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December 2016 CardioLAN Webinar Course Cholesterol: The Good, The Bad & The Ugly Guest Expert: Chelsea E. Leonard PharmD, Clinical Pharmacist This material was prepared by Quality Insights, the Medicare Quality Innovation Network-Quality Improvement Organization supporting the Home Health Quality Improvement National Campaign, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The views presented do not necessarily reflect CMS policy. Publication number 11SOW-WV-HH-MMD-111516A Continuing Education Credits Nursing: 1.25 hrs of Continuing Education – Approved by the Alabama State Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation HHQI Announcements My HHQI Blog Learn About Cholesterol: The Good, the Bad, and the Ugly (9/16/16) – Chelsea E. Leonard, PharmD, Clinical Pharmacist – Frances V. Cohenour, PharmD, Clinical Pharmacist & Co-Owner – Chad’s Payless Pharmacy (Florence, Alabama) Cholesterol: The Good, The Bad, and The Ugly CHELSEA E. LEONARD, PHARMD Disclosure I do not have (nor does any immediate family member have) actual or potential conflict of interest, within the last twelve months, a vested interest in or affiliation with any corporate organization offering financial support or grant monies for this continuing education activity, or any affiliation with an organization whose philosophy could potentially bias this presentation. Objectives Differentiate between the different types of cholesterol Identify the treatment guidelines for cholesterol management Explain to patients about lifestyle modifications that can improve cholesterol management Describe over-the-counter medications that can be used to improve cholesterol management Identify ways to involve community pharmacists in managing cholesterol Get the Facts 73.5 million adults in the United States have high LDL People with high cholesterol have twice the risk of heart disease Heart disease is the leading cause of death in the United States Other risk factors include: diabetes, obesity, poor diet, physical inactivity, excessive alcohol intake Less than half of adults with high cholesterol get treatment Center for Disease Control. High Cholesterol Facts. 2015 Heart Disease Heath Rates Center for Disease Control. Heart Disease Fact Sheet. 2016. What is Cholesterol? Waxy, fat-like substance that travels through the blood attached to proteins called lipoproteins Two sources: Produced in the body to make certain hormones Food (eggs, cheese, fatty meats, etc.) Build up of cholesterol can cause plaques in arteries Center for Disease Control. About High Cholesterol. 2015 Cholesterol Sources Cholesterol Panel HDL – “good” cholesterol Absorbs bad cholesterol and takes it back to the liver to be flushed out of the body Can reduce the risk of heart disease and stroke Ideal level: 40 mg/dL or higher LDL – “bad” cholesterol Makes up the majority of body’s cholesterol High levels can cause plaque buildup in arteries and lead to heart disease and stroke Ideal level: less than 100 mg/dL Center for Disease Control. LDL and HDL: “Bad” and “Good” Cholesterol. 2015 Cholesterol Panel (cont.) Triglycerides – “ugly” cholesterol Type of fat found in blood When combined with high LDL or low HDL, the risk of heart attack or stroke is increased Affected by eating fatty foods, refined sugars, carbohydrates Ideal level: less than 150 mg/dL Total cholesterol Ideal level: less than 200 mg/dL Center for Disease Control. LDL and HDL: “Bad” and “Good” Cholesterol. 2015 Triglycerides Cholesterol Screening Fasting full lipid panel Recommended years old Should years for adults over 20 be checked at least every 5 Center for Disease Control. LDL and HDL: “Bad” and “Good” Cholesterol. 2015 Fasting Lipid Panel At least 8 hours with no food or drink (except water or black coffee) If not: Polling Question #1 What is the ideal level of total cholesterol? A. <150 mg/dL B. <175 mg/dL C. <200 mg/dL D. <250 mg/dL Treatment Guidelines and Medications Treatment Guidelines Definitions Atherosclerotic cardiovascular disease (ASCVD) Acute coronary syndromes, MI, stable or unstable angina, coronary or other arterial revascularization, stroke or TIA, PAD ASCVD outcomes MI, stroke, ASCVD death Treatment guidelines aiming to prevent these outcomes Stone N J et al. Circulation. 