Lipid Management Case Studies · Nasopharyngitis, URI, UTI, rare myalgia, ... constitutes a...

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Heidi Kile, APRN‐C

Nebraska Heart Institute

Lipid ManagementCase Studies

The following relationships with commercial interestsrelated to this presentation existed during the past 12 months:

No relationships to discloseThe following FDA disclosure related to this presentation exist:

Nothing to disclose

Disclosures

•Review the 2018 Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults.

•Discuss tools used to establish risk of ASCVD•Discuss current medical therapy used to treat elevated cholesterol and triglycerides

•Review case studies

Objectives

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2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA

Guideline on the Management of Blood Cholesterol: Executive Summary

Citation

This slide set is adapted from the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA

Guideline on the Management of Blood Cholesterol: Executive Summary.

Available at: Journal of the American College of Cardiology and Circulation

The full-text guidelines are also available on the following Web sites: ACC (www.acc.org) and

AHA (professional.heart.org)

Table 1. Applying Class of Recommendation and

Level of Evidence to Clinical Strategies,

Interventions, Treatments, or

Diagnostic Testing in Patient Care*

(Updated August 2015)

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• Focus on ASCVD Risk Reduction• Based on a comprehensive set of data from

Randomized Controlled Trials that identified 4 statin benefit groups

• Identifies high‐intensity and moderate‐intensity statin therapy for use in primary and secondary prevention

What’s New in the Guideline?

Four Major Statin Benefit Groups

• Individuals with clinical ASCVD• Individuals with primary elevations of LDL‐C > 190 mg/dl

• Individuals with diabetes aged 40 to 75 years with LDL‐C >70

• Individuals without clinical ASCVD or diabetes with LDL‐C 70 to 189 mg/dl and an estimated 10‐year ASCVD risk > 7.5%


• A New Perspective on LDL‐C and/or Non‐HDL‐C Treatment Goals

• The Expert Panel was unable to find RCT evidence to support continued use of specific LDL‐C and/or non‐HDL‐C treatment targets.

• The appropriate intensity of statin therapy should be used to reduce ASCVD risk in those most likely to benefit.

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• Nonstatin therapies do not provide acceptable ASCVD risk reduction benefits compared to their potential for adverse effects in the routine prevention of ASCVD

Medications Used For Hyperlipidemia

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Statins

• Statins (also called HMG‐CoA reductase inhibitors) block an enzyme called HMG‐CoA reductase (3‐hydroxy‐3‐methylglutaryl coenzyme A reductase) that is involved in the synthesis of mevalonate, a naturally occurring substance that is then used by the body to make sterols, including cholesterol.

Statins

• By inhibiting this enzyme, cholesterol and LDL‐cholesterol production is decreased. Statins also increase the number of LDL receptors on liver cells, which enhances the uptake and breakdown of LDL‐cholesterol. Most of the effects of statins, including the blocking of the HMG‐CoA reductase enzyme) occur in the liver.

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Non Statin Medications

EZETIMIBECholesterol Absorption Inhibitor

• Impairs dietary and biliary cholesterol absorption at the brush border of the intestines without affecting fat‐soluble vitamins

• Reducing the pool of cholesterol absorbed from the diet results in a reduced pool of cholesterol available to the liver

• The liver in turn will up regulate the LDL receptor, trapping more LDL particles from the blood and result in a fall in measured LDL cholesterol.

Bile Acid Sequesterants

• Block bile acid in your stomach from being absorbed in your blood. Your liver then needs the cholesterol from your blood to make more bile acid.

• Colestipol (Colestid)

• Cholestyramine (Questran)

• Colesevalam (Welchol)

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PSCK9‐inhibitors

• PCSK9 binds to LDL‐receptor on the surface of hepatocytes.

• Promotes LDL‐receptor degradation within the liver.

• LDLR is the primary receptor that clears circulating LDL, therefore the decrease in LDLR levels by PCSK9 results in higher blood levels of LDL‐C

• By inhibiting PCSK9, there are more LDL‐ receptors available, which clear circulating LDL and decrease the blood levels of LDL‐C.

