HLD Treatment and 2013 AHA ACC Guidelines
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Megan Chan, PGY-2 UHCMC 2015 Drug HMG-CoA reductase inhibitors: “Statins” Effect on LDL ↓↓↓ Effect on HDL ↑ Effect on TG ↓ Niacin (Vit B3) ↓↓ Bile acid resins: Cholestyramine Colestipol Colesvelam Cholesterol absorption blockers: Ezetimibe Fibrates: Gemfiborzil Fenofibrate Clofibrate ↓↓ ↓↓ ↓ ↑↑ Slight ↑ -- ↑ ↓ Slight ↑ -- ↓↓↓ Mechanism of Action Side Effects Inhibits rate limiting step of cholesterol precursor formation Hepatotoxicity Rhabdomyolysis (esp in combo with fibrates & niacin) Inhibits lipolysis in adipose tissue; Reduces hepatic VLDL synthesis Flushed face (vasodilation, ↓ w/ ASA) Hyperglycemia (↑ insulin resistance) Hyperuricemia Prevents intestinal reabsorption of bile acids; livers uses cholesterol to make more Bad taste GI upset ↓ absorption of fat-soluble vitamins Cholesterol gallstones Prevents cholesterol absorption in small intestine Rare ↑ LFTs Diarrhea Upregulate LPL gene ↑ TG clearance Myositis Hepatotoxicity Cholesterol gallstones (esp with bile acid resins) Drug HMG-CoA reductase inhibitors: “Statins” Effect on LDL ↓↓↓ Effect on HDL ↑ Effect on TG ↓ Niacin (Vit B3) ↓↓ Bile acid resins: Cholestyramine Colestipol Colesvelam Cholesterol absorption blockers: Ezetimibe Fibrates: Gemfiborzil Fenofibrate Clofibrate ↓↓ ↓↓ ↓ ↑↑ Slight ↑ -- ↑ ↓ Slight ↑ -- ↓↓↓ Mechanism of Action Side Effects Inhibits rate limiting step of cholesterol precursor formation Hepatotoxicity Rhabdomyolysis (esp in combo with fibrates & niacin) Inhibits lipolysis in adipose tissue; Reduces hepatic VLDL synthesis Flushed face (vasodilation, ↓ w/ ASA) Hyperglycemia (↑ insulin resistance) Hyperuricemia Prevents intestinal reabsorption of bile acids; livers uses cholesterol to make more Bad taste GI upset ↓ absorption of fat-soluble vitamins Cholesterol gallstones Prevents cholesterol absorption in small intestine Rare ↑ LFTs Diarrhea Upregulate LPL gene ↑ TG clearance Myositis Hepatotoxicity Cholesterol gallstones (esp with bile acid resins) https://classconnection.s3.amazonaws.com/121/flashcards/1042121/png/lipid_lowering_agents1364672904716.png 2013 AHA/ACC Prevention Guidelines: http://content.onlinejacc. org/article.aspx?articleid =1879710 2013 AHA/ACC Prevention Guidelines: 2013 AHA/ACC Prevention Guidelines: • • • • Online Calculator: http://cvdrisk.nhlbi.nih.gov/ Calculates patient’s risk of an MI in the next 10 years. Low risk < 10%, Intermediate risk 10-20%, High risk >20% Factors: • • • • • • • Age Gender Total Cholesterol HDL Cholesterol Smoker Systolic BP Taking any anti-hypertensive agents High-Intensity Statin Lowers LDL by ≥ 50% Atorvastatin 40-80mg Rosuvastatin 20-40mg Moderate-Intensity Statin Lowers LDL by 30% to <50% Atorvastatin 10-20mg Rosuvastatin 5-10mg Simvastatin 20-40mg Pravastatin 40-80mg Lovastatin 40mg Fluvastatin 40mg BID Low-Intensity Statin Lowers LDL by <30% Simvastatin 10mg Prvastatin 10-20mg Lovastatin 20mg LDL Reduction Atorvastatin Lovastatin Simvastatin Pravastatin Rosuvastatin 20-30% -- 20mg 10mg 20mg -- 30-40% 10mg 40mg 20mg 40mg, 80mg -- 40-45% 20mg 80mg 40mg -- 5mg 45-50% 40mg -- -- -- 10mg 50-55% 80mg -- -- -- 20mg 55-60% -- -- -- -- 40mg http://www.globalrph.com/statins 2013 AHA/ACC Prevention Guidelines Secondary Cause High LDL High TG Diet Saturated fats Weight gain Anorexia nervosa Weight gain Very low fat diets High carb diets Excessive ETOH Drugs Diuretics Glucocorticoids Amiodarone Cyclosporine Oral estrogens, tamoxifen Glucocorticoids Bile acid sequestrants Protease inhibitors Beta blockers (not carvedilol) Thiazides, Sirolimus Diseases Nephrotic syndrome Biliary obstruction Nephrotic syndrome Chronic renal failure Lipodystrophies Disorders of altered states of metabolism Hypothyroidism Obesity Pregnancy Uncontrolled DM Hypothyroidism Obesity http://circ.ahajournals.org/content/129/25_suppl_2/S1/T8.expansion.html Pregnancy • First Aid • Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(25 Pt B):2889-934. • Trevor AJ, Katzung BG, Kruidering-Hall M, et al. Katzung & Trevor’s Pharmacology Examination & Board Review, 10th ed. 2013. Mc Graw Hill. New York, NY. • Wilson PW, D'agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation. 1998;97(18):1837-47.
