when to screen and when to treat

Dyslipidemia

When to Screen and When to Treat

RISK FACTORS FOR

CORONARY ARTERY DISEASE

High Cholesterol

Smoking

Obesity

Male Gender

Female Gender

• > 55 years of age or

postmenopausal

without estrogen

replacement

Hypertension

Diabetes

Low HDL < 35

Family History of CAD,

stroke, peripheral

vascular disease,

sudden death (< 55

yrs in men or < 65 yrs

in females)

Screening of Children

American Academy of Pediatrics , July, 2008

Recommendations:

All children with family history of high

cholesterol, early atherosclerosis,

unknown family history and personal risk

factors i.e. diabetes, hypertension , obesity

and metabolic syndrome

Screening of Children (part2)

Screen at 2 years of age and repeat every two to three years.

Statin Drugs should be among the first line agents.

Statin Drugs should be started at 8 to 10 years of age in children with F H , diabetics with LDL>130 mg and be considered in metabolic syndrome & obesity.

TARGET Lipid Profile for Children

TC < 170

LDL < 110

TG < 150

HDL > 45 for boys

HDL > 55 for girls

Cholesterol Particles

Screening Tests

1. Fasting Lipid Profile: TC, LDL, HDL and TG

2. Thyroid Functions

3. Liver Functions

4. Hgb A1c, glucose, insulin particularly in

Metabolic syndrome

Familial Hypercholesterolemia

1. Family History

2. TC: 250-350, LDL : 150-250

3. HDL & TG are usually normal

4. Goals are to reduce LDL to 100 and TC to

170

Metabolic Syndrome

1. Overweight:BMI >25 or >85%

Obese:BMI >30 or > 97%

2. Hypertension

3. Diabetes Mellitus,type 2

4. Acanthosis nigricans

5. Fatty liver: NASH

6. Sleep apnea

7. Endocrine abnormalities: polycystic ovary disease, gynecomastia

8. Blount disease

Metabolic Syndrome

1. Atherogenic Lipid Profile: elevated TG > 150

normal or elevated LDL & decreased HDL < 40

2. Enhanced hepatic VLDL synthesis with increase

in small LDL particle i.e. Lpa, the most atherogenic

form of LDL

3. Peripheral tissue lipprotein lipase resistance

with increase in TG

4. Goals are to reduce TG,Lpa and increase HDL

Therapeutic Lifestyle Change

Reduce sat.fat to <10% of calories

Reduce Cholesterol intake to <300 mg /day

Add in dietary adjuncts:

• Plant Stanol/sterols

• Viscous fiber

Reduce Weight

Increase physical exercise

Diet Therapy: 5% reduction LDL

Low fat/low cholesterol

Increase water soluble fibers: soya,

psyllium, cereals

Fruits/vegetable : bannanas, berries, citrus,

broccoli, brussels, sprouts, beans, peas

Oils: unsaturated, polyunsaturated, omega

3, nuts

Aerobic Exercise: 1 hour daily

Increase in HDL : 15%

Decrease in TG : 20%

Increase in lean muscle mass

Decrease in body fat

Improvement in cardiovascular fitness

Over the counter medications

A. Niacin: most effective way to increase

HDL, decrease TG & decrease Lpa

B. Plant Sterol/Stanol Esters: reduce LDL

C. Water Soluble Fiber : reduce LDL

D. Omega 3/Omega 6 Oils : reduce TG

E. Natural Statins: Red Yeast Rice

F. Aspirin: 81 mgm over 12 years

NIACIN/B3

ACTIONS- Increase HDL 20-30%,

Decrease TG 20-25%,

Decrease LpA 10-25%

Forms of Niacin/B3

1. B complex-50mg under 12 yrs, B-complex-100

over 12 yrs.

2. Liquid B complex: 20 mgm/ml, orange flavored:

dose: 2 ½ ml<12 yrs, 5 ml>12 yrs.

3. Crystalline Niacin: 100, 250 & 500 mgm

4. Sustained release Niacin: 250 & 500 mgm

5. Niaspan (prescription) : 500,750 &1000 mgm,

maximum dose: 2000 mgm

NIACIN SIDE EFFECTS/TOXICITY

Effects are related to increasing dose

(1.5-3mg)• Cutaneous Effects: flushing, pruritus, rash

• GI Effects: nausea, vomiting, diarrhea, anorexia

• Metabolic Effects: glucose, uric acid (gout) and hepatic enzymes

(> 2 gm daily)

Precautions:• Should always be taken with or after a meal

• Prophylactic salicylates and avoidance of hot beverages or soups

or strenuous exercise will help to mitigate any adverse symptoms

EFFECTS OF NIACIN

Effect on Triglycerides

• Diurnal variation in plasma triglycerides (higher at night)

• Decreases lipolysis of adipose tissue fatty acids which leads to a

release of free fatty acids for use as food

•

• Perhaps acts on hormone sensitive lipase therefore smaller

quantities of fatty acids are transported to the liver with a

resultant decrease of triglycerides, VLDL, LDL, Lpa, and total

cholesterol

EFFECTS OF NIACIN

Effect on HDL

• Scavenger receptor (SR-BI) selectively

removes cholesterol ester

• Catabolic pathway involves a “holoparticle

uptake” of HDL (Apo A1)

• Niacin increases Apo A1 and HDL by decreasing

hepatic catabolism without effecting

cholesterol ester elimination

ACTION OF NIACIN TO ELEVATE HDL

LIPID PROFILE RESPONSE

PLACEBO VS NIASPAN

RELATIONSHIP OF HDL-C LEVELS

AND CORONARY ARTERY DISEASE

PLANT STANOL/STEROL ESTERS

Benecol, Take Control Margarine(1.5-3 grams daily)

• Developed in Finland

• Combined with Canola Oil and soy in a margarine

• Lowers LDL by 10-20% without reducing HDL!