PSCK9‐inhibitorsEvolocumab and Alirocumab

• Given Q 2 weeks or 1X monthly SQ

• Recheck Lipids after 2 doses

• Allergic reactions: rash, eczema, erythema, urticaria

• Adverse Reactions: Diabetes, Nasopharyngitis, URI, UTI, rare myalgia, injection site reaction

PSCK9‐inhibitorsEvolocumab and Alirocumab

• Discontinuation rate similar to placebo in trials

• No dose adjustment for mild to moderate renal impairment

• Severe renal impairment or HD‐use not studied

• Reduces LDL‐C by up to 60%

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PSCK9‐inhibitors

Evolocumab (Repatha)

• 140mg SQ q 2 weeks prefilled syringe or

• 420mg SQ q monthly on body injector

• Caution if sensitive to Latex (in the cap)

• Adverse reactions: Hypersensitivity reactions, angioedema

Alirocumab (Praluent)

• 75 mg SQ q 2 weeks

• 150mg SQ q 2 weeks

• No Latex in packaging

PSCK9‐inhibitors

Fenofibrates

• Used to treat triglycerides and cholesterol

• Inhibits triglyceride synthesis and stimulates catabolism of triglyceride‐rich lipoproteins

• Use in combination with statins and Zetia may increase adverse effects

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Omega‐3 Fatty Acids

• Exact mechanism unknown

• Reduces hepatic triglyceride synthesis

• Omega‐3‐acid ethyl esters (Lovaza) 1‐2g BID

• OTC fish oils 2‐4g total EPA/DHA

Iscosapent Ethyl (Vascepa)

• Mechanism of ActionStudies suggest that EPA reduces hepatic very low‐density lipoprotein triglycerides (VLDL‐TG) synthesis and/or secretion and enhances TG clearance from circulating VLDL particles. Potential mechanisms of action include increased β‐oxidation; inhibition of acyl‐CoA:1,2‐diacylglycerol acyltransferase (DGAT); decreased lipogenesis in the liver; and increased plasma lipoprotein lipase activity.


• It is not known whether patients with allergies to fish and/or shellfish are at increased risk of an allergic reaction to VASCEPA. VASCEPA should be used with caution in patients with known hypersensitivity to fish and/or shellfish.

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• The primary endpoint was a composite first occurrence of CV Death, Nonfatal MI, Nonfatal Stroke, Coronary Revascularization, and Unstable Angina Requiring Hospitalization (5‐point MACE)


• The secondary endpoint was a composite first occurrence of CV Death, Nonfatal MI, and Nonfatal Stroke (3‐point MACE)


• Median percent change in TG for VASCEPA 4 g/d compared to placebo was ‐19.7%. Median percent change in LDL‐C for VASCEPA 4 g/d compared to placebo was ‐6.6%

• For those with very high triglycerides, 33% reduction in TG without raising LDL‐C vs. placebo (MARINE trial)

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• Adverse events (AE) and serious adverse event (SAE) rates leading to study drug discontinuation were similar to placebo.

• A single serious adverse event (SAE) occurred at a frequency of at least 2%, which was pneumonia (2.6% in the VASCEPA group and 2.9% in the placebo group, p=0.42)

Top 10 Take‐Home Messages

2018 Cholesterol Guidelines

Top 10 Take Home Messages

1. In all individuals, emphasize a heart‐healthy lifestyle across the life course.

A healthy lifestyle reduces atherosclerotic cardiovascular disease (ASCVD) risk at all ages. In younger individuals, healthy lifestyle can reduce development of risk factors and is the foundation of ASCVD risk reduction.

In young adults 20 to 39 years of age, an assessment of lifetime risk facilitates the clinician–patient risk discussion (see No. 6) and emphasizes intensive lifestyle efforts. In all age groups, lifestyle therapy is the primary intervention for metabolic syndrome.

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•Abdominal obesity (Waist circumference of greater than 40 inches in men, and greater than 35 inches in women)

•Triglyceride level of 150 milligrams per deciliter of blood (mg/dL) or greater

Metabolic Syndrome (need at least 3)

Metabolic Syndrome

•HDL cholesterol of less than 40 mg/dL in men or less than 50 mg/dL in women

•Systolic blood pressure (top number) of 130 millimeters of mercury (mm Hg) or greater, or diastolic blood pressure (bottom number) of 85 mm Hg or greater

• Fasting glucose of 100 mg/dL or greater

Metabolic Syndrome

• The underlying causes of metabolic syndrome include overweight and obesity, physical inactivity, genetic factors and getting older.

