Transcript The Hyperlipidaemias What are they and how to treat

The Hyperlipidaemias
What are they and how to treat
Dr John O’Donnell
Consultant Clinical Biochemist
Borders General Hospital
The Hyperlipidaemias
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Familial Hypercholesterolaemia
Mixed hyperlipidaemias
Post menopausal hypercholesterolaemia
‘Polygenic’ hypercholesterolaemia – the
bog standard high cholesterol
Polygenic hypercholesterolaemia
• Simply ‘high’ cholesterol
• Secondary and primary risk
• Management base on National and local
guidelines
Familial hypercholesterolaemia
• 1 in 500 – relatively common
• Cholesterol > 7.5 – bear in mind family
history
• Clinical signs – tendon xanthoma,
xanthelasma, and arcus senilis
• Genetic testing - problems
Postmenopausal
Hypercholesterolaemia
• Increase in cholesterol of 1-2 mmol/L
• Increased cardiovascular risk postmenopause
• Role of HRT – highly controversial
• NOT same risk as familial
hypercholesterolaemia
Mixed Hyperlipidaemia
• Essentially high cholesterol and high
triglyceride
Hypertriglyceridaemia
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Triglyceride above 1.7 – 3.0
Usually secondary to alcohol or diabetes
Trig > 10mmol/L – risk of pancreatitis
Increased cardiovascular risk
Limited evidence that treating triglycerides
changes risk (Field study) – but we treat it
anyway!
HDL Cholesterol
• Independent risk factor for cardiovascular risk
• HDL less than 1.0 consider as high risk
• HDL > 3.0 – cardiovascular protection – Familial
hyperalphalipoproteinaemia
• Measurement of HDL requires a fasting sample
(as does triglyceride)
• Not much evidence that treating HDL makes any
difference
Drugs treating lipids
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Anion resins – cholestyramine et al
Ezetimibe
Fibrates
Fish oils
Nicotinic acid
Statins
Newer agents coming to market – biologic agents
Resins
• Rarely used
• New capsule format introduced ???
• Did work, and some patients preferred them
– most did not
• Antiquated and barely have a role
Ezetimibe
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Recently introduced
Modest reduction in cholesterol
Effective in combination
Few side-effects
No effect on triglycerides
Fibrates
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Really only means fenofibrate
Effective against triglyceride
Effective against cholesterol
Some side-effects
Effective in combination – side-effects over
exaggerated
• DON’T MIX GEMFIBROZIL WITH
STATIN - EVER
Fish Oils
• Omacor and Maxepa
• Only evidence of effect is with Omacor
• Need a barrel of fish per week to give
appropriate levels of the active fish oil
• Uses in hypertriglycerides
• Some evidence of protection post MI Gissi trial (absence of statins)
Nicotinic acid
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In many ways ideal lipid drug
Lowers LDL cholesterol
Lowers Triglyceride
Raises HDL cholesterol
Needs high doses
SIDE – EFFECTS up to 100% of patients
Last line of treatment – approximately 50%
tolerate it
• New preparation – attempting to reduce sideeffects – trial stopped due to side-effect concern
Statins
• ‘All statins are equal – but some are more
equal than others’ – unnamed DOH senior
civil servant
• Undeniably scientifically proven to
REDUCE DEATH
• Side – effects – myalgia,myositis and
rhabdomyolysis
• Think carefully about 80mg of any statin
Suggested treatment strategies
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Predominantly High Cholesterol – then
1st line statin
2nd line ezetimibe
3rd line fibrate if statin intolerant
Nb fibrates tend to interfere with statin
effect so do not combine in simple high
cholesterol
Treatment strategies
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Predominantly high triglyceride (>6.0)
Fibrate
Omacor
In diabetes patients (?impaired glucose
tolerance) pioglitazone
• Treat cholesterol level appropriately with
statin if need be (nb previous caution)
Management of patient
• Full history and examination (ECG)
• Blood tests
• Cholesterol, Triglyceride and HDL –
FASTING
• Glucose
• LFTs, U & Es, TSH
Management of patient
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Primary or secondary
Clinical guidelines – MOST are flawed
Poor recognition of family history, ethnicity
Use common sense (terminal cancer,
dementia)
Some practical points
• Familial hypercholesterolaemia and
children – refer to me
• Statins and fibrates(fenofibrate!) are safe
• Ezetimibe and fibrates are off licence –
refer to me
• Reasonable referrals – statin intolerance,
mixed hyperlipidaemias, familial
hypercholesterolaemias
Some more practical points
• Increase in LFTs – no concern up to 2x
upper limit of ref range
• Between 2x and 3x – monitor every three
months
• > 3x ref range stop tablets and review
therapy
• CK – Symptoms more important than level
Even more practical points
• In asymptomatic patients – CK 5x ref range
check three monthly
• CK 10x ref range – stop drug
• NB Africans and Afro-Caribbean's have
different ref range – usually higher
• Hypothyroidism can increase CK
• Other muscle myopathies
The Future?
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Statins in the water?
More aggressive treatments
Alternative treatments
More guidelines