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Managing CAD and Hyperlipidemia in a 56-Year-Old Male with Statin Intolerance

This case study focuses on the management of a 56-year-old male with coronary artery disease (CAD), familial combined hyperlipidemia, and statin intolerance. The patient's lipid profile is stable on current medications but experiences adverse symptoms. The discussion includes risk factors, assessments, initial treatment, and management strategies.

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Managing CAD and Hyperlipidemia in a 56-Year-Old Male with Statin Intolerance

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  1. 56 Year Old Male with CAD, Familial Combined Hyperlipidemia and Statin Intolerance Case Categories Primary Prevention Secondary Prevention Pediatric Case Familial Hypertriglyceridemia Diabetes Metabolic Syndrome Low HDL Familial Combined Hyperlipidemia Familial Hypercholesterolemia Elevated Lipoprotein (a) Statin Intolerance Case category: Familial Combined Hyperlipidemia, Elevated Lipoprotein(a), Statin Intolerance History of present illness: 56 year old male with CAD and familial combined hyperlipidemia. History of statin intolerance (severe muscle aches). Lipids are stable on current medications, but he is experiencing adverse symptoms. He is motivated to improve his diet and increase exercise.

  2. Patient Information

  3. Patient History

  4. Current Medications

  5. Lipid Profile on Plavix 75, Crestor 40, Niaspan 3000, Metformin 1500, Lovaza 4 and Vitamin D3 5000 Fasting: Not Specified NT = Not Tested

  6. Other Labs Worth Noting on Plavix 75, Crestor 40, Niaspan 3000, Metformin 1500, Lovaza 4 and Vitamin D3 5000 Fasting: Not Specified NT = Not Tested

  7. Labs on Plavix 75, Crestor 40, Niaspan 3000, Metformin 1500, Lovaza 4 and Vitamin D3 5000

  8. NMR LipoProfile Insert NMR Lipoprofile 071211 HD55 Insert Page 1 Insert NMR Lipoprofile 071211 HD55 Insert Page 2

  9. NMR Interpretation

  10. Questions to Consider Question 1 Question 2: Previous statin intolerance. How is he tolerating Crestor 40? Taking at least 300-600 mg Co Q 10? Question 3 Question 4

  11. Initial Treatment & Management Continue Plavix 75. Continue Crestor 40, Niaspan 3000, metformin 1500 and Lovaza 4 for familial combined hyperlipidemia. Niaspan 3000, metformin 1500 and Lovaza 4 will help lower Lp(a) and CRP. Continue taking vitamin D3 5000 for vitamin D Deficiency. Continue taking folic acid 800 for vitamin B12 deficiency. Increase CO Q 10 to 300-600 for muscle aching.

  12. Discussion (1 of 7) Risk Factors: Heart Disease, Premature Family History of Heart Disease/Stroke, Hypertension, Hyperlipidemia Assessment: CAD