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Heart Healthy Lifestyle Recommendations

Emphasizes

• Intake of vegetables, fruits, whole grains, legumes

• Healthy protein sources (low‐fat dairy products, low‐fat poultry (without the skin), fish/seafood, and nuts)

• Nontropical vegetable oils

Heart Healthy Lifestyle Recommendations

• Limit intake of sweets, sugar‐sweetened beverages, and red meats.

• Engage in aerobic (moderate to vigorous intensity) physical activity 3‐4 sessions per week, lasting on average 40 minutes per session

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TOOLS WE USE TO HELP ESTABLISH RISK

LDL‐C testing

• LDL‐C is the dominant form of atherogeniccholesterol.

• 20 years and older

• Fasting or nonfasting initial testing acceptable

• If nonfasting TG >400mg/dl, get a fasting panel for accurate baseline measurement of TG and LDL

ASCVD Risk Calculators

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10 Year and Lifetime RiskWeb‐Based Calculator

•Sex•Age•Race•Total Cholesterol•HDL‐C

•Systolic Blood Pressure•Treatment for High Blood Pressure

•Diabetes•Smoking

MESA 10 year CHD Risk with Coronary Artery Calcification

This online calculator is most appropriate for patients in the 45‐85 year age range and in one of the following racial/ethnic groups: Caucasian, Chinese American, African American, or Hispanic.

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Coronary Calcium Score

Coronary Calcium Score

Why evaluate coronary calcium?

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Table 6 continued

Risk‐Enhancing Factors

Lipid/biomarkers: Associated with increased ASCVD risk

o Persistently* elevated, primary hypertriglyceridemia (≥175 mg/dL);

o If measured:

▪ Elevated high‐sensitivity C‐reactive protein (≥2.0 mg/L)

▪ Elevated Lp(a): A relative indication for its measurement is family

history of premature ASCVD. An Lp(a) ≥50 mg/dL or ≥125 nmol/L

constitutes a risk‐enhancing factor especially at higher levels of Lp(a).

▪ Elevated apoB ≥130 mg/dL: A relative indication for its measurement

would be triglyceride ≥200 mg/dL. A level ≥130 mg/dL corresponds to

an LDL‐C >160 mg/dL and constitutes a risk‐enhancing factor

▪ ABI <0.9

Lipoprotein (a) Lp(a)

• Causal association between high lipoprotein(a) [Lp(a)] and atherosclerotic cardiovascular disease–related events and mortality.

• Lp(a) testing is reasonable to refine risk assessment for ASCVD events in adults with:

• First‐degree relatives with premature ASCVD (55 y of age in men; ,65 y of age in women).

• A personal history of premature ASCVD.

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Lipoprotein (a) Lp(a)

• Primary severe hypercholesterolemia (LDL‐C >/=190 mg/dL) or suspected FH.Lp(a) testing may be reasonable in adults:

• To aid in the clinician‐patient discussion about whether to prescribe a statin in those aged 40‐75 y with borderline (5%–7.4%) 10‐y ASCVD risk.

• To identify a possible cause for a less‐than‐anticipated LDL‐C lowering to evidence‐based LDL‐C–lowering therapy.

• To use in cascade screening of family members with severe hypercholesterolemia.

• To identify those at risk for progressive VAS.

Top 10

2. In patients with clinical ASCVD, reduce low‐density lipoprotein cholesterol (LDL‐C) with high‐intensity statin therapy or maximally tolerated statin therapy.

The more LDL‐C is reduced on statin therapy, the greater will be subsequent risk reduction.

Use a maximally tolerated statin to lower LDL‐C levels by ≥50%.


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Clinical ASCVD• acute coronary syndrome (ACS)

• myocardial infarction (MI)

• stable or unstable angina

• coronary or other arterial revascularization

• stroke, transient ischemic attack (TIA)

• peripheral artery disease (PAD) including aortic aneurysm

Ira, 66 runs, golfsIntolerant to 2 statins, ezetemibe, niacin

• 07/10/2018

• Total 199

• TG 94HDL 25.00

• LDL 159

• CAC 727 (LAD 409 RCA 301)

• TM MPI 13.4 metsDuke TM 10.4 negimaging

Ira

• Repatha 140mg SQ q 2 weeks

• Total 104

• HDL 28

• LDL 72

• TG 79

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Top 10

3. In very high‐risk ASCVD, use a LDL‐C threshold of 70 mg/dL (1.8 mmol/L) to consider addition of nonstatins to statin therapy.

