surface

y Increase clearance from blood

y reduce LDL cholesterol


24/30


25/30

Case 1y 41 Y.O M

y Type 2 diabetes

y TG of12.6 mmol/L on routine lipid evaluation

y Total cholesterol (6.0) mmol/L, HDL (0.9) mmol/L

y Fasting Glucose (9.6) mmol/L , A1c (8.9%)

y LDL ???y TG > 4

{LDL=Tchol-VLDL-HDL, (VLDL=TG/2.2)}


26/30

Back to guidelines:Back to guidelines:


27/30

Case 2y 28 years old girl

y

Fashion student at McgillyAnnual checkup


y TG (3.0) mmol/L, T.C (7.0) mmol/L

y HDL (0.8) mmol/L, LDL 4.8 mmol/L


28/30

Case 3y 45Y.O M Truck driver

y Smokes 15 cig/day

y HTNy Lipid profile as follow

y TG( 1.5) mmol/L , T.C ( 5.2 ) mmol/L,

y HDL(0.9) mmol/L, LDL( 3.6) mmol/L


29/30

Secondary Preventiony 38 Y.O Male Bank accountant

y Had confirmed MI couple of days ago, currently in

CCU just after the market crashed down y Occasional smoking

y No HTN, No DM

y No other relevant

y Lipid profile ??

y ??? Treat or not ???


30/30

OMAR Al NOZHA

Documents

Approach to Hyperlipidemia