Endocrinology and Hyperlipidemia Chapter 26 Paauw

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What level of triglycerides can cause life-threatening pancreatitis?: TG levels greater than 1000 mg/dL
T or F: Treating high levels of LDL is particular has been shown to reduce the risk of future CAD events.: T
What causes hyperlipidemia?: While some lipid abnormalities are caused by known inborn erros of lipid metabolism, the majority of lipid disorders arise from a combination of dietary factors, lack of exercise and some degree of genetic susceptibility. Coexisting conditions and medications may also affect lipid levels.
What are some secondary causes of hyperlipidemia?: 1. Poorly controlled diabetes
2. Hypothyroidism
3. Obstructive liver disease
4. Nephrotic syndrome
5. Chronic renal failure
6. Smoking
7. Drugs: corticosteroids, anabolic steroids, progestins, protease inhibitors
What drugs can cause hyperlipidemia?: 1. corticosteroids
2. anabolic steroids
3. progestins
4. protease inhibitors
Whom should I test for hyperlipidemia?: 1. Anyone with known cardiovascular disease
2. The NCEP currently recommends screening every 5 years in adults older than age 20
3. A reasonable approach would be to begin screening at age 35, and earlier only if the patient has significant cardiovascular risk factors or a family history of hyperlipidemia.
What is in a complete lipid panel?: A complete lipid panel provides direct measurement of total cholesterol (TC), HDL, and TG and is measured after a 12-hour fast, usually in the morning before breakfast.
How do you calculate LDL?: LDL is calculated based on the formula ...

LDL = TC - HDL - (TG/5)
What are the cardiovascular risk factors ,per NCEP Guidelines (besides elevated LDL cholesterol)?: 1. Age (men over 45 or women over 55)
2. Cigarette smoking
3. Diabetes mellitus
4. Family history of premature CAD: CAD event in a 1st degree male relative over 55 and a 1st degree female relative over 65
5. HDL less than 40 mg/dL
6. HTN (greater than 140/90 or on medication)
Note: HDL greater than 60 counts as a negative risk factor
What test should I use for hyperlipidemia for screening purposes?: Measure nonfasting levels of TC and HDL for convenience and decreased expense. If the TC is greater than or equal to 200 mg/dL or the HDL is less than 40 mg/dL, a complete fasting lipid panel is indicated.
For any patient in whom treatment is possible or currently under way, what test should you get?: A fasting lipid panel.
When looking for causes of pancreatitis, what test should you get?: An isolated TG level may be useful.
If patient's TG level is greater than 400, the LDL cannot be accurately calculated. This is problematic since treatment guidelines are generally based on LDL levels. What can you do?: To circumvent this problem, you can assume the TG to be 400. This provides a conservative (high) estimate of your LDL (LDL = TC - HDL - 400/5), because a TG level higher than 400 would actually subtract more from the LDL figure.
What does the NCEP stand for?: National Cholesterol Education Program
NCEP Guidelines for the Treatment of Hypercholesterolemia: If you have 0-1 risk factors, what is the threshold LDL for starting drug therapy? What is the goal LDL (by diet or drugs)?: Threshold LDL: greater or equal to 190 mg/dL
Goal LDL: less than 160 mg/dL
NCEP Guidelines for the Treatment of Hypercholesterolemia: If you have 2+ risk factors (and 10 year risk of less than 10%), what is the threshold LDL for starting drug therapy? What is the goal LDL (by diet or drugs)?: Threshold LDL: greater or equal to 160 mg/dL
Goal LDL: less than 130 mg/dL
NCEP Guidelines for the Treatment of Hypercholesterolemia: If you have 2+ risk factors (and 10 year risk of 10%-20%), what is the threshold LDL for starting drug therapy? What is the goal LDL (by diet or drugs)?: Threshold LDL: greater or equal to 130 mg/dL
Goal LDL: less than 130 mg/dL
If you have CAD, other atherosclerotic disease, diabetes mellitus or 10-year risk greater than 20%, what is the threshold LDL for starting drug therapy? What is the goal LDL (by diet or drugs)?: Threshold LDL: Greater or equal to 130 mg/dL
Goal LDL: less than 100 mg/dL
How do you calculate the 10-year risk of CAD events?: It can be calculated using a point system or computerized risk model. One example of a risk calculator is based on the Framingham study, and is available at the National Heart, Lung and Blood Institue website.
For a person with mild hyperlipidemia, what can you do before starting medications?: Try a 6 to 12 week trial of lifestyle modification, with or without referral to a dietitian.
T or F: Diet, exercise, weight loss and alcohol restriction are first line therapy for hypertriglyceridemia.: T
What is first line therapy in patients with known CAD and elevated LDL?: The "statins", aka HMG CoA reductase inhibitors. Treatment is focused on reducing LDL level, which is most efficienty accomplished by statins.
What are some side effects of statins?: Side effects of statins include rare myopathy and generally insignificant liver enzyme elevations.
For patients without known CAD who have high LDL and low HDL levels, which is an alternative to statins?: Niacin is a low-cost alternative to statins.
What about the flushing and headached associated with taking niacin?: These symptoms can be attenuated by pretreatment with aspirin and slow upward dose titration. Older extended-release niacin preparations were associated with hepatotoxicicty, but newer preparations appear to be safer.
For patients who have very elevated TG, or low HDL levels in the absence of elevated LDL, what drugs should you use?: A fibric acid derivative such as gemfibrozil may be indicated.
Is hormone replacement therapy a reasonable alternative for treatment of hyperlipidemia in postmenopausal women?: No, estrogen with or without progestin should not be used for the treatment of hyperlipidemia, although it may be indicated for other reasons.
What are side effects of the statins?: 1. myopathy
2. elevated liver enzymes
3. GI distress
4. Headache
5. Insomnia
What are the side effects of nicotinic acid (niacin)?: 1. flushing, headache, tachycardia and pruritus
2. hyperuricemia
3. hyperglycemia
4. hepatotoxicity
What are the side effects of fibric acids (gemfibrozil, clofibrate): 1. myopathy, small increased risk with statins, huge increase in risk with cyclosporine, erthromycin and ketoconazole
2. gallstones
3. hepatotoxicity
4. GI malignancy
5. nausea
What are the side effects of bile-acid sequestrants?: 1. decreased absorption of many other medications
2. GI distress, constipation
What is the effect of statins on LDL, TG and HDL?: LDL: Lowers a lot!
TG: Lowers a little
HDL: Raises a little
What is the effect of niacin on LDL, TG and HDL?: LDL: Lowers a little
TG: Lowers a lot!
HDL: Raises a little
What is the effect of fibrates on LDL, TG and HDL?: LDL: Lowers a little
TG: Lowers a lot
HDL: Raises a lot!
What is the effect of bile-acid sequestrants on LDL, TG and HDL?: LDL: Lowers a little
TG: Raises a little (bad)
HDL: no change
How much omega-3 fatty acids should you recommend?: Increasing dietary omega-3 fatty acids by consuming fish and fish oil (30 gm/day or two fish meals weekly) has been shown to reduce total cholesterol, triglycerides, raise HDL and lower mortality.
What other foods have been shown to lower cholesterol levels?: soluble dietary fiber, found in legumes, oat bran, fruit and psyllium.
How much alcohol consumption is beneficial in raising HDL levels and reducing incidence of CAD.: Less than 1oz/day = 2 oz whiskey = 8 oz wine = 24 oz of beer) is recommended.
What are the well-established effective ways to prevent CAD events (other than medications and diet counseling)?: Assess and treat any cardiovascular risk factors. Counsel patients to quit smoking, and aggressively treat hypertension and diabetes mellitus.

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