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คณะแพทยศาสตรศิริราชพยาบาล มหาวิทยาลัยมหิดล
WORK SHOP: DYSLIPIDEMIAWORK SHOP: DYSLIPIDEMIA
Apiradee SriwijitkamolDivision of Endocrinology and Metabolism
Department of MedicineFaculty of Medicine Siriraj Hospiral
Case 1
25 year old womanCame for check upShe had family history of dyslipidemia.Her brother had CABG last year.PELab: CH 560, TG 340,
HDL-C 30
What is the diagnosis?A. Combined dyslipidemiaB. Familial dyslipidemiaC. Secondary dyslipidemia
Case 2
25 year old womanCame for check upShe had no family history of dyslipidemia.PE: P 60/min, myoedema +ve, diffuse
thyroid enlargement 40 gLab: CH 360, TG 240, HDL-C 30
What is the diagnosis?A. Combined dyslipidemiaB. Familial dyslipidemiaC. Secondary dyslipidemia
Case 3
35 year old manHad skin lesion as shownHe had family history of diabetes.PE: Lab: CH 260, TG 540, HDL-C 30
FPG 180, A1C 8%
What is the diagnosis?A. Combined dyslipidemiaB. Familial dyslipidemiaC. Secondary dyslipidemia
Approach to Dyslipidemia
Familial DyslipidemiaSecondary DyslipidemiaPrimary Dyslipidemia
คณะแพทยศาสตรศิริราชพยาบาล มหาวิทยาลัยมหิดล
Familial Dyslipidemia
Tendon xanthomas
Tuberous xanthomas
Xanthelasma
Corneal arcus
Signs of longstanding high LDL-C
Eruptive xanthomas Palmar xanthomas
Lipemia Retinalis
Signs of High trigeridemia
Fredrickson classification of lipid disorders
Typical lipid levelsFredericksonphenotype Lipoprotein abnormality
I
IIa
IIb
III
IV
V
Chylomicron
LDL
LDL, VLDL
Remnant of VLDL (IDL), Chylomicron
VLDL
VLDL, Chylomicron
TG
TC
TC,TG,ApoB
TC,TG
TG
TG
Chylomicron Test
•Persistent lipemia•After 12 hr fast•Place in the refrigerator (4°C) for 6-10 hour
•creamy layer: defect in chylomicron metabolism•Turbid: disorder of VLDL catabolism•Clear: disorder of LDL catabolism
Fredrickson classification of lipid disorders
Typical lipid levelsFredericksonphenotype Lipoprotein abnormality
I
IIa
IIb
III
IV
V
Chylomicron
LDL
LDL, VLDL
Remnant of VLDL (IDL), Chylomicron
VLDL
VLDL, Chylomicron
TG
TC
TC,TG,ApoB
TC,TG
TG
TG
คณะแพทยศาสตรศิริราชพยาบาล มหาวิทยาลัยมหิดล
Secondary Dyslipidemia
Secondary causes of Dyslipidemia
Diabetes mellitusAlcohol overuseChronic kidney diseaseHypothyroidismPrimary biliary cirrhosis and other cholestaticliver diseasesDrugs such as– Thiazides– β-blockers– Retinoids– highly active antiretroviral agents– estrogen and progestins– glucocorticoids.
