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Managing Multiple Diseases: Hyperlipidemia : 

Managing Multiple Diseases: Hyperlipidemia Joanne J. Orrick, PharmD, BCPS Clinical Assistant Professor University of Florida Faculty, Florida/Caribbean AIDS Education and Training Center

Hyperlipidemia Guidelines : 

Hyperlipidemia Guidelines Third Report of the Expert Panel on the Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm

Hyperlipidemia Guidelines : 

Hyperlipidemia Guidelines Guidelines for the Evaluation and Management of Dyslipidemia in HIV-Infected Adults Receiving ARV Therapy: Recommendations of HIVMA of IDSA and the Adult AIDS Clinical Trials Group. Clinical Infectious Diseases 2003;37:613-27. http://www.idsociety.org/HIVMA_Template.cfm?Section=HIVMA_HIV_AIDS_Practice_Guidelines

Patient Case : 

Patient Case KB is a 53-year-old male who presents to your office for a routine follow up. He has been HIV-infected for the past 2 years and has been well-controlled on a regimen of Lamivudine/zidovudine (Combivir?) + lopinavir/ritonavir (Kaletra ?) CD4 438 cells/mm3, Viral load < 50 copies/mL He has not been on any other antiretrovirals besides these medications

Patient Case : 

Patient Case Past Medical History HIV x 2 years Hypertension x 5 years Depression x 3 years Family History Mother deceased at age 67 due to breast cancer Father deceased at age 51 due to MI

Patient Case : 

Patient Case Social History Smokes cigarettes 2 packs per day Denies use of street drugs Drinks alcohol occasionally Medications Citalopram 20 mg po qd Lisinopril 20 mg po qd Lamivudine/zidovudine 150/300 mg po bid Lopinavir/ritonavir 400/100 mg po bid

Patient Case : 

Patient Case BP 158/85, P 74, RR 18, Height 5'10", Weight 211 lbs Comprehensive metabolic panel is within normal limits

Lipid Panel : 

Lipid Panel Labs (fasting, 2 week prior to visit), mg/dL: Cholesterol 233 Triglycerides 195 HDL 38 LDL 158 Labs (fasting, prior to initiation of ARVs), mg/dL: Cholesterol 175 Triglycerides 98 HDL 35 LDL 110

Question 1 : 

Question 1 How many major heart disease risk factors does this patient have? 2 3 4 5 6

Major Risk Factors That Modify LDL Goals : 

Major Risk Factors That Modify LDL Goals Cigarette smoking Hypertension (BP ? 140/90 mmHg or on antihypertensive medication) Low HDL cholesterol (< 40 mg/dL)† Family history of premature CHD CHD in male first degree relative < 55 years CHD in female first degree relative < 65 years Age (men ? 45 years; women ? 55 years) † HDL cholesterol ?60 mg/dL counts as a “negative” risk factor; its presence removes one risk factor from the total count.

Question 2 : 

Question 2 What is the patient’s 10 year risk of developing CHD according to the Framingham Risk Assessment? 5 10 20 25 = 30

Major Risk Factors That Modify LDL Goals : 

Major Risk Factors That Modify LDL Goals

Estimate of 10-year Risk : 

Estimate of 10-year Risk

Question 3 : 

Question 3 What is the minimum LDL goal for this patient? < 160 < 130 < 100

Coronary Heart Disease or Risk Equivalents : 

Coronary Heart Disease or Risk Equivalents Coronary heart disease (CHD) CHD Risk Equivalents Symptomatic carotid artery disease Peripheral arterial disease Abdominal aortic aneurysm Diabetes mellitus

LDL-Cholesterol Goals by Risk : 

Risk Category CHD and CHD riskequivalents Multiple (2+) risk factors Zero to one risk factor LDL Goal (mg/dL) <100 <130 <160 LDL-Cholesterol Goals by Risk

Question 4 : 

Question 4 How would you initially manage this patient’s hyperlipidemia? Change antiretrovirals and initiate TLC Initiate TLC Initiate TLC and drug therapy Initiate drug therapy

LDL-Cholesterol Goals by Risk : 

LDL-Cholesterol Goals by Risk

Progression of Drug Therapy in Primary Prevention : 

Progression of Drug Therapy in Primary Prevention

Question 5 : 

Question 5 After 8 weeks of the TLC, the patient is not at his LDL goal, which drug class of drugs would you initiate? Fibrate Niacin Statin Bile acid sequestrant

Drug Therapy : 

Drug Therapy

HMG CoA Reductase Inhibitors (Statins) : 

? LDL-C 18–55% ? TG 7–30% ? HDL-C 5–15% Major side effects Myopathy Increased liver enzymes Contraindications Absolute: liver disease Relative: use with certain drugs HMG CoA Reductase Inhibitors (Statins)

Statins : 

Statins *Florida Medicaid Formulary

Statins : 

Statins *Florida Medicaid Formulary

Statin Drug Interactions : 

Statin Drug Interactions Lovastatin, Simvasatin > Atorvastatin are dependent on CYP3A4 metabolism Lovastatin and Simvastatin are contraindicated with protease inhibitors Use pravastatin, fluvastatin, or low-dose atorvastatin Rosovastatin?

Fibrates : 

Fibrates Major actions ? LDL-C 5–20% (with normal TG) May ? LDL-C (with high TG) ? TG 20–50% ? HDL-C 10–20% Side effects: dyspepsia, gallstones, myopathy Contraindications: Severe renal or hepatic disease

Fibrates : 

Fibrates *Florida Medicaid Formulary

Fibrates-Drug Interactions : 

Fibrates-Drug Interactions Increased risk of rhabdomyolysis when used with statins-use with caution! Decrease max doses of statins Ex: Rosuvastatin 5 mg qd Simvastatin 10 mg qd ? ezetimibe levels-? Clinical significance

Fibrates : 

Fibrates

Nicotinic Acid : 

Nicotinic Acid Major actions ? LDL-C 5–25% ? TG 20–50% ? HDL-C 15–35% Side effects: flushing, hyperglycemia, hyperuricemia, upper GI distress, hepatotoxicity Contraindications: liver disease, severe gout, peptic ulcer

Nicotinic Acid : 

Nicotinic Acid *Florida Medicaid Formulary

Management of Low HDL : 

Management of Low HDL LDL cholesterol is primary target of therapy Weight reduction and increased physical activity (if the metabolic syndrome is present) Non-HDL cholesterol is secondary target of therapy (if triglycerides ?200 mg/dL) Consider nicotinic acid or fibrates (for patients with CHD or CHD risk equivalents)

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