Cholestoff, tablet / capsule• One to four a day

STRUCTURE OF PLANT

STEROLS/CHOLESTEROL

Omega 3/Omega 6 Oils

Effect: 30-50% decrease in TG

Dose: 1-3 grams daily

Forms:

1. Capsule

2. liquid

3. Gel: coromga 2gm/package

4. Eggs & Milk

5. Flaxseed fiber

6. Cold water fish

7. Chocolate Omega Truffles: 2.5 gm

Natural Statin

1. Red Yeast Rice: fermented rice similar to

Mevacor in action. Produces 20-30%

reduction in LDL

2. Advantages: well tolerated, inexpensive,

OTC

3. Dose: 600-1200 mgm daily

Prescription Medications

1. Statin Drugs: reduce LDL

2. Bile Acid Sequestrants : reduce LDL

3. Fibrates: reduce TG & increase HDL

4. Cholesterol Absorption Inhibitors: Zetia

HMG Coa REDUCTASE INHIBITORS

20-60% decrease in LDL

Action: inhibits LDL production in the liver

Products

• Fluvastatin: Lescol

• Lovastatin: Mevacor

• Pravastin: Pravachol

• Simvastatin: Zocor

• Atorvastatin: Lipitor

• Rosuvastatin: Crestor

• Liver toxicity (must check liver functions periodically)

• At increasing doses may produce rhabdomyalysis, insomnia

( switching to a more powerful statin is more cost effective than

increasing the dose of the same medication)

Statin Drugs: 20-60% decrease in

LDL

Lovastatin: Mevacor: 10, 20, 40 mg: generic

Pravastatin: Pravachol: 10, 20, 40, 80 mg:

generic

Simvastatin: Zocor: 5, 10, 20, 40, 80 mg:

generic

Statin Drugs : cont.

Atorvastatin: Lipitor: 10, 20, 40, 80 mg. no

generic.

Rosouvastatin: Crestor: 5, 10, 20, 40 mg. no

generic. Increases HDL 8-12%.

Red Yeast Rice: 600 mg. OTC. Natural statin

START WITH SMALLEST DOSE & TITRATE TO

DESIRED LDL 100-110.

BILE ACID SEQUESTRANTS

Cholestyramine: Questran

Colestipol: Colestid

Colesevelam: Welchol

Binds cholesterol in the intestinal tract with a

decrease in LDL of 10-15%

Needs to be taken 2-3 times daily

May cause bloating, constipation, flatulence

Fibric Acids

Action: reduces triglycerides 30% ,LDL

10% and increases HDL 20%.

Product:

• Gemfibrozil: Lopid : 600 mgm

• Fenofibrate: Tricor : 48 & 145 mgm

Should be used cautiously in combination

with Statins.

Cholesterol Absorption Inhibitor:

Zetia

Decreases LDL 18-20%

Is metabolized in small intestine & liver

with primary biliary excretion

No pharmacologic differences in

adolescents & adults

Effective in Homozygous Familial

Hypercholesterolemia & Sitosterolemia

COMBINATION MEDICATIONS

VYTORIN: Zocor & Zetia: triples the effect of

the statin without side effects:

10/10,10/20,10/40& 10/80

Simcor: Zocor & Niaspan: 500/20, 1000/20&

2000/20

Advicor: Mevacor & Niaspan: 500/20, 750/

20, 1000/20& 1000/40

TREATMENT RECOMMENDATIONS

FOR PROFILE # 1

PROFILE

• Total cholesterol = 235

• Triglycerides = 90

• HDL = 46

• LDL = 173

TREATMENT PLAN

• Dietary Fiber

• Plant Stanol Esters

• Statin


FOR PROFILE #2

PROFILE



• HDL = 27

• LDL = 165

TREATMENT PLAN

• Dietary Fiber


• Niacin

• Omega 3/6

• Fibrate

• statin

Vytorin: Zocor & Zetia

Advantage: use smaller dose of statin drug

with the effect of tripling the dose of the

statin

Dosage: 10/10, 10/20, 10/40, 10/80


FOR PROFILE #3

PROFILE



• HDL = 39

• LDL = 243

TREATMENT PLAN

• Dietary Fiber


• Niacin

• Statin


FOR PROFILE #4

PROFILE



• HDL = 34

• LDL = NC

TREATMENT PLAN

• Dietary fiber


• Niacin

• Omega 3/6

• Fibrates

• statin

Personal Favorites

Benecol or Cholestoff

Balanced B complex 50 or 100

Omega 3/6 oils

Water soluble fiber: psyllium

Red Yeast Rice

Zocor/ Pravachol

Fenofibrates

when to screen and when to treat

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