Approach to

patient of
Dyslipidemia

DR. HIRAL GOLAKIYA,

ASSISTANT PROFESSOR,

GAIMS, BHUJ.
 Hypolipidaemic drugs

HMG-CoA reductase Bile acid Lipolysis and Sterol absorption

inhibitors (Statins) sequestrants triglyceride inhibitor
Lovastatin (Resins) synthesis inhibitor Ezetimibe
Simvastatin Cholestyramine Nicotinic acid
Pravastatin Colestipol
Atorvastatin Colesevelam
Rosuvastatin
Pitavastatin Lipoprotein lipase
activators (PPAR α
agonists: Fibrates,
Fibric acid
derivatives)
Gemfibrozil
Bezafibrates
Fenofibrates
Clofibrates
Interpretation of plasma lipid levels [adopted from NCEP
(2001)]

Plasma lipid levels (mg/dl)

Total CH LDL-CH HDL-CH TGs
1. Optimal/Desirable <200 <100 (<70 for >40 (men) < 150
CAD pts) >50 (women)
2. Borderline high 200-239 130-159 – 150-199
3. High ≥ 240 160-189 >60 200-499
4. Very high – ≥ 190 – ≥ 500
 Risk factors for coronary artery disease

▪ Men >45 yrs, women >55 yrs

▪ Family history of MI/sudden cardiac death before 55yrs (men), 65 yrs (women)
age in 1st degree relative
▪ Smoking
▪ Hypertension (BP >140/90 or use of antihypertensive medication)
▪ Diabetes mellitus
▪ Lower HDL-CH (<40 mg/dl in men, <50 mg/dl in women)
▪ Higher LDL-CH (≥ 160 mg/dl) or total CH ≥ 240mg/dl
▪ Obesity (BMI >25 kg/m2) or waist > 40″ (men), > 35″ (women)
 Diet
Non pharmacologic
Exercise

Decrease the production of lipoproteins

Pharmacologic Increase breakdown or removal

Decrease absorption of lipids

Therapeutic lifestyle change

Total fat 25-35% of total calories

Saturated fat < 7% of total calories
Polyunsaturated fat Up to 10% of total calories
Monounsaturated fat Up to 20% of total calories
Carbohydrates 50-60% of total calories
Cholesterol <200 mg per day
Dietary fibres 20-30 grams per day
Plant sterols 2 grams per day
Protein Approximately 15% of total calories
Total calories To achieve & maintain desirable body weight
Statin therapy

1 High Intensity Statin Therapy Lowers LDL by > 50%

Moderate Intensity Statin
2 Lowers LDL by 30- 50%
Therapy
3 Low Intensity Statin Therapy Lowers LDL by < 30%

Current indication for statins therapy

1. All subjects with Atherosclerotic cardiovascular disease (ASCVD) irrespective of plasma
CH level
2. All subjects with LDL-CH above 190 mg/dl
3. All diabetics aged 40 years or more
4. Subjects aged 40 years or more with estimated 10 yr ASCVD risk more than 7.5%,
irrespective of plasma CH level
Special population: Children
1 < 2 yrs No dietary restriction or drug therapy

2 2-10 yrs Dietary restriction But no drug therapy

3 >10 yrs Dietary restriction And Drug therapy

First line Agent: Bile Acid Binding Agents

Not Tolerated than,

Statins
➢ > 8 yrs- Pravastatin
➢ > 11 yrs- Atorva, Lova, Simva
Special population: Pregnancy

▪ DOC During Pregnancy- Bile Acid Binding Resins

▪ Statins used with CAUTION- In women or girls of Child bearing

Age

▪ Post Menopausal Women who want to Start HRT:

➢First Control TGs
 LDL
1 Statin + Ezetimibe (Safest combination)
2 Statin + Resins
3 Statin + Fenofibrate
4 Statin + Niacin

VLDL
1 Nicotinic acid + fibric acid
2 Addition of fish oils
Diabetic patient

▪ Defects
➢Elevated TGs/ LDL
➢Low HDL-c
➢Glycosylated LDL

▪ Treatment Options:
▪ Diet and lifestyle changes
▪ Drugs
▪ Niacin- Impaired Glucose tolerance
▪ Resins- Increase TGs
▪ First generation Fibrates: Increase LDL

▪ Ideal combination
➢Statin + Fenofibrate
P Drug – 05 – Lipid
lowering agent

DR. HIRAL GOLAKIYA,

ASSISTANT PROFESSOR,
GAIMS, BHUJ.
 Exercise

▪ An adult asymptomatic male executive (Wt 78Kg), had the following biochemical
test profile upon annual check-up. There was a family history of IHD also.
▪ Fasting Blood sugar: 102 mg%,
▪ Total Cholesterol: 240 mg%,
▪ LDL-C: 190 mg%,
▪ Triglycerides: 150 mg%,
▪ VLDL-C: 45 mg% and
▪ HDL-C: 30 mg%.