2013. Treatment Guidelines – Statin Benefit Groups Clinical ASCVD LDL > 190 Diabetes 10-yr risk ≥ 7.5% Stone N J et al. Circulation. 2013. ASCVD Risk 10-yr risk estimate based on: • • • • • Gender Age Race Total cholesterol HDL • • • • Smoking status Diabetes Hypertension Systolic Blood Pressure ASCVD Risk Estimator can be found here: http://tools.acc.org/ASCVD-Risk-Estimator Stone N J et al. Circulation. 2013. Statin Medications Atorvastatin (Lipitor) Rosuvastatin (Crestor) Simvastatin (Zocor) Lovastatin (Mevacor) Pitavastatin (Livalo) Fluvastatin (Lescol) Statin Medications Work in liver to prevent formation of cholesterol, thus decreasing amount of cholesterol in the blood Most potent total cholesterol and LDL-lowering agents Cholesterol-independent effects: Increase stability of atherosclerotic plaques Decrease inflammation Inhibit thrombogenic response Atorvastatin. Lexicomp Online® Lexi-Drugs.® Treatment Guidelines Stone N J et al. Circulation. 2013. Statin Intensity High Intensity (lowers LDL ≥ 50%) •Atorvastatin 40 or 80 mg •Rosuvastatin 20 or 40 mg Moderate Intensity (lowers LDL 30-50%) •Atorvastatin 10 or 20 mg •Rosuvastatin 5 or 10 mg •Simvastatin 20 or 40 mg •Pravastatin 40 or 80 mg •Lovastatin 40 mg •Fluvastatin XL 80 mg •Fluvastatin 40 mg BID •Pitavastatin 2 or 4 mg Low Intensity (lowers LDL <30%) •Simvastatin 10 mg •Pravastatin 10 or 20 mg •Lovastatin 20 mg •Fluvastatin 20 or 40 mg •Pitavastatin 1 mg Stone N J et al. Circulation. 2013. Statin Medications Dosed once daily in the evening Atorvastatin, rosuvastatin, and pitavastatin can be given any time during the day Most common side effect reported is muscle symptoms Cramps, pain, weakness, etc. Women have higher risk of muscle symptoms If symptoms become problematic, dose of current statin should be lowered or patient should be switched to a different statin Atorvastatin. Lexicomp Online® Lexi-Drugs.® Statin Medications Significant drug interactions: Amiodarone Azole antifungals (fluconazole, ketoconazole, etc.) Calcium channel blockers (amlodipine, diltiazem, etc.) Cimetidine Colchicine Digoxin Warfarin Grapefruit juice Atorvastatin. Lexicomp Online® Lexi-Drugs.® Non-Statin Medications Bile acid sequestrants • Cholestyramine (Questran), colestipol (Colestid), colesevelam (Welchol) Fibric acid derivatives • Fenofibrate (TriCor), gemfibrozil (Lopid) Cholesterol• Ezetimibe (Zetia) absorption inhibitors Niacin • Immediate-release and extendedrelease (Rx only) Bile Acid Sequestrants Can lower LDL by 15-30% Useful when patient also has diabetes Gastrointestinal side effects Constipation, bloating, belching Must be titrated over a few months to avoid GI upset Other tips: Separate from other medications – give either 1 hour before or 4 hours after other mediations Give with lots of water Increase fiber intake Cholestyramine. Lexicomp Online® Lexi-Drugs.® Fibric Acid Derivatives Can increase HDL and decrease triglycerides Side effects: Combination with statins increases risk of myalgia/myopathy Nausea, vomiting, diarrhea, abdominal pain Avoid gemfibrozil with simvastatin or lovastatin Other tips: Gemfibrozil should be given 30 minutes before meals Gemfibrozil. Lexicomp Online® Lexi-Drugs.® Cholesterol Absorption Inhibitor Decreases Mild LDL by ~17% side effects Increased LFTs – should be monitored periodically Other Can tips: be given with or without food Ezetimibe. Lexicomp Online® Lexi-Drugs.® Niacin Decreases LDL, increases HDL, decreases triglycerides Most common side effects: flushing and itching Can give 325 mg aspirin 30 minutes before niacin Avoid spicy foods and hot beverages Extended-release formulation (Rx only) can also reduce flushing Combination with statin may increase risk of myalgia/myopathy Other tips: Give with food to reduce GI side effects “No flush” formulations should be avoided as they do not affect lipids Niacin. Lexicomp Online® Lexi-Drugs.