• Very high‐risk includes a history of multiple major ASCVD events or 1 major ASCVD event and multiple high‐risk conditions.

• In very high‐risk ASCVD patients, it is reasonable to add ezetimibe to maximally tolerated statin therapy when the LDL‐C level remains ≥70 mg/dL (≥1.8 mmol/L).

• In patients at very high risk whose LDL‐C level remains ≥70 mg/dL (≥1.8 mmol/L) on maximally tolerated statin and ezetimibe therapy, adding a PCSK9 inhibitor is reasonable, although the long‐term safety (>3 years) is uncertain and cost‐effectiveness is low at mid‐2018 list prices.


Robert 65 yo, NIDDM2, HTN, Mixed Hyperlipidemia

• 2001 TG 2330

• CAD Stents 2003, 2010, 2011

• 3/2017 with MI

– 2017 LDL 53, on Rosuvastatin 2.5 daily, Ezetimide 10, Lovaza 1gm 2 BID

– Tolerated muscle aches as he knew importance of it

Robert continued

– 7/2017 readmitted with angina and had in‐stent restenosis (ISR) got another stent.

– 8/2017 Stopped Rosuvastatin and Ezetimibe, LDL went to 114

– He felt much better off both meds– Started Evolocumab 140mg SQ every two weeks

• LDL 38 TG 336– Added Fenofibrate– Total Chol 125 LDL 59 TG 178 HDL 55

– So far, he has not returned for any further interventions

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Top 10

4. In patients with severe primary hypercholesterolemia (LDL‐C level ≥ 190 mg/dL[≥4.9 mmol/L]) without calculating 10‐year ASCVD risk, begin high‐intensity statin therapy without calculating 10‐year ASCVD risk.

•If the LDL‐C level remains ≥100 mg/dL (≥2.6 mmol/L), adding ezetimibe is reasonable

• If the LDL‐C level on statin plus ezetimibe remains ≥100 mg/dL (≥2.6 mmol/L) & the patient has multiple factors that increase subsequent risk of ASCVD events, a PCSK9 inhibitor may be considered,although the long‐term safety (>3 years) is uncertain and economic value is low at mid‐2018 list prices.


Vern 63 CAD, stents, intol to most statins

• 8/26/2019

• Lp (a) 71

• ApoB 104

• LDL‐P 1705

• Total 204

• TG 353

• HDL 32

• LDL 101 on Rosuvastatin 5mg daily

Vern 63 CAD, stents, intol to most statins

• Had been on Evoculumab, had insurance issues

• Restarted 140mg SQ Q 2 weeks

• Add Vascepa 1gm 2 tabs BID

• Reiterate diet and lifestyle

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Yelana, 30Familial Hyperlipidemia

• Father age 58 MI and CABG with Familial Hyperlipidemia

• Total Chol 360• LDL 283• TG 79

• Apo B 210• LDL‐P <3195• Lp(a) <15• hsCRP 3.2

Yelena

• Started Atorvastatin 80mg daily• Goal LDL is to reduce by >50%• Consider Ezetimibe if not to goal.• CAC offered

Katelyn, 29Familial hyperlipidemia since age 6

• Tried all statins, research study, plasmaphoresis

• Hasn’t been on anything since late teens

• Morbidly Obese BMI 47

• Insulin Resistant

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Katelyn

• 4/15/2019 Total Chol 503, LDL 413, HDL 31, TG 297

• ApoB 289

• LDL‐P >3195

• hs‐crp 16

• Lp(a) 25

• LpLPA2 259

Katelyn

• CAC was 0

• Desire for another baby is high, she is discussing with OB

• Diet not optimal

• Smokes

Katelyn

• Repatha 140mg SQ given in office

• 1 week later

• Total 368

• HDL 31

• TG 197

• LDL 298

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Lori 54 y, familial hyperlipidemia

• Prior LDL as high as 271

• Maintained for years on Atorvastatin 10mg daily

• 3/23/2019 Total chol 237

• HDL 65

• LDL 170

• TG 77

• AopB 122 LDL‐P 1672

• Lp(a) 112 CAC 5


• Increased Atorvastatin 80mg daily

• Did not tolerate

• 8/30/2019

• Total chol 219

• HDL 70

• LDL 137

• TG 59


• Carotid duplex 1‐39% bilateral

• MPI stress test negative for ischemia

• Suggested changing statin, and/or adding Ezetimibe or PCSK9 Inhibitor

• Wants to keep things the same and work on lifestyle

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Top 10

5. In patients 40 to 75 years of age with diabetes mellitus and LDL‐C ≥70 mg/dL (≥1.8 mmol/L), start moderate‐intensity statin therapy without calculating 10‐year ASCVD risk.