Case 1
25 year old womanCame for check upShe had family history of dyslipidemia.Her brother had CABG last year.PELab: CH 560, TG 340,
HDL-C 30
Tuberous xanthomas
What is the diagnosis?A. Combined dyslipidemiaB. Familial dyslipidemiaC. Secondary dyslipidemia
Case 2
25 year old womanCame for check upShe had no family history of dyslipidemia.PE: P 60/min, myoedema +ve, diffuse
thyroid enlargement 40 gLab: CH 360, TG 240, HDL-C 30
Diagnosis: Hypothyroidism
What is the diagnosis?A. Combined dyslipidemiaB. Familial dyslipidemiaC. Secondary dyslipidemia
Case 3
35 year old manHad skin lesion as shownHe had family history of diabetes.PE: Lab: CH 260, TG 540, HDL-C 30
Eruptive xanthoma
What is the diagnosis?A. Combined dyslipidemiaB. Familial dyslipidemiaC. Secondary dyslipidemia
Case 4
45 year old manTaxi driverFamily Hx of CVD: fatherSmoking 1 pack/yrBMI 18, WC 80BP 150/90CH 250, TG 350, HDL 50, LDL 130FPG 93
What should be treated first?A. LDL-CB. TriglyceridesC. HDL-C
Case 5
45 year old manTeacherBMI 30, BP 130/90CH 380, TG 1,200, HDL 35, LDL 205FPG 180, A1C 8.0%
What should be treated first?A. LDL-CB. TriglyceridesC. HDL-C
Case 4 (again)
45 year old manTaxi driverFamily Hx of CVD: fatherSmoking 1 pack/yrBMI 18, WC 80BP 150/90CH 250, TG 350, HDL 50, LDL 130FPG 93
What is his LDL-C goal?A. 70B. 100C. 130D. 160
Case 5 (again)
45 year old manTeacherBMI 30, BP 130/90CH 380, TG 1,200, HDL 35, LDL 205FPG 180, A1C 8.0%
What is his LDL-C goal?A. 70B. 100C. 130D. 160
Case 6
45 year old manTeacherNo family history of DM or dyslipidemiaBMI 30, BP 130/90CH 240, TG 200, HDL 30, LDL 170FPG 103
What is his LDL-C goal?A. 70B. 100C. 130D. 160
คณะแพทยศาสตรศิริราชพยาบาล มหาวิทยาลัยมหิดล
NCEP GUIDELINE
Approach to the Patient at Risk for CHD
- Count risk factors;if more than 2, use Framinghamrisk score
- Rule outsecondary hyperlipidemia
11Assess the
Patient’s RiskStatus
- Determine goal LDL-C according to global risk
22
Get LDL-Cto Goal
33
Get Non HDL-Cto Goal
First Step: Risk Assessment
Multiple (2 ormore) Risk factors
That confers a Risk of 10-20% in 10 years)
HTSmokingLow HDLAgeFamily history of
premature CHD
ModMod
Zero to 1Risk factors
10-year risk < 10%
LowLow
DMPADAAASymptomatic
carotid a. diseaseMultiple risk
factors that confer a risk of >20% in 10 yearsCKD
HighHigh
CHD or CHD riskEquivalent
Note: Risk estimates were derived from the experience of the Framingham Heart Study, a predominantly Caucasian population in Massachusetts, USA.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
Assessing CHD Risk in MenStep 1: Age
Years Points20-34 -935-39 -440-44 045-49 350-54 655-59 860-64 1065-69 1170-74 1275-79 13
Step 2: Total Cholesterol
TC Points at Points at Points at Points at Points at(mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79
<160 0 0 0 0 0160-199 4 3 2 1 0200-239 7 5 3 1 0240-279 9 6 4 2 1≥280 11 8 5 3 1
HDL-C(mg/dL) Points
≥60 -150-59 040-49 1<40 2
Step 3: HDL-Cholesterol
Systolic BP Points Points(mm Hg) if Untreated if Treated
<120 0 0120-129 0 1130-139 1 2140-159 1 2≥160 2 3
Step 4: Systolic Blood Pressure
Step 5: Smoking Status
Points at Points at Points at Points at Points atAge 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79
Nonsmoker 0 0 0 0 0Smoker 8 5 3 1 1
AgeTotal cholesterolHDL-cholesterolSystolic blood pressureSmoking statusPoint total
Step 6: Adding Up the Points
Point Total 10-Year Risk Point Total 10-Year Risk<0 <1% 11 8%0 1% 12 10%1 1% 13 12%2 1% 14 16%3 1% 15 20%4 1% 16 25%5 2% ≥17 ≥30%6 2%7 3%8 4%9 5%
10 6%
Step 7: CHD Risk
ATP III Framingham Risk Scoring
Point Total 10-Year Risk Point Total 10-Year Risk<9 <1% 20 11%9 1% 21 14%
10 1% 22 17%11 1% 23 22%12 1% 24 27%13 2% ≥25 ≥30%14 2%15 3%16 4%17 5%18 6%19 8%
Assessing CHD Risk in Women
Note: Risk estimates were derived from the experience of the Framingham Heart Study, a predominantly Caucasian population in Massachusetts, USA.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
