Dyslipidemiacase#6Husam Hassouneh

Patient Presentation

Chief Complaint

“ I need refills.” HPI

Felecia A. Thorngrass is a 56-year-old woman who

presents to pharmacotherapy clinic for intake. She

has recently moved to your area, and states she has

not seen her primary care provider for the last 11

months. Her prescriptions have expired, and she is

coming to you for "refills."

Patient Presentation Past Medical History (PMH)

o Obesity (BMI 31.5 kg/m2)

o Dyslipidemia x 4 years

o HTN x 15 years

o Postmenopausal—has not had GYN screening since onset of menopause (14 years ago)

Patient Presentation

Family History (FH)o Father; age 74 with extensive cardiovascular history,

most notably first MI at age 42.

o Mother; died at age 61 from MVA, medical history unknown.

o Patient has one older sister with hypertension and history of “mini-strokes” and one younger sister with hypertension only.

o Her children’s medical conditions are noncontributory

Patient Presentation Social History

o Patient is married with three children, all of whom live out of state.

o College graduate, works as librarian.

o Denies current alcohol and tobacco use, but does admit to occasional marijuana use when she is visiting her children.

o Began sporadic exercise regimen when diagnosed with dyslipidemia.

Patient Presentation

Medications ( Per Patient History; She Did Not Bring Records)o Metoprolol tartrate 50 mg po BID

o Ezetimibe 10 mg po once daily

o Aspirin 81 mg po once daily

o Ibuprofen 200 mg, four tablets po PRN leg cramps

o Naproxin 220 mg, two tablets po PRN leg cramps

o Garlic capsules

Patient Presentation

Allergies o “Statin” drugs– states she had occasional leg

cramps after starting atorvastatin

Neuroo No gross-sensory deficits present

Patient Presentation

Review of Systems (ROS)

Patient states that she just needs refills. She is argumentative about getting labs done and cannot understand why you would not just refill her medications. She denies any acute changes in health. She denies unilateral weakness, numbness/tingling, or changes in vision. She denies CP, and only has SOB when she walks in the park. With further questioning you find that she rarely exercises, but when she does go for a walk she typically overdoes it. She denies changes in bowel or urinary habits and states she does not need to have GYN follow-ups anymore, because she has gone through “the change.” She denies any lower extremity edema.

Lab Findings (Fasting)

Na 142 mEq/L (135-145) Ca 8.2 mg/dL (.6-10.3 mg/dL) Fasting Lipid profile:

K 4.9 mEq/L (3.3-4.9 mEq/L) Mg 2.0 mEq/L (1.3-2.2 mEq/L) TC 240 mg/dL

Cl 103 mEq/L (97-110 mEq/L) AST 28 U/L (11-47 U/L) HDL 41 mg/dL

CO2 23 mEq/L (22-30 mEq/L) ALT 31 U/L (7-53 U/L) LDL 163 mg/dL

BUN 16 mg/dL (8-25 mg/dL) T. bili 0.5 mg/dL (.3-1.1 mg/dL) TG 183 mg/dL

SCr 0.9 mg/dL (.6-1.1 mg/dL) T. prot 7.1 g/dL (6-8 g/dL) hsCRP 4.6 mg/L

Glucose 105 mg/dL (70-100mg/dL)

Hgb 11.6mg/dL (12.1-15.1 mg/dL)

Hct 34% (36.1% - 44.3%) CrCl= 67.7 ml/min

Assessment

Mrs. Thorngrass is an obese Caucasian woman who presents to

pharmacotherapy clinic for intake. She has a significant family history of

cardiovascular disease. She has uncontrolled hypertension, treated with

metoprolol tartrate, and dyslipidemia, treated only with ezetimibe and garlic.

She reports an allergy to atorvastatin, but admits that her leg cramps have

not improved since discontinuing the drug and coincide with her rare bouts

of exercise. She reports liberal use of ibuprofen and naproxen to relieve the

cramps. She also has previously undiagnosed anemia.

