Managing Multiple Diseases: Hyperlipidemia

1. Managing Multiple Diseases: Hyperlipidemia Joanne J. Orrick, PharmD, BCPS Clinical Assistant Professor University of Florida Faculty, Florida/Caribbean AIDS Education and Training Center Enter the title of your presentation and your name to this title slide. When saving your presentation, please add your name and session title to the existing file name (i.e. �15th_Conf_Slides_Beal_Managing_Multiple_Diseases.ppt�) Please call Michael Ikeya at (813) 974-9005 if you have any questions. No Changes Made.Enter the title of your presentation and your name to this title slide. When saving your presentation, please add your name and session title to the existing file name (i.e. �15th_Conf_Slides_Beal_Managing_Multiple_Diseases.ppt�) Please call Michael Ikeya at (813) 974-9005 if you have any questions. No Changes Made.

2. 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 No Changes Made. No Changes Made.

3. 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 No Changes Made. No Changes Made.

4. 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 No Changes Made.No Changes Made.

5. 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 No Changes Made. No Changes Made.

6. 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 No Changes Made. No Changes Made.

7. Patient Case BP 158/85, P 74, RR 18, Height 5'10", Weight 211 lbs Comprehensive metabolic panel is within normal limits No Changes Made.No Changes Made.

8. 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 No Changes Made. No Changes Made.

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

10. 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) See next slide for proposed change.See next slide for proposed change.

11. Question 2 What is the patient�s 10 year risk of developing CHD according to the Framingham Risk Assessment? 5 10 20 25 = 30 Points+ 16, risk= 25%Points+ 16, risk= 25%

12. Major Risk Factors That Modify LDL Goals Added slide with chart from dyslipidemia.pdf. Delete if you do not want this slide. Added slide with chart from dyslipidemia.pdf. Delete if you do not want this slide.

13. Estimate of 10-year Risk Added slide with chart from dyslipidemia.pdf. Delete if you do not want this slide. Added slide with chart from dyslipidemia.pdf. Delete if you do not want this slide.

14. Question 3 What is the minimum LDL goal for this patient? < 160 < 130 < 100 Answer B: < 130Answer B: < 130

15. 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 See the next slide for proposed change.See the next slide for proposed change.

16. 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 See the slide that is two slides ahead for proposed change. Change will incorporate this and the next slide, if approved.See the slide that is two slides ahead for proposed change. Change will incorporate this and the next slide, if approved.

17. 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 Answer: C Initiate TLC and drug therapy or B: Initiate TLCAnswer: C Initiate TLC and drug therapy or B: Initiate TLC

18. LDL-Cholesterol Goals by Risk Replaced text with comparable chart from dyslipidemia.pdf, resulting in 2 previous slides being combined. Either delete this slide or the previous two slides. Replaced text with comparable chart from dyslipidemia.pdf, resulting in 2 previous slides being combined. Either delete this slide or the previous two slides.

19. Progression of Drug Therapy in Primary Prevention Added slide with chart from dyslipidemia.pdf. Delete if you do not want this slide. Added slide with chart from dyslipidemia.pdf. Delete if you do not want this slide.

20. 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 This slide was changed to read �Question 5� to keep question sequence. This slide was changed to read �Question 5� to keep question sequence.

21. Drug Therapy Added slide with chart from dyslipidemia.pdf. Delete if you do not want this slide. Added slide with chart from dyslipidemia.pdf. Delete if you do not want this slide.

22. ? 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) No Changes Made. No Changes Made.

23. Statins No Changes Made.No Changes Made.

24. Statins No Changes Made.No Changes Made.

25. 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? No Changes Made.No Changes Made.

26. 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 No Changes Made. No Changes Made.

27. Fibrates No Changes Made. No Changes Made.

28. 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 No Changes Made. No Changes Made.

29. Fibrates Added slide with chart from dyslipidemia.pdf. Delete if you do not want this slide. Added slide with chart from dyslipidemia.pdf. Delete if you do not want this slide.

30. 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 No Changes Made. No Changes Made.

31. Nicotinic Acid No Changes Made. No Changes Made.

32. 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) No Changes Made. No Changes Made.