Step 1: Age
Years Points20-34 -735-39 -340-44 045-49 350-54 655-59 860-64 1065-69 1270-74 1475-79 16
TC Points at Points at Points at Points at Points at(mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69Age 70-79
<160 0 0 0 0 0160-199 4 3 2 1 1200-239 8 6 4 2 1240-279 11 8 5 3 2≥280 13 10 7 4 2
HDL-C(mg/dL) Points
≥60 -150-59 040-49 1<40 2
Step 3: HDL-Cholesterol
Systolic BP Points Points(mm Hg) if Untreated if Treated
<120 0 0120-129 1 3130-139 2 4140-159 3 5≥160 4 6
Step 4: Systolic Blood Pressure
Step 5: Smoking Status
Points at Points at Points at Points at Points atAge 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79
Nonsmoker 0 0 0 0 0Smoker 9 7 4 2 1
AgeTotal cholesterolHDL-cholesterolSystolic blood pressureSmoking statusPoint total
Step 6: Adding Up the Points
Step 7: CHD Risk
Step 2: Total Cholesterol
ATP III Framingham Risk Scoring
First Step: Risk Assessment
Multiple (2 ormore) Risk factors
That confers a Risk of 10-20% in 10 years)
HTSmokingLow HDLAgeFamily history of
premature CHD
ModMod
Zero to 1Risk factors
10-year risk < 10%
LowLow
DMPADAAASymptomatic
carotid a. diseaseMultiple risk
factors that confer a risk of >20% in 10 yearsCKD
HighHigh
CHD or CHD riskEquivalent Moderate
10-year risk < 10%
Moderately high10-year risk 10-20%
Very highCombinations
Approach to the Patient at Risk for CHD
- Count risk factors;if more than 2, use Framinghamrisk score
- Rule outsecondary hyperlipidemia
11Assess the
Patient’s RiskStatus
- Determine goal LDL-C according to global risk
22
Get LDL-Cto Goal
or optional
100 mg/dL*
or optional
70 mg/dL*
NCEP ATP III: LDL-C Goals (2004 Modifications)
Grundy SM et al. Circulation 2004;110:227-239.
High Risk
CHD or CHD risk equivalents
(10-yr risk >20%)
LD
L-C
level
100
160
130
190
Lower Risk
< 2 risk factors
Moderately High Risk
≥ 2 risk factors
(10-yr risk 10-20%) goal
160mg/dL
goal
130mg/dL
70 -
goal
100 mg/dL
Moderate Risk
≥ 2 risk factors
(10-yr risk <10%)
goal
130 mg/dL
Existing LDL-C goals
Proposed LDL-C goals
Approach to the Patient at Risk for CHD
- Count risk factors;if more than 2, use Framinghamrisk score
- Rule outsecondary hyperlipidemia
11Assess the
Patient’s RiskStatus
- Determine goal LDL-C according to global risk
22
Get LDL-Cto Goal
33
Get Non HDL-Cto Goal
Non-HDL-C: Secondary Target after LDL-C
Non-HDL-Cholesterol
= (Total Cholesterol)-(HDL-Cholesterol)
Goal = (goal of LDL-Cholesterol) + 30 mg/dl
Case 4 (again)
45 year old manTaxi driverFamily Hx of CVD: fatherSmoking 1 pack/yrBMI 18, WC 80BP 150/90CH 250, TG 350, HDL 50, LDL 130FPG 93
Note: Risk estimates were derived from the experience of the Framingham Heart Study, a predominantly Caucasian population in Massachusetts, USA.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
Assessing CHD Risk in MenStep 1: Age
Years Points20-34 -935-39 -440-44 045-49 350-54 655-59 860-64 1065-69 1170-74 1275-79 13
Step 2: Total Cholesterol
TC Points at Points at Points at Points at Points at(mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79
<160 0 0 0 0 0160-199 4 3 2 1 0200-239 7 5 3 1 0240-279 9 6 4 2 1≥280 11 8 5 3 1
HDL-C(mg/dL) Points≥60 -1
50-59 040-49 1<40 2
Step 3: HDL-Cholesterol
Systolic BP Points Points(mm Hg) if Untreated if Treated
<120 0 0120-129 0 1130-139 1 2140-159 1 2≥160 2 3
Step 4: Systolic Blood Pressure
Step 5: Smoking Status
Points at Points at Points at Points at Points atAge 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79
Nonsmoker 0 0 0 0 0Smoker 8 5 3 1 1
AgeTotal cholesterolHDL-cholesterolSystolic blood pressureSmoking statusPoint total
Step 6: Adding Up the Points
Point Total 10-Year Risk Point Total 10-Year Risk<0 <1% 11 8%0 1% 12 10%1 1% 13 12%2 1% 14 16%3 1% 15 20%4 1% 16 25%5 2% ≥17 ≥30%6 2%7 3%8 4%9 5%
10 6%
Step 7: CHD Risk
ATP III Framingham Risk Scoring
or optional
100 mg/dL*
or optional
70 mg/dL*
NCEP ATP III: LDL-C Goals (2004 Modifications)
Grundy SM et al. Circulation 2004;110:227-239.