In patients with diabetes mellitus at higher risk, especially those with multiple risk factors or those 50 to 75 years of age, it is reasonable to use a high‐intensity statin to reduce the LDL‐C level by ≥50%.


Table 5. Diabetes‐Specific Risk Enhancers That Are Independent of Other Risk Factors in Diabetes Mellitus

Risk Enhancers

Long duration (≥10 years for type 2 diabetes mellitus (S.4.3‐20) or ≥20 years

for type 1 diabetes mellitus)

Albuminuria ≥30 mcg of albumin/mg creatinine

eGFR <60 mL/min/1.73 m2

Retinopathy

Neuropathy

ABI <0.9

Top 10

6. In adults 40 to 75 years of age evaluated for primary ASCVD prevention, have a clinician–patient risk discussion before starting statin therapy.

Risk discussion should include a review of major risk factors (e.g., cigarette smoking, elevated blood pressure, (LDL‐C), hemoglobin A1C [if indicated], and calculated 10‐year risk of ASCVD);

• the presence of risk‐enhancing factors (see No. 8); • the potential benefits of lifestyle and statin therapies; • the potential for adverse effects and drug–drug interactions; • the consideration of costs of statin therapy; and • the patient preferences & values in shared decision‐making.


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Table 8. Selected Examples of Candidates for CAC Measurement Who Might Benefit From Knowing Their CAC Score Is Zero

CAC Measurement Candidates Who Might Benefit from Knowing Their CAC

Score Is Zero

Patients reluctant to initiate statin therapy who wish to understand their

risk and potential for benefit more precisely

Patients concerned about need to reinstitute statin therapy after

discontinuation for statin‐associated symptoms

Older patients (men, 55‐80 y of age; women, 60‐80 y of age) with low

burden of risk factors who question whether they would benefit from

statin therapy

Middle‐aged adults (40‐55 y of age) with PCE‐calculated 10‐year risk of

ASCVD 5% to <7.5% with factors that increase their ASCVD risk, although

they are in a borderline risk group

Kim, 50

• Mom CABG 59

• Very faithful to heart healthy diet

• Exercises 5‐7 days a week plus golfs 2‐3 times a week

• Youngest child has elevated cholesterol

Kim, 50

• Total Chol 221• LDL 146• HDL 75• TG 59• Lp(a) 19• LDL‐P 1569• 10 year risk 1.5%• Lifetime Risk 39%• CAC 338 (LAD 331)

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Kim, 50

• Started Atorvastatin 40mg QD

• Total 156

• LDL 68

• TG 90

• TG 56

• Decided we wanted to try to be more aggressive

Kim, 50

Changed to Crestor 40mg daily

• 8/28/2019

• Total chol 153

• TG 42

• HDL 92

• LDL 53

Top 10

7. In adults 40 to 75 years of age without diabetes mellitus and with LDL‐C levels ≥70 mg/dL (≥1.8 mmol/L), at a 10‐year ASCVD risk of ≥7.5%, start a moderate‐intensity statin if a discussion of treatment options favors statin therapy.

Risk‐enhancing factors favor statin therapy (see No. 8).

If risk status is uncertain, consider using coronary artery calcium (CAC) to improve specificity (see No. 9). If statins are indicated, reduce LDL‐C levels by ≥30%, and if 10‐year risk is ≥20%, reduce LDL‐C levels by ≥50%.


