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Cholesterol and Lipids

Cholesterol and Lipids. TIPS Wokefield Park 15/5/2013. Just a few questions!. What is the NDA target for total cholesterol and LDL cholesterol? What are the QOF targets for cholesterol? What is the ideal time to take a statin and why? Name the most serious side effect of statins.

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Cholesterol and Lipids

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  1. Cholesterol and Lipids TIPS Wokefield Park 15/5/2013

  2. Just a few questions! • What is the NDA target for total cholesterol and LDL cholesterol? • What are the QOF targets for cholesterol? • What is the ideal time to take a statin and why? • Name the most serious side effect of statins. • What blood test would you order if you suspected it? • Name another side effect of statins. • All statins increase HDL cholesterol – true or false? • What is the most typical lipid profile for type 2 diabetes? • What is the most typical lipid profile for type 1 diabetes?

  3. R77 Statins & Ezetimibe For a person who is 40 yrs+ • Simvastatin (to 40 mg) unless CVS risk from non-hyperglycaemia-related factors is low (see R72)

  4. R72 Consider a person to be at high CVS risk unless…… • Not overweight • Normotensive • No microalbuminuria • Non-smoker • No high risk lipid profile • No h/o CVS disease • No FH of CVS disease

  5. If low CVS risk………… • Assess CVS risk using UKPDS risk engine • Start simvastatin if CVS risk > 20% over 10 yrs

  6. Once on a statin……….. • Repeat lipid profile in 1-3 months then annually • If total cholesterol>4.0 or LDL cholesterol >2.0 mmol/L titrate simvastatin to 80 mg daily

  7. Consider intensifying if……. • Existing/newly diagnosed CVS disease • Choose different statin/ezetimibe

  8. If h/o raised triglycerides……. • Consider secondary causes • Full lipid profile • Prescribe fenofibrate if Tg remain > 4.5 mmol/L • If Tg remain > 2.3 mmol/L consider adding fenofibrate to statin

  9. Kaplan–Meier Estimates of the Incidence of Outcome Events in the Total Study Population. Estruch R et al. N Engl J Med 2013;368:1279-1290

  10. Statins do not alter the risk of LowHDL Heart Protection Study (Diabetes subgroup) % CHD Events placebo HDL Cholesterol (mmol/L) simvastatin 40mg Adapted from Heart Protection Study Collaborative Group. Lancet 2003; 361: 2005-2016.

  11. If you needed to treat these lipids what would you prescribe? • Total cholesterol 5.35 mmol/L • HDL cholesterol 1.4 mmol/L • Triglycerides 1.68 mmol/L

  12. L I P I D

  13. LIPID RESULTS • 22% reduced mortality P<0.001 • 24% reduced CHD mortality p<0.001 • 29% reduced all CVS outcomes p<0.001 • 20% reduced revascularisation p<0.001

  14. LIPID – Diabetics & Non-smokers No (%) CHD Events Placebo Pravastatin Diabetics 88(23) 76(19) Non-smokers 167(13) 139(12) New Eng J Med 1998; 339: 1349-57

  15. ASCOT • Age 40-79 • Untreated BP 160/100 or more • Treated BP 140/90 or more • Total cholesterol < 6.5 mmol/L • 3+ of LVH,ischaemic ECG,type 2 diabetes,PVD,previous stroke or TIA,male, age > 55,smoker,microalbuminuria,family history of premature CHD Lancet 2003;361:1149-1158

  16. Figure 2 Source: The Lancet 2003; 361:1149-1158 (DOI:10.1016/S0140-6736(03)12948-0) Terms and Conditions

  17. Figure 5 Source: The Lancet 2003; 361:1149-1158 (DOI:10.1016/S0140-6736(03)12948-0) Terms and Conditions

  18. CARDS Recruitment Criteria • 2838 T2DM • Age 40-75 • No known CVS disease • Hypertension or retinopathy or microalbuminuria • Serum LDL < 4.14 mmol/L • Serum triglycerides < 6.8 mmol/L

  19. Figure 4 Source: The Lancet 2004; 364:685-696 (DOI:10.1016/S0140-6736(04)16895-5) Terms and Conditions

  20. CARDS Baseline Characteristics • Total cholesterol 5.35 mmol/L • HDL cholesterol 1.4 mmol/L • Triglycerides 1.68 mmol/L

  21. Figure 2 Source: The Lancet 2004; 364:685-696 (DOI:10.1016/S0140-6736(04)16895-5) Terms and Conditions

  22. VA-HIT: Diabetic Subgroup Analysis Arch Intern Med;162:2597-2604

  23. Numbers needed to treatto prevent one non-fatal MI or CHD death in 5 years All Patients Diabetics • CARE 33 29 • LIPID 28 29 • HPS 32 31 • VA-HIT 23 12

  24. Question You are a bigdeal trialist designing a study to test the efficacy of a fibrate in the prevention of CHD in type 2 diabetes. What ideally would you like the average baseline lipid profile to be?

  25. FIELD Study • 9795 participants • Type 2 diabetes • Age 50- 75 yrs • No prior statin/fibrate therapy • 2131 previous CVS disease • 7664 no known previous CVS disease

  26. FIELD - Recruitment Lipids • Total cholesterol 3-6.5 mmol/L + • Either TC:HDL cholesterol > 4 • Or triglycerides 1.0-5.0 mmol/L

  27. Original ArticleEffects of Combination Lipid Therapy in Type 2 Diabetes Mellitus The ACCORD Study Group N Engl J Med Volume 362(17):1563-1574 April 29, 2010

  28. Lipid Values The ACCORD Study Group. N Engl J Med 2010;362:1563-1574

  29. Kaplan-Meier Analyses of the Primary Outcome, Expanded Macrovascular Outcome, and Death The ACCORD Study Group. N Engl J Med 2010;362:1563-1574

  30. Conclusion • The combination of fenofibrate and simvastatin did not reduce the rate of fatal cardiovascular events, nonfatal myocardial infarction, or nonfatal stroke, as compared with simvastatin alone • These results do not support the routine use of combination therapy with fenofibrate and simvastatin to reduce cardiovascular risk in the majority of high-risk patients with type 2 diabetes

  31. Baseline Characteristics of the Patients The ACCORD Study Group. N Engl J Med 2010;362:1563-1574

  32. Conclusions • Statins are safe, benefit many diabetics and almost all diabetics should be on them • Treat total cholesterol & LDL cholesterol to target • There is still a place for fibrates in combination and first line for those with HDL<1 and/or Tg>2.3

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