Managing Multiple Diseases: Hyperlipidemia

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Managing Multiple Diseases Hyperlipidemia

• Joanne J. Orrick, PharmD, BCPS
• Clinical Assistant Professor
• University of Florida
• Faculty, Florida/Caribbean AIDS Education and
  Training Center

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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/in
  dex.htm

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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 200337613-27.
• http//www.idsociety.org/HIVMA_Template.cfm?Sectio
  nHIVMA_HIV_AIDS_Practice_Guidelines

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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 lt 50 copies/mL
• He has not been on any other antiretrovirals
  besides these medications

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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

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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

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Patient Case

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

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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

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Question 1

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

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Major Risk Factors That Modify LDL Goals

• Cigarette smoking
• Hypertension (BP ? 140/90 mmHg or on
  antihypertensive medication)
• Low HDL cholesterol (lt 40 mg/dL)
• Family history of premature CHD
• CHD in male first degree relative lt 55 years
• CHD in female first degree relative lt 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.
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Question 2

• What is the patients 10 year risk of developing
  CHD according to the Framingham Risk Assessment?
• 5
• 10
• 20
• 25
• 30

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Major Risk Factors That Modify LDL Goals
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Estimate of 10-year Risk
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Question 3

• What is the minimum LDL goal for this patient?
• lt 160
• lt 130
• lt 100

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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

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LDL-Cholesterol Goals by Risk

• Risk Category
• CHD and CHD riskequivalents
• Multiple (2) risk factors
• Zero to one risk factor

• LDL Goal (mg/dL)
• lt100
• lt130
• lt160

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Question 4

• How would you initially manage this patients
  hyperlipidemia?
• Change antiretrovirals and initiate TLC
• Initiate TLC
• Initiate TLC and drug therapy
• Initiate drug therapy

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LDL-Cholesterol Goals by Risk
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Progression of Drug Therapy in Primary
Prevention
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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

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Drug Therapy
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HMG CoA Reductase Inhibitors (Statins)

• ? LDL-C 1855
• ? TG 730
• ? HDL-C 515
• Major side effects
• Myopathy
• Increased liver enzymes
• Contraindications
• Absolute liver disease
• Relative use with certain drugs

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Statins
Florida Medicaid Formulary
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Statins
Florida Medicaid Formulary
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Statin Drug Interactions

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

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Fibrates

• Major actions
• ? LDL-C 520 (with normal TG)
• May ? LDL-C (with high TG)
• ? TG 2050
• ? HDL-C 1020
• Side effects dyspepsia, gallstones, myopathy
• Contraindications Severe renal or hepatic disease

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Fibrates
Florida Medicaid Formulary
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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

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Fibrates
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Nicotinic Acid

• Major actions
• ? LDL-C 525
• ? TG 2050
• ? HDL-C 1535
• Side effects flushing, hyperglycemia,
  hyperuricemia, upper GI distress, hepatotoxicity
• Contraindications liver disease, severe gout,
  peptic ulcer

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Nicotinic Acid
Florida Medicaid Formulary
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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)