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Lynn, 62 male

• 10 year risk 10.1%• Total chol 137• TG 91• HDL 34• LDL 85• Discussed intermediate risk, goal to reduce LDL

30%• Discussed CAC• He declines, PCP also gave same recommendations

Clifford, 68

• 10 year 8.9%

• Currently on Lipitor 20mg daily

• Total chol 157

• HDL 52

• TG 115

• LDL 82

Clifford, 68

• CAC 77

• Lipitor to 40mg daily

• Reported Muscle aches, had CPK drawn

• CPK 415

• Held Lipitor 3 weeks

• Went back to 20mg daily

• Repeat CPK 175

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Clifford, 68

• Will repeat CPK in 1 month

• Repeat Lipid, CPK 2 months

• Consider adding ? Zetia

• Option for PCSK9 inhibitor

Top 10

8. In adults 40 to 75 years of age without diabetes mellitus and 10‐year risk of 7.5% to 19.9% (intermediate risk), risk‐enhancing factors favor initiation of statin therapy (see No. 7).

Risk‐enhancing factors include

• family history of premature ASCVD; • persistently elevated LDL‐C levels ≥160 mg/dL (≥4.1 mmol/L); • metabolic syndrome; • chronic kidney disease;

• history of preeclampsia or premature menopause (age <40 yrs) • chronic inflammatory disorders (e.g., rheumatoid arthritis, psoriasis, or chronic HIV);

• high‐risk ethnic groups (e.g., South Asian); • persistent elevations of triglycerides ≥ 175 mg/dL (≥1.97 mmol/L);


Table 6. Risk‐Enhancing Factors for Clinician–Patient Risk Discussion

Risk‐Enhancing Factors

Family history of premature ASCVD (males, age <55 y; females, age <65 y)

Primary hypercholesterolemia (LDL‐C, 160–189 mg/dL [4.1–4.8 mmol/L); non–

HDL‐C 190–219 mg/dL [4.9–5.6 mmol/L])*

Metabolic syndrome (increased waist circumference, elevated triglycerides [>175

mg/dL], elevated blood pressure, elevated glucose, and low HDL‐C [<40 mg/dL in

men; <50 in women mg/dL] are factors; tally of 3 makes the diagnosis)

Chronic kidney disease (eGFR 15–59 mL/min/1.73 m2 with or without albuminuria;

not treated with dialysis or kidney transplantation)

Chronic inflammatory conditions such as psoriasis, RA, or HIV/AIDS

History of premature menopause (before age 40 y) and history of pregnancy‐

associated conditions that increase later ASCVD risk such as preeclampsia

High‐risk race/ethnicities (e.g., South Asian ancestry)

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Top 10

8. In adults 40 to 75 years of age without diabetes mellitus and 10‐year risk of 7.5% to 19.9% (intermediate risk), risk‐enhancing factors favor initiation of statin therapy (see No. 7).

Risk‐enhancing factors include

and, if measured in selected individuals• apolipoprotein B ≥130 mg/dL• high‐sensitivity C‐reactive protein ≥2.0 mg/L• ankle‐brachial index <0.9 and l• lipoprotein (a) ≥50 mg/dL or 125 nmol/L, especially at higher values of lipoprotein (a).

Risk‐enhancing factors may favor statin therapy in patients at 10‐year risk of 5‐7.5% (borderline risk)


Top 10

9. In adults 40 to 75 years of age without diabetes mellitus and with LDL‐C levels ≥70 mg/dL‐ 189 mg/dL (≥1.8‐4.9 mmol/L), at a 10‐year ASCVD risk of ≥7.5% to 19.9%, if a decision about statin therapy is uncertain, consider measuring CAC.

• If CAC is zero, treatment with statin therapy may be withheld or delayed, except in cigarette smokers, those with diabetes mellitus, and those with a strong family history of premature ASCVD. • A CAC score of 1 to 99 favors statin therapy, especially in those ≥55 years of age. • For any patient, if the CAC score is ≥100 Agatston units or ≥75th percentile, statin therapy is indicated unless otherwise deferred by the outcome of clinician–patient risk discussion.