  13. Discussion (2 of 7) Assessment: Familial Combined Hyperlipidemia

  14. Discussion (3 of 7) Assessment: Elevated Lipoprotein(a)

  15. Discussion (4 of 7) Assessment: Elevate CRP

  16. Discussion (5 of 7) Assessment: Vitamin D Deficiency

  17. Discussion (6 of 7) Assessment: Vitamin B12 Deficiency

  18. Discussion (7 of 7) Assessment: Myalgia

  19. 4 Month Follow Up on Plavix 75, Metformin 1500, Lovaza 1 and Vitamin D3 5000. OFF Crestor 40 and Niaspan 3000 (1 of 3) • Familial Combined Hyperlipidemia – Deteriorated. • Stopped Crestor 40 and Niaspan 3000 6 weeks ago due to severe muscle aches and fatigue. Continues to take Plavix 75, metformin 1500 and Lovaza 4. • Off Crestor and Niaspan, total cholesterol increased from 154 to 231. Optimal is <200. LDL-C increased to 145 from 61. Optimal is <100. Triglycerides increased from 76 to 148. Optimal is <150. HDL lowered from 78 to 59. LDL-P more than doubled from 888 to 2100. Small LDL-P increased from <90 to 1145. • IR-score increased from 33 to 64. Optimal is <45. HbA1c not tested today. • Start trial of Livalo 2 mg/day. Livalo is a newer statin that may be better tolerated. Another option is to take lower dose of Crestor 2 mg every other day. • Slowly restart Niaspan 1000 mg/day. Gradually increase to 3000 mg/day. Another option is to add Welchol to Niaspan for LDL-P reduction. • Continue Plavix 75, metformin 1500 and Lovaza 4.

  20. 4 Month Follow Up on Plavix 75, Metformin 1500, Lovaza 1 and Vitamin D3 5000. OFF Crestor 40 and Niaspan 3000 (2 of 3) • Elevated Lp(a) – Deteriorated. • Stopped Niaspan 3000 6 weeks ago. Currently taking metformin 1500 and Lovaza 4. • Off Niaspan, Lp(a) is 204. Optimal is <30. • Restarting Niaspan to 3000 mg/day. • Will trial new statin, Livalo, 2 mg/day to help lower Lp(a). • Elevated CRP – Unchanged. • Stopped Niaspan 3000 6 weeks ago. Currently taking metformin 1500 and Lovaza 4. • Levels are 2.4 Optimal is <1.0. • Continue therapy. • Vitamin D Deficiency – Unchanged. • Currently taking Vitamin D3 5000 IU/day. • Levels remain about the same at 51. • Continue supplements.

  21. 4 Month Follow Up on Plavix 75, Metformin 1500, Lovaza 1 and Vitamin D3 5000. OFF Crestor 40 and Niaspan 3000 (3 of 3) • Vitamin B12 Deficiency – Unchanged. • Currently taking folic acid 800 mcg/day. • Levels not checked today. • Continue supplements. • Myalgia – Improved. • Off Crestor, myalgia improved. • Will trial new statin, Livalo 2 mg/day, which may be better tolerated. • Continue CO Q 10 supplementation. • CAD – Unchanged. • Asymptomatic on Plavix 75. • Will order platelet genetic testing to determine if CYP2C19 is abnormal. • Continue therapy.

  22. 4 Month Follow Up Labs on Plavix 75, Metformin 1500, Lovaza 1 and Vitamin D3 5000. OFF Crestor 40 and Niaspan 3000 (1 of 7)

  23. 4 Month Follow Up Labs on Plavix 75, Metformin 1500, Lovaza 1 and Vitamin D3 5000. OFF Crestor 40 and Niaspan 3000 (2 of 7)

  24. 4 Month Follow Up Labs on Plavix 75, Metformin 1500, Lovaza 1 and Vitamin D3 5000. OFF Crestor 40 and Niaspan 3000 (3 of 7)

  25. 4 Month Follow Up Labs on Plavix 75, Metformin 1500, Lovaza 1 and Vitamin D3 5000. OFF Crestor 40 and Niaspan 3000 (4 of 7)

  26. 4 Month Follow Up Labs on Plavix 75, Metformin 1500, Lovaza 1 and Vitamin D3 5000. OFF Crestor 40 and Niaspan 3000 (5 of 7)

  27. 4 Month Follow Up Labs on Plavix 75, Metformin 1500, Lovaza 1 and Vitamin D3 5000. OFF Crestor 40 and Niaspan 3000 (6 of 7)

  28. 4 Month Follow Up Labs on Plavix 75, Metformin 1500, Lovaza 1 and Vitamin D3 5000. OFF Crestor 40 and Niaspan 3000 (7 of 7)

