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Lipids

Leonie Dupuis

Background

  • 1º prevention: pts at increased risk who have not yet had a vascular event
  • 2º prevention: pts with pre-existing occlusive vascular disease or ASCVD (e.g. stroke, TIA, CAD + angina, ACS, coronary or arterial revascularization, PAD)
  • Screening: All adults ≥ 20y
    • USPSTF 2016 Guidelines: q5years for adults 40-75yrs
    • ACC/AHA 2019 Guideline: adults 20-39 q4-6yrs; <21yrs if strong fam hx; 40-75 “routinely” assess CV risk and calculate ASCVD risk (dot phrase .ASCVD2013)

Evaluation

  • Fasting not routinely needed unless evaluating for hyperTG; if non-fasting TG >440, then obtain 12-14h fasting panel
  • Consider 2º causes of HLD in initial workup: hypothyroidism, DM, EtOH use, smoking, liver disease, nephrotic syndrome, CKD, meds (e.g. thiazide, glucocorticoids)
  • In pts with borderline ASCVD risk (5%-7.5% risk) or hesitant to take statins with low risk, CAC score can help with shared decision making. Therapy is recommended.
  • Check lipoprotein(a) (once in a lifetime) in pts with personal or family history of ASCVD, or in pts with less than expected LDL lowering after starting a statin. Management
  • Lifestyle changes: weight loss, exercise, smoking cessation, limiting alcohol
    • Diet low in sat. fat a/w 15-20 mg/dL ↓ in LDL-C, ~50% ↓risk of CAD
    • Diet Avoiding: trans/saturated fats (red meat, processed meat, butter, cheese), sodium (<2300 mg/day) and sugar-sweetened foods and beverages
    • Diet Emphasizing: vegetables, fruits, legumes, lean protein, whole grains, nuts
  • Figure from 2018 ACC/AHA Guideline for the management of primary prevention : https://www.ahajournals.org/cms/asset/c4c7b8c7-5c95-40d4-9919-be9c725b5ea9/e1082fig02.gif
  • Figure from 2018 ACC/AHA Guideline for the management of secondary prevention: https://www.ahajournals.org/cms/asset/0882d0f2-9af3-4bfa-aefe-c21d406f82be/e1082fig01.jpg

Statin Therapy

  • Check AST/ALT prior to initiation
  • Note that ASCVD risk equation is best validated for non-Hispanic whites and blacks. Consider use of additional risk prediction tools/factors in other pt populations
  • Lipid panel should be checked 6-8 weeks following initial statin to ensure LDL-C has fallen 30-50%. After this, consider checking lipid panel yearly to assess adherence.
Statin Potency Statin Properties
High-Intensity
(≥50% ↓LDL-C)		 Atorvastatin 40-80 mg
Rosuvastatin 20-40 mg
 Safest in CKD: atorva, fluva (no renal dose adj.required) Safest in cirrhosis: prava Lowest rate of myopathy: prava, fluva, pitava Lower overall s.e.: prava, rosuva (both hydrophilic) Biggest Change in LDL: rosuvastatin > atorvastatin > simvastatin
Moderate-Intensity
(30-49% ↓LDL-C)		 Atorvastatin 10-20mg, Rosuvastatin 5-10mg
Simvastatin 20-40mg, Pravastatin 40-80mg
Lovastatin 40-80mg, Fluvastatin XL 80mg, Fluvastatin 40mg BID, Pitavastatin 1-4mg
Low-Intensity
(<30% ↓LDL-C)		 Simvastatin 10mg, Pravastatin 10-20mg, Lovastatin 20 mg, Fluvastatin 20-40mg

Statin Side effects:

  • Spectrum of statin associated muscle symptoms (SAMS) include myalgias, myopathy, rhabdomyolysis, autoimmune myopathy
    • Myalgias: bilateral involving large muscle groups, onset within weeks of initiation of therapy and should resolve within weeks of cessation; CK should be normal
    • Consider evaluation with CK, BMP, TSH, and vitamin D
    • "ACC Statin Intolerance Calculator” can help assess etiology of symptoms

Additional Information

  • If pt is not tolerating a statin, consider
    • Holding statin until symptoms resolve and trialing lower dose or other statin
    • Every other day dosing with rosuvastatin (longer half-life and hydrophilic)
    • If repeated failed attempts, consider ezetimibe, PCSK9 inhibitor
  • Consider adding ezetimibe if pt has very high ASCVD and LDL >70 while on maximally tolerated high-intensity statin
  • PCSK9 inhibitor requires referral to Lipid Clinic

Hypertriglyceridemia

  • Moderate: TG 175-499 mg/dL; Moderate-severe 500 - 999; Severe: TG > 1000
  • Focus on addressing lifestyle factors and stopping medication that increase TG’s (HCTZ, some BB’s, estrogens, some ART, antipsychotics)
  • Consider medical therapy when TG> 500mg/dL (increased risk of pancreatitis)
    • Omega-3-fatty acids (icosapent ethyl) 4gms daily or Vascepa 4gm daily
    • Fibrates: fenofibrate 120 mg daily (avoid in CKD), gemfibrozil 600mg BID (increased risk of myopathy with concomitant statin)

VA- Specific Guidelines

  • https://www.healthquality.va.gov/guidelines/cd/lipids/index.asp
  • Lowest LDL goal recognized for VA Criteria for Use is 100
  • Preferred statins: atorvastatin, simvastatin, lovastatin
  • Statins that require PADR: pravastatin, rosuvastatin (2nd-line high-intensity statin)
    • Must have documented intolerances or DDI to all preferred statins
  • Other agents that require PADR
    • Ezetimibe
      • Pt has tried and failed or not tolerated all statins (allergy, AE, etc.)
      • Pt not meeting goal on max dose of statin PLUS bile acid sequestrants or niacin
    • Fenofibrate
      • Pt has tried all formulary alternatives or has contraindication to use of formulary alternatives (statin, niacin, gemfibrozil, cholestyramine, fish oil)
      • If TG > 500 mg/dL, fenofibrate should be approved