Anita 69Father CAD, Brother stents at 78

Mixed HyperlipidemiaHas myalgias already

10 year ASCVD risk 10.6%

• Ezetimibe 10• Fish oil 2 tabs (hx TG 561)• 1/2019 Labs• Total chol 205• TG 129• LDL‐C 143• HDL‐C 58• Discussed Statins• Offered CAC again

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RH 71, female10 year ASCVD risk 9.9%

Total chol 249LDL‐C 143HDL‐C 100TG 65Tolerating Ezetimibe10mg daily

Hesitant about starting statinLp(a) 51hsCRP .2CAC 117Rosuvastatin 5 M‐W‐F Goal to reduce her LDL‐C by 30%

Hypertriglyceridemia• 20 years of age or older with moderate hypertriglyceridemia (fasting or nonfastingtriglycerides 175 to 499 mg/dL [1.9 to 5.6 mmol/L])

• Clinicians should address and treat lifestyle factors (obesity and metabolic syndrome), secondary factors (diabetes mellitus, chronic liver or kidney disease and/or nephrotic syndrome, hypothyroidism), and medications that increase triglycerides.

Hypertriglyceridemia

• In adults 40 to 75 years of age with severe hypertriglyceridemia (fasting triglycerides ≥500 mg/dL [≥5.6 mmol/L]) and ASCVD risk of 7.5% or higher

Reasonable to: start statin therapy

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• In adults with severe hypertriglyceridemia (fasting triglycerides ≥500 mg/dL [≥5.7 mmol/L]), and especially fasting triglycerides ≥1000 mg/dL (11.3 mmol/L)),

• Identify and address other causes of hypertriglyceridemia), and if triglycerides are persistently elevated or increasing, to further reduce triglycerides by starting or increasing statin therapy


• implementation of a very low‐fat diet, avoidance of refined carbohydrates and alcohol,

• consumption of omega‐3 fatty acids, and, if necessary to prevent acute pancreatitis, fibrate therapy.

• 1/2016 total chol 390, TG 4850

• 3/2016 total chol 137, TG 332, LDL 37

• 3/2017 total chol 544, TG 3373, HDL 32

• NIDDM2. BMI 39

• Was on Fish oil OTC, Simvastatin

Henry, 54 y/o malereferred for high triglycerides

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Henry, 54referred for high triglycerides

• Started Atorvastatin 20mg, Lovaza 1gm 2 tabs BID, fenofibrate 160 (prior to 2018 guidelines)

• Reported angina symptoms, + stress test,

• Heart cath‐ multivessel disease, Stent to RCA

Top 10

10. Assess adherence and percentage response to LDL‐C–lowering medications and lifestyle changes with repeat lipid measurement 4 to 12 weeks after statin initiation or dose adjustment, repeated every 3 to 12 months as needed.

• Define responses to lifestyle and statin therapy by percentage reductions in LDL‐C levels compared with baseline. • In ASCVD patients at very high‐risk, triggers for adding nonstatin drug therapy are defined by threshold LDL‐C levels ≥70 mg/dL (≥1.8 mmol/L) on maximal statin therapy (see No. 3).


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Henry, 54 y/o malereferred for high triglycerides

• Lost 40#, improved diet

• 6/2017 total chol 117, TG 177, HDL 32, LDL 64

• Really important to adhere to very low fat diet, (5‐10%)

Seth 44 Familial Hyperlipidemia, RA

• 1/2017

• Total chol 339

• TG 205

• HDL 43

• LDL 255

• Intolerant to statins

• Praluent 75mg Q 2 wk

• 5/2017

• Total 160

• TG 164

• HDL 47

• LDL 87

Seth 44 Familial Hyperlipidemia, RA

• 8/20/2019 Annual Follow up

• Total chol 318

• TG 174

• LDL 249

• Had stopped meds due to inconvenience of calling pharmacy for monthly shipment

• Convinced to restart, prior auth completed

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Susan 65IDDM, premature fh cadintol 5 statins, zetia, tricor

• 4/2019

• Total chol 309

• LDL‐C 181

• HDL 41

• TG 676

• LDL‐P >3195

• Lp(a) <15 (normal)

• hs‐CRP 1.2

• HbA1c 7.4

• Insulin 19

• ApoB 174

Susan 65IDDM, premature fh cadintol 5 statins, zetia, tricor

• Vascepa 1gm 2 BID

• Colestipol ( has IBS)

• PCSK9 added

• 8/2019

• Total Chol 186

• TG 613

• LDL not calc, asked for direct LDL 67

• Emphasized low fat diet, RD referral

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Special Populations

• AGE >75

• After evaluation of the potential for ASCVD risk reduction, adverse effects, and drug‐drug interactions, as well as patient frailty and patient preferences:

Age >75

•Reasonable to start moderate to high intensity statins with clinical ASCVD

•Reasonable to continue high intensity statins who are tolerating high‐intensity statin therapy

Special Populations:

• CHF

• Ischemic Cardiomyopathy

• Life expectancy >3‐5 years

• Moderate intensity statins can be considered if not already on to reduce ASCVD events

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Special Populations

Women

• Premature menopause (age <40 years)

• History of pregnancy‐associated disorders (hypertension, preeclampsia, gestational diabetes mellitus, small‐for‐gestational‐age infants, preterm deliveries), when discussing lifestyle intervention and the potential for benefit of statin therapy.