Questions and Answers A. Problem Identification What drug related problems does this patient have ?

o uncontrolled dyslipidemia : ineffective drug therapy

o uncontrolled HTN : ineffective drug therapy

o two NSAIDs : the patient is at high risk for developing ADR and

needs monitoring or prophylaxis

o anemia : untreated condition

o Obesity; patient has a body mass index (BMI) of 31.5 kg/m2

that contributes to her hypertension.

Questions and Answers

what laboratory values indicate the presence and severity

of dyslipidemia in this patient ?

o TG =183 mg /dl and it should be <150

o HDL=41 mg/dl for women should be >50 mg/dl

o LDL=163 mg /dl should be reduced according to risk

(7.3) reduce up to 30-50%

o TC=240 mg /dl should be reduced to less than 200

o hsCRP should be less than 3 mg/L.

Questions and Answers what are the patient's risk factors (both

modifiable and non-modifiable) for cardiovascular disease ?

Non-modifiable risk factor :

premature menopause without estrogen replacement therapy

significant family history of CVD

Questions and Answers

modifiable :

hypertension

obesity

physical inactivity

Low HDL Cholesterol

Questions and Answers what is this patient's risk classification for cardiovascular disease and

how does this related to her individual lipid goals ?

• This patient has 2+ risk factors, but no known CHD or risk

equivalents—this puts her in the following LDL category

•Desired LDL <130 mg/dL

• Framingham risk stratification calculation (old guidelines):

•Female, age 56 = 8 points

•Total cholesterol 240–279 mg/dL, age 50–59 = 5 points

•Nonsmoking = 0 points

•HDL 40–49 mg/dL = 1 point

• Systolic BP (on treatment) ≥160 mm Hg = 6 points

•Total 20 points, giving the patient an 11% 10-year risk of a

CV event

Questions and Answers

what is this patient's risk classification for cardiovascular disease and how does this related to her individual lipid goals ?

• ASCVD risk factor scoring system ( new Guidelines) The patient’s 10-year ASCVD (AtheroSclerotic CardioVascular

Disease) risk, according to Omibus Risk Estimator is 7.3

The patient does not fall in any of the four statin benefit groups but other factors support the use of statin treatment such as

• Family history of premature ASCVD

• LDL-C levels >160 mg/dL

• hsCRP protein > 2 mg/dL

Questions and Answers

7.3

Questions and Answers

B. Desired Outcome

what are the pharmacologic and nonpharmacological goals of treatment in this patient?

Lipid goals are to reduce total cholesterol, triglycerides, and LDL cholesterol (LDL-C) while increasing HDL cholesterol, via moderate intensity statin

Questions and Answers

what are the pharmacologic and nonpharmacological goals of treatment in this patient? (cont.…)

Therapeutic lifestyle changes (TLC)

o Obesity—reduce weight with a goal of attaining ideal height/weight proportions.

o Reduce saturated fats and dietary cholesterol.

o Increase physical activity.

o Enhance LDL lowering with plant stanols/sterols and viscous fiber.

Blood pressure goal according to JNC 8 guidelines for this patient is

<140/90 mm Hg.

Questions and Answers

C. Therapeutic Alternatives

What nonpharmacological therapies are necessary for this patient to achieve and maintain target cholesterol values?o Reduce intakes of saturated fat to <7% of total calories and

dietary cholesterol to <200 mg/day

o Modify dietary fat intake to provide up to 10% of total calories from polyunsaturated fat and up to 20 % from monounsaturated fat (combined with limited saturated fats can reduce LDL by 5-15%)

o Modification of diet towards weight reduction

Questions and Answers

Therapeutic Alternatives cont’d…

o Carbohydrate should compromise 50-60% of total caloric intake and should come from foods rich in complex carbohydrates such as whole grains, fruits and vegetables

o Increase fiber intake to 25-30 mg/d (fats shouldn't make more than 20%-30% of a meal)

o Exercise 30-40 min most of days and for obese 60-90min/d most of the days

o Plant stanols/sterols (up to 2 g per day) may be used for additive effect in lowering LDL-C.