High Risk
CHD or CHD risk equivalents
(10-yr risk >20%)
LD
L-C
level
100
160
130
190
Lower Risk
< 2 risk factors
Moderately High Risk
≥ 2 risk factors
(10-yr risk 10-20%) goal
160mg/dL
goal
130mg/dL
70 -
goal
100 mg/dL
Moderate Risk
≥ 2 risk factors
(10-yr risk <10%)
goal
130 mg/dL
Existing LDL-C goals
Proposed LDL-C goals
What is his LDL-C goal?A. 70B. 100C. 130D. 160
Case 5 (again)
45 year old manTeacherBMI 30, BP 130/90CH 380, TG 1,200, HDL 35, LDL 205FPG 180, A1C 8.0%
or optional
100 mg/dL*
or optional
70 mg/dL*
NCEP ATP III: LDL-C Goals (2004 Modifications)
Grundy SM et al. Circulation 2004;110:227-239.
High Risk
CHD or CHD risk equivalents
(10-yr risk >20%)
LD
L-C
level
100
160
130
190
Lower Risk
< 2 risk factors
Moderately High Risk
≥ 2 risk factors
(10-yr risk 10-20%) goal
160mg/dL
goal
130mg/dL
70 -
goal
100 mg/dL
Moderate Risk
≥ 2 risk factors
(10-yr risk <10%)
goal
130 mg/dL
Existing LDL-C goals
Proposed LDL-C goals
What is his LDL-C goal?A. 70B. 100C. 130D. 160
Case 6
45 year old manTeacherNo family history of DM or dyslipidemiaBMI 30, BP 130/90CH 240, TG 200, HDL 30, LDL 170FPG 103
New Criteria for Diagnosis MSNCEP, IDF, AHA
3 out of 5Diagnosis
< 40 (M)or 50 (F)
HDL-C (mg/dl)> 150TG (mg/dl)
> 130/85BP (mmHg)100FPG (mg/dl)
WC >90 (M)or 80 (F)
Obesity
Criteria
Alberti KG. Circulation. 2009;120:1640.
Metabolic syndrome increase risk of cardiovascular events regardless of Framingham risk score
Girman CJ, et al. Am J Cardiol. 2004;93:136-141.
