Diagnosis and Treatment of Dyslipidemia  New guidelines are based on the “Adult Treatment Plan III (ATP III)” 2004  Focus = multiple risk factor assessment to determine those individuals at highest absolute Coronary Heart Disease (CHD) risk  Diabetes is identified as being a CHD risk equivalent - in other words, a person with Diabetes is considered at the same risk of CHD as a person with a previous hx of CHD

Assessing CHD Risk  Framingham Risk Score - Projects potential for 10 year absolute CHD Risk (ranges from 20%)  Use in patients without CHD or CHD Risk Equivalents

Lipid Evaluation  Done after a 9 – 12 hour fast to ensure an adequate evaluation of all components of a lipid profile  If Triglycerides are extremely elevated, calculation of the LDL can be difficult  Non-fasting samples should not be used for diagnosis

LDL Goals Risk Category LDL-C Goal Initiate Lifestyle Change Consider Drug Treatment High Risk (  20%) CHD or CHD equiv < 100mg/dl  100mg/dl Moderately High Risk  2 risk factors (10-20%) < 130mg/dl  130mg/dl Moderate Risk  2 risk factors (10%) < 130mg/dl  130mg/dl  160mg/dl Low Risk 0-1 risk factors < 160mg/dl  160mg/dl  190mg/dl

Medications for Treatment of Dyslipidemia  New Recommendations in Therapeutics - Combination therapy is recommended for selected high risk patients for selected high risk patients - Despite success of the statins as a group, coronary event rates remain high group, coronary event rates remain high - Combination therapy may be as efficacious as single therapy with less side effects as single therapy with less side effects - Side effects and toxicity of statins increase with each dosage increment with each dosage increment

Types of Medications  Drugs that Affect Hepatic Lipoprotein Metabolism 1) HMG-CoA Reductase Inhibitors (statins) - Lovastatin, pravastatin, simvastatin, fluvastatin (statins) - Lovastatin, pravastatin, simvastatin, fluvastatin 2) Nicotinic Acid - Immediate release (IR), sustained release (SR), extended release (ER) (IR), sustained release (SR), extended release (ER) 3) Fibrates - Gemfibrozil, fenofibrate, clofibrate

Types of Medications  Drugs that Affect Intestinal Metabolism of Cholesterol 1) Bile Acid Sequestrants - Cholestyramine, colestipon, colesevelam colestipon, colesevelam 2) Inhibitors of cholesterol absorption (vegetable derived) - Sterol/stanol esters (available in dietary margarine – BeneChol®) 3) Selective Cholesterol Absorption  Inhibitor (CAI) - Ezetimibe  NEW CLASS

Lifestyle Treatment of Dyslipidemia  Lifestyle Changes Still Recommended for all patients  Physical Activity  Smoking cessation  Weight Loss  Dietary modification  Reduce saturated and “trans” fats  Increase fiber (25g/day)  Consider plant sterols/stanols (2-3 servings/day)