▪ He is already following dietary restrictions. He is keen for treatment of

Hyperlipidemia. Choose a P-drug for this Patient.
1. Define the patients problem.
This patient is having hypercholesterolemia and low HDL levels.
2. Specify the therapeutic objective.
▪ In addition to life style changes (Weight reduction, Reduction in fat intake
and regular exercise), the target LDL-C should be about 130 mg or lower.
▪ In order to achieve a 36%-40% LDL-C reduction, an effective drug (lipid
lowering agent) must be used.
3. Make an inventory of effective groups of drugs.
4. Choose an effective group according to criteria.
5. Choose a ‘p’ drug from that group.
6. Write a prescription.
Step iii: Make an inventory of effective groups of drugs.

▪ There are five groups of lipid lowering agents

1. Statins
2. Resins
3. Fibrates
4. Lipolysis & TG synthesis inhibitor
5. Sterol absorption inhibitor
Step iv: Choose an effective group according to criteria

Groups Efficacy Safety Suitability Cost

Statins (HMG- ↓LDL(20-55%), Hepatotoxicity, Once daily dose Variable
CoA reductase ↓TG(10-35%), myopathy
inhibitors) ↑HDL(5-15%) (generally mild
↓vascular ADRs)
inflammation and
oxidative stress
(Extensively
studied)

Resins (Bile acid ↓LDL(15-30%), Constipation, Bulky, unpalatable, Lower cost

sequestrants) may↑TG, ↑HDL(3- Flatulence, inconvenient for
5%) ↓absorption of long term use
concurrent Add-on drugs only
medicines
Step iv: Choose an effective group according to criteria

Groups Efficacy Safety Suitability Cost

Fibrates ↓LDL(5-20%), Hepatotoxicity, Single or divided doses Variable
(Lipoprotein ↓TG(20-50%), myopathy
lipase activators) ↑HDL(10-20%)
Niacin ↓LDL(15-25%), Gastric upset, Not suitable for diabetics, Lower
(↓VLDL ↓TG(20-50%), flushing, pruritus, Frequent dosing 1-3 per day,
production, ↑HDL(20-35%) skin rash, acanthosis More adverse effects
↓ lipolysis) nigricans, ↑SGPT, Not well tolerate usually
IGT, hyperuricemia, without aspirin
macular oedema
Ezetimibe Reduce LDL by Mild hepatic Once a day Similar to
(Interfere with 15-20% dysfunction and Alone it is weak lipid lowering statins
intestinal CH myositis agent so used as adjuvant
absorption)
➢Therefore the ‘P’ group is Statins or HMG-CoA Reductase Inhibitors
 Step v: Choose a P-drug

Drug Efficacy Safety Suitability Cost

(Equivalent Dose for 36-40% (Rs./day)
Reduction of LDL-C)

Lovastatin (80 mg) Effective Muscle Aches, Rise Requires 20 mg tab Rs:7-8/tab;
in SGPT, CK Evening thus 28-32 per day
(myopathy common dose
with Fibrates)
Contraindicated in
pregnancy

Simvastatin (40 mg) Effective As above Requires 20 mg tab Rs:13-

Evening 14/tab
dose so 26-28 Rs. per day
 Drug Efficacy Safety Suitability Cost

Atorvastatin Effective +Anti As Above Any Time of Day 20 mg tab

(20 mg) oxidant Rs:10-12/tab
i.e.,10-12 Rs.
per Day
Pravastatin Effective and not Less myopathy Evening dose 20 mg tab
(80 mg) metabolized by CYP with fibrates Rs:16 so 48/-
system per Day

Pitavastatin Effective (less well Newer Evening dose 2 mg tab

(4 mg) studied presently) Rs:15/- Thus
30/- per Day
 Drug Efficacy Safety Suitability Cost
Rosuvastatin Effective and greater rise in As Above Any time 10 mg tab
(10 mg) HDL-C, Rs:10-20
Not extensively metabolized by thus Rs
CYP 3A4 10-20/-
per Day

Fluvastatin- Effective; Not extensively Less Evening dose 80 mg tab

(80 mg) metabolized by CYP 3A4 myopathy Rs:17/-
with fibrates per Day

▪ So, the P-Drug is ATORVASTATIN

▪ NB: treatment is almost life-long and baseline LFTs to be monitored
▪ Initial dose is lower and then titrate the dose in 3-4 weeks
 Dr. ABC, MBBS
Regi. No. G - 45789
Address: GKGH, Bhuj
Ph no. 9898989898
For, Date: 29/07/2020
Mr. XYZ
Age: 78 yrs
Address: Bhuj
Contact number: 8989898989
℞
Tab. ATORVASTATIN 10 mg (30)
Direction: one tablet to be taken once a day
Follow-up after one month.
Sign
Registration no.

Advice:
• Avoid drinking alcohol (↑TG levels & may ↑risk of liver damage).
• Avoid Grapefruit juice (may interact with atorvastatin & lead to
potentially dangerous effects).
Thank you!!!