Special Populations

• Women of childbearing age who are treated with statin therapy and are sexually active should be counseled to use a reliable form of contraception.

Special Populations

• Women of childbearing age with hypercholesterolemia who plan to become pregnant should stop the statin 1 to 2 months before pregnancy is attempted

• If they become pregnant while on a statin, should have the statin stopped as soon as the pregnancy is discovered.

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Special Populations

Chronic Kidney Disease

• In adults 40 to 75 years of age with LDL‐C 70 to 189 mg/dL (1.7 to 4.8 mmol/L)

• 10‐year ASCVD risk of 7.5% or higher, CKD not treated with dialysis or kidney transplantation is a risk‐enhancing factor


• Initiation of a moderate‐intensity statin or moderate‐intensity statins combined with ezetimibe can be useful.


• In adults with advanced kidney disease that requires dialysis treatment who are currently on LDL‐lowering therapy with a statin, it may be reasonable to continue the statin.

• In adults with advanced kidney disease who require dialysis treatment, initiation of a statin is not recommended.

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Special Populations

• Adults 40 to 75 years of age with LDL‐C 70 to 189 mg/dL (1.7 to 4.8 mmol/L)

• 10‐year ASCVD risk of 7.5% or higher

• chronic inflammatory disorders and HIV

• risk discussion favor moderate‐intensity statin therapy or high‐intensity statin therapy.

Secondary Prevention

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Recommendations for Statin Therapy for ASCVD Prevention

ClinicalASCVD

LDL-C >190mg/dl

No

No

No

Age < 75 yHigh-intensity statin

Age > 75 y OR not candidatefor high-intensity statin

Moderate-intensity statin

Yes

Yes

YesHigh-intensity statin

(moderate-intensity statin if notcandidate for high-intensity statin)

DiabetesAge 40-75 y

Yes

Yes Moderate-intensity statin

Estimated 10-y ASCVD risk > 7.5%High-intensity statin

Estimated 10-y ASCVD Riskwith Pooled Cohort Equations

>7.5% est10-y ASCVD

risk andage 40-75 y

Yes Moderate-to-high intensity statinNo

ASCVD prevention benefit of statin therapy may be less clear than in other groupsConsider additional factors

Influencing ASCVD risk, drug-drugInteractions, and pt preferences

Adults age > 21 y anda candidate for statin therapy Yes

Implementation of Guidelines

Interventions to improve adherence to prescribed therapy includes:

• telephone reminders, calendar reminders

• integrated multidisciplinary educational activities


• Clinicians, health systems, and health plans should identify patients who are not receiving guideline‐directed medical therapy and should facilitate the initiation of appropriate guideline‐directed medical therapy, using multifaceted strategies to improve guideline implementation.

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• Before therapy is prescribed, a patient‐clinician discussion should take place to promote shared decision‐making and should include the potential for ASCVD risk‐reduction benefit, adverse effects, drug‐drug interactions, and patient preferences.

Thank you for attending!

Questions anytime

[email protected]

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Resources

• Cardiovascular Risk Reduction with Icosapent Ethyl for Hypertriglyceridemia January 3, 2019 N Engl J Med 2019; 380:11‐22 DOI: 10.1056/NEJMoa1812792

• National Lipid Association lipid.org

• 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Executive Summary https://www.ahajournals.org/doi/10.1161/CIR.0000000000000624

• Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes 2019 https://care.diabetesjournals.org/content/diacare/42/Supplement_1/S103.full.pdf

• Use of Lipoprotein(a) in clinical practice: A biomarker whose time has come. A scientific statement from the National Lipid Association https://www.lipid.org/sites/default/files/files/Use%20of%20Lipoprotein(a)%20in%20clinical%20practice.pdf

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