  29. NMR LipoProfile Insert NMR Lipoprofile 112111 HD55 Insert

  30. 6 Month Follow Up on Plavix 75, Livalo 2 Niaspan 3000, Metformin 1500, Lovaza 4 and Vitamin D3 4000 (1 of 3) • Familial Combined Hyperlipidemia – Improved. • Last visit, started Livalo 2 and restarted Niaspan 3000. Tolerating Livalo. Also currently taking Plavix 75, metformin 1500 and Lovaza 4. • Total cholesterol dropped from 231 to 200. LDL-C lowered from 145 to 104. Triglycerides decreased from 148 to 60. HDL increased from 59 to 72. LDL-P decreased from 2100 to 1130. Optimal is <700. Small LDL-P lowered to 1145 to 105. Excellent response. • IR – score improved from 64 to 16. • Sterol testing suggests that he may be over-absorbing. Zetia may be a treatment option. Will monitor and review next visit. • Continue therapy. • Elevated Lp(a) – Unchanged. • Currently taking Niaspan 3000, metformin 1500 and Lovaza 4. • Lp(a) is decreased from 204 to 190. Optimal is <30.

  31. 6 Month Follow Up on Plavix 75, Livalo 2 Niaspan 3000, Metformin 1500, Lovaza 4 and Vitamin D3 4000 (2 of 3) • Elevated CRP – Unchanged. • Currently taking Niaspan 3000, metformin 1500 and Lovaza 4. • CRP increased from 2.4 to 2.7. Optimal is <1.0. • Vitamin D Deficiency – Deteriorated. • Currently taking Vitamin D3 4000 IU/day. • Levels decreased from 51 to 41. • Increase vitamin D3 to 5000 IU/day. • Vitamin B12 Deficiency – Deteriorated. • Currently taking folic acid 800 mcg/day. • Levels decreased from 357 to 290. • Continue supplements.

  32. 6 Month Follow Up on Plavix 75, Livalo 2 Niaspan 3000, Metformin 1500, Lovaza 4 and Vitamin D3 4000 (3 of 3) • CAD – Unchanged. • Asymptomatic on Plavix 75. • Platelet genetic testing shows that CYP2C19 is abnormal. • Continue therapy. • Homocystinemia – New. • Homocysteine is 15. Optimal is <10. • Homocystinemia is an independent risk factor for premature CVD caused by deficiencies in folate, B12, and B6. Increased risk for CVD is >10. • We do not know that treatment of elevated homocysteine will be able to reduce risk of future events. • Currently taking folic acid.

  33. 6 Month Follow Up Labs on Plavix 75, Livalo 2 Niaspan 3000, Metformin 1500, Lovaza 4 and Vitamin D3 4000 (1 of 6)

  34. 6 Month Follow Up Labs on Plavix 75, Livalo 2 Niaspan 3000, Metformin 1500, Lovaza 4 and Vitamin D3 4000 (2 of 6)

  35. 6 Month Follow Up Labs on Plavix 75, Livalo 2 Niaspan 3000, Metformin 1500, Lovaza 4 and Vitamin D3 4000 (3 of 6)

  36. 6 Month Follow Up Labs on Plavix 75, Livalo 2 Niaspan 3000, Metformin 1500, Lovaza 4 and Vitamin D3 4000 (4 of 6)

  37. 6 Month Follow Up Labs on Plavix 75, Livalo 2 Niaspan 3000, Metformin 1500, Lovaza 4 and Vitamin D3 4000 (5 of 6)

  38. 6 Month Follow Up Labs on Plavix 75, Livalo 2 Niaspan 3000, Metformin 1500, Lovaza 4 and Vitamin D3 4000 (6 of 6)

  39. NMR LipoProfile Insert NMR Lipoprofile 010912 HD55 Insert

  40. Clinical Pearls Combination medical therapy is usually needed for genetic disorders like Familial Combined Hyperlipidemia. A lower dose statin in combination with medications like Niaspan will be very efficacious at getting patients to goal when higher dose statin is not tolerated.

  41. Case Summary

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