Hyperlipidemia
Introduction
Hyperlipidemia is frequently encountered in routine screening and physical exams.
All adults over the age of 20 should have a random total cholesterol blood test. A total cholesterol less than 200 mg/dl is desirable, 201-239 mg/dl is borderline and
greater than 240 mg/dl is considered high. Patients with desirable levels should be
counseled on prudent diet and risk factor modification to maintain a low risk for
cardiovascular disease. Total cholesterol
should be measured every 5 years. Patients with
a total cholesterol over 200 mg/dl should have a fasting (12-14 hours) total
cholesterol,
HDL (high density lipoprotein) cholesterol, and triglycerides measured. The LDL (low
density lipoprotein) cholesterol in routine measurement is a value calculated as follows: total cholesterol - HDL -
(TRIG/5). This is accurate if the triglyceride level is less
than 400 mg/dl). A desirable triglyceride level is < 200 mg/dl.
Risk factors for coronary heart
disease
The patient should be screened and questioned for symptoms or history of known
coronary artery disease (CAD) (angina, myocardial infarction) and risk factors for CAD
(coronary artery disease): smoking, male gender, first degree relatives with CAD under age
55, diabetes mellitus, hypertension (> 140/90 mm Hg), symptoms of peripheral vascular
disease (PVD), history of CVA/TIA, obesity (> 30 percent ideal body weight (IBW), and
HDL < 35 mg/dl. This information is important for therapeutic decisions. Additionally,
secondary and potentially correctable causes of hyperlipidemia should be sought including
diabetes mellitus, hypothyroidism, renal failure, nephrotic syndrome, alcohol abuse, and
liver disease. Certain drugs (thiazide diuretics, beta blockers, and glucocorticoids) can
also elevate cholesterol.
Physical exam and laboratory studies
On physical examination, note the blood pressure, peripheral pulses, weight, tendon
or eruptive xanthoma, or xanthelasma and abdominal/peripheral bruits. Examine the eyes for
findings of diabetes or hypertension. Laboratory studies may include thyroid function
studies (including TSH), BUN, creatinine, liver function
tests, urinalysis, and fasting
blood glucose. Therapy is goal-directed. In the absence of CAD, and with one of the above
risk factors for CAD, the patient's target LDL is < 160 mg/dl. With CAD or two or more
risk factors the goal LDL is < 130 mg/dl. If the patient has known CAD or PVD
(peripheral vascular disease), the ideal LDL
should be even lower; 100 to 130 mg/dl.
Table 1
Drug |
Starting
Dose |
Maximum
Dose |
Primary
Side Effects |
Primary
Contraindications |
Monitoring |
Comments |
HMG CoA Reductase Inhibitors |
|
Fluvastatin |
20 mg QD |
40 mg QD |
GI Discomfort |
Liver
Disease, Pregnancy or lactation, use of Niacin or Gemfibrozil. Drug interaction with
erythromycin and cyclosporine. |
LFTs, CPK, BUN creatinine, uric acid if symptoms Consistent with Myositis |
Avoid
in females of childbearing age. If used, discontinue when pregnancy is contemplated. Well
tolerated for mild hypercholesterolemia. Simvastatin is the most potent on a milligram
basis. |
Pravastatin |
10 mg QD |
40 mg QD |
Hepatitis |
Lovastatin |
10 mg QD |
80 mg QD |
Myositis |
Simvastatin |
10 mg QD |
80 mg QD |
GI Discomfort |
Nicotinic Acid (Vitamin B3) |
|
Nicotinic
Acid
(Niacin) |
250-500 mg BID
however, lower dosages can be used |
1 gm TID |
Flushing,
nausea, hepatitis, gout exacerbation, worsened
glucose control in diabetics |
DM, peptic
ulcer disease, gout, liver disease, use of lovastatin/simvastatin |
LFTs, uric acid, glucose in appropriate clinical situations. |
Rx ASA 325 mg
30' before niacin, low
starting dose and gradual increase in daily dose can all decrease
flushing. Sustained release
preparations may cause hepatitis. |
Bile Acid Sequestrants |
|
Cholestyramine
(Questran, Questran Light) |
4 gm QD or BID |
8 gm TID |
GI -
constipation, bloating, gas |
Relatively
contraindicated with increased triglycerides |
May need to
adjust co-administered drugs |
Take other
meds 1 hour before & 4-6 hrs after resin. Sour juices (e.g., grapefruit) may increase
palatability. Can combine with any other anti-lipid drug class. |
Colestipol
(Colestid) |
5 gm QD or BID |
10 gm TID |
Fibric Acid Derivatives |
|
Gemfibrozil
(Lopid) |
600 mg BID |
600 mg BID |
Hepatitis,
GI, rash, gallstones |
Lovastatin
use, hepatic or severe renal dysfuction, gallstones |
LFTs |
Limit use to
patients with severe hypertriglyceridemia. Not recommended for routine
hypercholesterolemia. Interacts
coumadin - increases PT. |
Treatment recommendations
Therapy centers around diet. The Step One diet (total fat intake < 30 percent of
total calories, saturated fats < 10 percent and total cholesterol < 300 mg/day) is
prescribed. Numerous references are available to guide both the physician and patient.
Emphasize that diet, not medication, is the mainstay of therapy, requiring a permanent
lifestyle modification. Sensitive, but persistent, work with the supply officer can help
lower dietary fat and cholesterol not only for an individual patient, but also for the
whole crew. The services of a registered dietitian, where available, prove invaluable.
When the Step One diet is insufficient, and before the addition of medical therapy,
dietary consultation (for the more rigid, Step Two, dietary management) is mandatory.
Treatment also involves risk factor reduction. Smoking must cease. Regular exercise should
be encouraged since this raises HDL
and lowers weight and blood pressure. Hypertension
should be aggressively treated. Before prescribing an anti-lipid drug, secondary causes of
hyperlipidemia should be treated, and if the patient is taking a medication that could
cause hyperlipidemia, consideration should be made to changing the drugs, if possible.
Retest the lipid panel in 8 to 12 weeks after any therapeutic changes. These steps may
allow the patient to achieve his or her target LDL
level without additional drugs.
Medications
Medications (see table 1) are added to, not substituted for treatment if
the above target LDL levels are not met after a 6 month trial of diet and exercise,
provided the patient is not high risk. Long-term follow-up is vital, as side effects may
be significant (and asymptomatic) and patient motivation may wane. Contact the nearest
internal medicine, endocrinology, or cardiology service for assistance in the specifics of
evaluation and treatment of hyperlipidemia. Patients who require more than diet and one
medication, who have secondary causes not readily evaluated or managed at the GMO level,
or who are suspected of having CAD should be referred.
Reference
- National Cholesterol Education Program. (Adult Treatment Panel 11.) Summary of the
Second Report of the National Cholesterol Education Program Expert Panel on Detection,
Evaluation and Treatment of High Blood Cholesterol in Adults. JAMA 1993; 269:3015-3023.
Revised by CAPT K.M. Shakir, MC, USN, Endocrinology & Metabolism Division,
National Naval Medical Center, Bethesda, MD (1999).
|
Preface
· Administrative Section
· Clinical Section
The
General Medical Officer Manual , NAVMEDPUB 5134, January 1, 2000
Bureau
of Medicine and Surgery, Department of the Navy, 2300 E Street NW, Washington, D.C.,
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