Lipids

Lipids – Jonathan Davis

Background

  • 1º Prevention: pts  at increased risk who have not yet had a vascular event
  • 2º Prevention: pts  with pre-existing occlusive vascular disease or ASCVD (e.g., stroke, TIA, CAD + angina, ACS, coronary or arterial revascularization, PAD)
  • Screening:  USPSTF 2016 Guidelines: adults 40-75yrs
    • ACC/AHA 2018 Guideline: adults 21-75 q 4-6yrs; <21yrs  if strong fam hx

 

Evaluation

  • Fasting vs Non-Fasting Lipid Panel.
    • Triglycerides are most impacted by non-fasting testing which can artificially lower LDL-C depending on how the laboratory measures/calculates LDL. Consider fasting lipid panels when triglyceride levels are high
  • Consider 2º causes of HLD in initial workup: hypothyroidism, DM, EtOH use, smoking, liver disease, nephrotic syndrome, CKD, meds (e.g., thiazide, glucocorticoids)

 

Management

  • Lifestyle changes:
    • Heart Healthy Diet: trans/saturated fats, choose skim milk, low-fat dairy products
    • Emphasizes fruits, vegetables, whole grains, poultry, fish, nuts and olive oil, while limiting red and processed meats, sodium and sugar-sweetened foods and beverages
    • Promote a healthy weight, regular exercise, smoking cessation, limit EtOH

 

Statin Therapy

  • Initiate as outlined in the following algorithms (Note: check AST/ALT prior to initiation)

 

Lipid One

 

Lipid Two

 

High Intensity
( $LDL-C by > 50%)

Moderate Intensity
($LDL-C by 30% - 49%)

Low Intensity
($LDL-C by <30%)

Atorvastatin (40mg) 80mg*

Rosuvastatin 20mg (40mg)

Atorvastatin 10mg (20mg)

Rosuvastatin (5mg) 10mg

Simvastatin 20 - 40mg

Simvastatin 10mg

 

Pravastatin 40mg (80mg)

Lovastatin 40mg (80mg)

Fluvastatin XL 80mg

Fluvastatin 40mg BID

Pitavastatin 1-4mg

Pravastatin 10-20mg

Lovastatin 20 mg

Fluvastatin 20-40mg

*Bold denotes dosing with RTC proven LDL lowering benefit

 

Statin Side effects:

  • Myalgias: bilateral involving large muscle groups, onset within weeks of initiation of therapy and should resolve within weeks of cessation
  • Spectrum of statin associated muscle symptoms (SAMS) include myalgias, myopathy, rhabdomyolysis, autoimmune myopathy, etc.
    • Consider evaluation with CK, BMP, TSH, and vitamin D
    • ACC has a “Statin Intolerance Calculator” to help assess etiology of symptoms

 

Additional Information

  • If patient is not tolerating a statin, consider:
    • Holding statin until symptoms resolve and trialing lower dose or alternative statin (Pravastatin and Fluvastatin may have lower risks of myopathy)
    • Every other day dosing with atorvastatin and rosuvastatin (longer half-lives)
  • If repeated failed attempts, consider alternative agents: Ezetimibe 10mg daily

 

Hypertriglyceridemia:

  • Moderate: TG 175-499 mg/dL; Severe: TG > 500 mg/dL
    • Focus on addressing lifestyle factors and stopping medication that increase TG’s  (HCTZ, some BB’s, estrogens, some ART, antipsychotics)
    • Consider medical therapy when TG> 500mg/dL to $ risk of pancreatitis with:
      • Omega-3-fatty acids: 4gms daily or Vascepa 4gm daily
      • Fibrates: Fenofibrate 120mg daily (avoid in CKD), Gemfibrozil 600mg daily (increased risk of myopathy with concomitant statin)
  • PCSK9 inhibitor requires referral to Lipid Clinic

 

VA- Specific Guidelines

  • https://www.healthquality.va.gov/guidelines/cd/lipids/index.asp
  • Lowest LDL goal recognized for VA Criteria for Use is 100
  • Preferred statins: Atorvastatin, Simvastatin, Lovastatin
  • Statins that require PADR: Pravastatin, Rosuvastatin (2nd line high intensity statin)
    • Must have documented intolerances or drug-drug interaction to all preferred statins
  • Other agents that require PADR:
    • Ezetimibe
      • pt has tried and failed or not tolerated all statins (allergy, AE, etc.)
      • pt not meeting goal on max dose of statin PLUS bile acid sequestrants or niacin
    • Fenofibrate
      • Pt has tried all formulary alternatives or has contraindication to use of formulary alternatives (statin, niacin, gemfibrozil, cholestyramine, fish oil)
      • If TG > 500 mg/dL, fenofibrate should be approved