Questions and Answers What pharmacotherapeutic options are available for controlling this

patient’s hyperlipidemia to prevent future CVD events?

o HMG-CoA reductase inhibitors (statins) are the most appropriate antihyperlipidemic agents for primary prevention of CHD. (They can reduce LDL by 20–50% or more)

o Ezetimibe is approved both as monotherapy but as mainly used as an adjunctive therapy with a statin in the treatment of dyslipidemia. It interferes with the absorption of cholesterol from the brush border of the intestine.

o Red yeast rice (Monascus purpureus) has been touted as a “nondrug” or “natural” alternative to prescription cholesterol-lowering therapies.

o Garlic is commonly used as natural alternative to prescription cholesterol-lowering therapy and also antihypertensive agents. As with the red yeast rice, the patient needs to be aware that contraindications and drug interactions can still exist.

Questions and Answers D. Optimal Plan

Design a plan that details specific lifestyle modification for this patient .o Reduce body weight. This patient is well above her ideal body weight and

has a BMI of 31.5 kg/m2

o Reduce dietary fat and cholesterol.

o Implement an exercise program

o Continue to avoid tobacco and alcohol, and discontinue use of marijuana.

o Avoid excessive use of NSAIDs. NSAIDs may decrease the benefit of antihypertensive treatment by increasing sodium and water retention.

Questions and Answers

Develop a specific pharmacotherapeutic regimen for this patient’s dyslipidemia and uncontrolled HTN. This regimen should include drug, dosage, and duration of therapy.o Replace ezetimibe by 10 mg daily of atorvastatin life long to start

o Chlorthalidone 12.5 mg once daily

o Replace ibuprofen & naproxen by paracetamol 500 mg

What options are available if the pharmacotherapy regimen you chose fails, or if she develops an adverse drug reaction?o In case of adverse drug reactions Atorvasatin should be discontinued and

replaced with either rosuvastatin 5 mg daily or simvastatin 10-20 mg daily. (for myopathy, check creatine kinase levels)

o In case of failure to reach target LDL-C than the patient should be reassessed for adherence, other secondary causes of dyslipidemia, or tolerance

Questions and Answers

Questions and Answers

E. Outcome Evaluation

Based on your treatment regimen , what are the monitoring parameters for each pharmacologic agent selected ?o lifestyle modifications: dietary adjustments, exercise, and weight

reduction

o LDL-C, HDL cholesterol, and triglycerides: via fasting lipid profile baseline 6 weeks and 3 months after drug therapy. After reaching target goal patients can be monitored every 4-6 months

o Hepatic enzymes (ALT): monitored at baseline 6 and 12 weeks after initiation therapy and every 6 months afterwards

o adverse effects of drug therapy

o BP should be measured on a regular basis; after the addition of a thiazide diuretic, electrolytes should be checked within 2 weeks.

Questions and Answers

D. Patient Education Based on your recommendations, provide appropriate

education to this patient regarding pharmacologic and nonpharmacological treatments.o Do not drink Grapefruit juice as it interferes with statins

o General Health education

o Do not “double up doses” to make up for skipped doses

o Take Thiazide diuretics in the morning

Questions and Answers

You are at high risk for developing cardiovascular disease. In addition to having high cholesterol, you are clinically obese; you have high blood pressure, and a family history of premature cardiovascular disease. While some of these risks may be attenuated by drug therapy, your risk for problems will certainly increase if you do not take your medicine as directed and follow recommendations for lifestyle changes.

Questions and Answers

What steps can you take to ensure that patient is successful in implementing nonpharmacological measures?o Continued contact and encouragement is crucial for

therapeutic success.

Thank You