First Step: Risk Assessment
Multiple (2 ormore) Risk factors
That confers a Risk of 10-20% in 10 years)
HTSmokingLow HDLAgeFamily history of
premature CHD
ModMod
Zero to 1Risk factors
10-year risk < 10%
LowLow
DMPADAAASymptomatic
carotid a. diseaseMultiple risk
factors that confer a risk of >20% in 10 yearsCKD
HighHigh
CHD or CHD riskEquivalent Moderate
10-year risk < 10%
Moderately high10-year risk 10-20%
Very highCombinations
What is his LDL-C goal?A. 70B. 100C. 130D. 160
Case 4 (again again)
45 year old manTaxi driverFamily Hx of CVD: fatherSmoking 1 pack/yrBMI 18, WC 80BP 150/90CH 250, TG 350, HDL 50, LDL 130FPG 93
What is the management?A. Lifestyle modificationB. StatinC. FibratesD. Ezetimibe
Case 5 (again again)
45 year old manTeacherBMI 30, BP 130/90CH 380, TG 1,200, HDL 35, LDL 205FPG 180, A1C 8.0%
What is the management?A. Lifestyle modificationB. StatinC. FibratesD. Ezetimibe
Case 6 (again)
45 year old manTeacherNo family history of DM or dyslipidemiaBMI 30, BP 130/90CH 240, TG 200, HDL 30, LDL 170FPG 103
What is the management?A. Lifestyle modificationB. StatinC. FibratesD. Ezetimibe
คณะแพทยศาสตรศิริราชพยาบาล มหาวิทยาลัยมหิดล
Management of Dyslipidemia
• Reinforce reductionin saturated fat andcholesterol
• Consider addingplant stanols/sterols
• Increase fiber intake• Consider referral to
a dietitian
• Initiate Tx forMetabolicSyndrome
• Intensify weightmanagement &physical activity
• Consider referral to a dietitian
6 wks 6 wks Q 4-6 mo
• Emphasizereduction insaturated fat &cholesterol
• Encouragemoderate physicalactivity
• Consider referral toa dietitian
Visit IBegin LifestyleTherapies
Visit 2Evaluate LDLresponseIf LDL goal notachieved, intensifyLDL-Lowering Tx
Visit 3Evaluate LDLresponseIf LDL goal notachieved, consideradding drug Tx
A Model of Steps in Therapeutic Lifestyle Changes
MonitorAdherenceto TLC
Visit N
All Dietary Recommendations
Nutrient Recommended Intake
Saturated fat* <7% of total calories
Polyunsaturated fat Up to 10% of total calories
Monounsaturated fat Up to 20% of total calories
Total fat 25% - 35% of total calories
Carbohydrate (esp. complex carbs) 50% - 60% of total calories
Fiber 20 – 30 g/d
Protein ~15% of total calories
Cholesterol <200 mg/d
*Trans fatty acids also raise LDL-C and should be kept at a low intake.Note: Regarding total calories, balance energy intake and expenditure to maintain desirable body weight
New Options to Lower LDL-C
Avoid
− Trans fatty acids*
Add
− Dietary fiber
− Plant sterol/stanol ester margarines
Expert Panel. JAMA. 2001;285:2486-2497.
*Keep trans fatty acids low
Trans fat
8 grams
5 grams
7 grams
42 grams: trans fat 3 grams
A
B
C
D
Fat•Fat 1 portion = 45 Calories
•1 portion = 1 teaspoon or 5 grams
•Example of 1 portion:
•Oil 1 teaspoon
•Peanut 10 grains
•Fried bacon 1 piece
Fats
↑ LDL and ↓ HDLMost margarines; partially hydrogenated vegetable oil; deep-fried chips; many fast foods; most commercial baked goods
Trans
↑ LDL and HDLWhole milk, butter, cheese, and ice cream; red meat; chocolate; coconuts, coconut milk, and coconut oil
Saturated
↓ LDL; ↑ HDLCorn, soybean, safflower, and cottonseed oils; fish
Polyunsaturated
↓ LDL; ↑ HDLOlives oil, canola oil, peanut oil; cashews, almonds, peanuts, and most other nuts; avocados
Monounsaturated
Effects on lipid profiles
SourceType of fat
Dietary Adjuncts
TLC for patients with LDL-C = 160
Walden CE, et al. Arterioscler Thromb Vasc Biol. 1997;17:375-382.Jenkins DJ, et al. Curr Opin Lipidol. 2000;11:49-56.Cato N. Stanol meta-analysis. Personal communication, 2000.
––3636TotalTotal
––1616Plant Plant stanolsstanols/sterols (2 g/d)/sterols (2 g/d)
––88Viscous fiber (10Viscous fiber (10––25 g/d)25 g/d)
––1212Low saturated fat/dietary Low saturated fat/dietary cholesterolcholesterol
LDLLDL--C C ↓↓ (mg/(mg/dLdL))Dietary ComponentDietary Component
Case 4 (again again)
45 year old manTaxi driverFamily Hx of CVD: fatherSmoking 1 pack/yrBMI 18, WC 80BP 150/90CH 250, TG 350, HDL 50, LDL 130FPG 93
LDL-C goal = 100
What is the management?A. Lifestyle modificationB. StatinC. FibratesD. Ezetimibe
Drug Class MechanismInterfere with cholesterol synthesis, upregulate LDL receptors, reduce VLDL-C, increase HDL-C, reduce non–HDL-C
Reduces VLDL-C production, decreases uptake of HDL-C
Activate PPARα, increase lipoprotein lipase activity, decrease VLDL-C production
Statins
Niacin
Fibrates
Prevent reabsorption of bile acids, upregulate LDL receptors
Bile-acid binding resins
Cholesterol absorption inhibitors
Selectively inhibit intestinal cholesterol absorption
Medications for treatment ofDyslipidemia
Adapted from Gotto AM Jr. Management of lipid and lipoprotein disorders. In: Gotto AM Jr, Pownall HJ, eds. Manual of Lipid Disorders. Baltimore: Williams & Wilkins; 1992; Rubins HB, et al. N Engl J Med. 1999;341:410-418.* Adapted from NCEP ATP III. Circulation. 2002;106:3143-3421.
Resins ↓ 20%
Nicotinic acid ↓ 25%
Fibrates ↓ 15%
Statins ↓ 15%–60%
Selective cholesterol —absorption inhibitor*
Drug Class TC LDL HDL TG
Variable
↓ 20%–50%
↓ 20%–50%
↓ 10%–40%
No change
↑ 3%–5%
↑ 15%–35%
↑ 6%–15%
↑ 3%–15%
↑ 4%–9%
↓10%–20%
↓10%–15%
Variable
↓ 20%–60%
↓ 15%–20%
Effects on lipid profiles
Case 5 (again again)
45 year old manTeacherBMI 30, BP 130/90CH 380, TG 1,200, HDL 35, LDL 205FPG 180, A1C 8.0%
LDL-C goal = 100
What is the management?A. Lifestyle modificationB. StatinC. FibratesD. Ezetimibe
Case 6 (again)
45 year old manTeacherNo family history of DM or dyslipidemiaBMI 30, BP 130/90CH 240, TG 200, HDL 30, LDL 170FPG 103
LDL-C goal = 100
What is the management?A. Lifestyle modificationB. StatinC. FibratesD. Ezetimibe
Case 6 (again again)
45 year old manTeacherBMI 30, BP 130/90CH 240, TG 200, HDL 30, LDL 170FPG 103
•He was prescribed simvastatin 20 mg/d•2-month later, he complaint muscle painat his arm and thigh that he’s never experienced before•His CPK is normal
What should you do?A. Prescribed muscle relaxant + NSAIDSB. Reduced dose of simvastatinC. Stop simvastatinD. Change to gemfibrozil
Side Effects of Approved Drug Classes for Treating Dyslipidemia
Piepho RW. Am J Cardiol. 2000;86(suppl):35L-40L.
GI effects/discomfort < 5% GI problems < 6% ↑ Liver enzymes < 2% ↑ Liver enzymes ≤ 5%Myopathy < 0.3% Gallstones < 2%
Myopathy ~ 0.2%
(cholestyramine and colestipol)Flushing up to 90% Constipation ~ 30%Itching ~ 40% Heartburn ~ 20%Hyperglycemia ~ 8% Bloating ~ 10%Hyperuricemia ~ 5% Nausea ~ 10%Hepatitis < 1%
Statins Fibrates
Niacin SR Formulation Bile-Acid Binding Resins
Selective Cholesterol Absorption Inhibitor
Drug interaction with Statin
FibratesCyclosporinAzole antifungiMacrolide antibioticVerapamilHIV protease inhibitorsAmiodarone
Case 6 (again again)
45 year old manTeacherBMI 30, BP 130/90CH 240, TG 200, HDL 30, LDL 170FPG 103
•He was prescribed simvastatin 20 mg/d•2-month later, he complaint muscle painat his arm and thigh that he’s never experienced before•His CPK is normal
What should you do?A. Prescribed muscle relaxant + NSAIDSB. Reduced dose of simvastatinC. Stop simvastatinD. Change to gemfibrozil
Conclusion
Management of Dyslipidemia– Type of dyslipidemia– First Treat LDL-C, except TG > 1000– What is LDL-C goal?– Lifestyle modification always– Consider proper lipid lowering agents– Drugs interaction?– Side effects?
คณะแพทยศาสตรศิริราชพยาบาล มหาวิทยาลัยมหิดล
Question???