® Polling Question #2 Which class of medications does NOT decrease LDL? A. Fibric Acid Derivatives B. Statins C. Bile Acid Sequestrants D. Cholesterol Absorption Inhibitors Lifestyle Modifications Lifestyle Modifications Recommended as background therapy for ALL patients Typically implemented for six months prior to starting medications Should not be stopped when medications are introduced Lifestyle Modifications Heart healthy diet Low fat, high fiber American Heart Association recommends DASH diet (low sodium, low saturated fat) Regular exercise At least 40 minutes three to four days per week Avoidance of tobacco products Maintenance of a healthy weight American Heart Association. Lifestyle Changes and Cholesterol. 2016. Over-the-Counter Supplementation Coenzyme Q10 (CoQ10) Demonstrated some benefit in reducing muscle symptoms from statins Dosing: 300 mg per day Inexpensive Low-risk Should not be taken if patient is on a blood thinner like warfarin Ubiquinone. Lexicomp Online® Natural Products Database. 2016 Omega-3 Fish Oil Can decrease triglycerides and increase HDL Dosing: 2-4 grams per day Most common side effect: fishy aftertaste Enteric coated formulation helps reduce risk of fishy taste Can also freeze capsules or take with a meal to avoid Should not be taken if patient is on a blood thinner like warfarin Omega-3 also found in flaxseed, chia seeds, walnuts, seafood, soybeans, spinach, etc. Omega-3 Fatty Acids. Lexicomp Online® Lexi-Drugs.® 2016. Red Yeast Rice Considered the “natural statin” Contains monacolin K – chemically identical to active ingredient in lovastatin Dosing: 1,200mg twice daily Side effects similar to statins Should not be used while pregnant or breastfeeding Many drug interactions May be useful if patient is unable to tolerate statin Red Yeast Rice. Lexicomp Online® Natural Products Database. 2016 Red Wine Key ingredient - resveratrol May increase HDL and protect against plaque buildup May help protect the lining of blood vessels in heart A drink is defined as 5 ounces of wine Women: one drink per day Men > 65: one drink per day Men < 65: two drinks per day Resveratrol is also found in red/purple grapes, peanuts, blueberries, and cranberries – may not be as beneficial Mayo Clinic. Red wine and resveratrol: Good for your heart? 2016. How to Involve Your Community Pharmacist Polling Question #3 Do you have a community pharmacist you communicate with regularly? A. Yes B. No Adherence Medications are not effective unless taken properly Common adherence issues: Cost Pill burden Forgetfulness Side effects Side Effect Management Common reason for adherence issues Side effects could be reduced by taking medication with food, at a different time of day, etc. Dosage may be too high and pharmacist can communicate with prescriber to make recommendations Pharmacist can recommend OTC agents to help with side effects (ex. CoQ10 for muscle cramps) Drug Interactions Pharmacist can identify drug interactions and communicate with prescriber if action needs to be taken Pharmacists can determine if interactions can be prevented if the medications are separated Point-of-Care Testing Many pharmacists have the capability to check cholesterol in the pharmacy Can provide results in approximately 5 minutes and make recommendations for management New updates? New Statin Recommendations US Preventive Services Task Force released new recommendations in November Recommends that all patients 40 years and older should be screened to see if they need a statin regardless of history of cardiovascular disease Risk factors: High cholesterol High blood pressure Diabetes smoking United States Preventive Services Task Force. Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Preventive Medication. 2016. Chelsea E. Leonard, PharmD Chad’s Payless Pharmacy, Inc. Florence, AL Questions? [email protected] 256.766.3298 References Center for Disease Control. High Cholesterol Facts. 2015. Available at: http://www.cdc.gov/cholesterol/facts.htm Center for Disease Control. Heart Disease Fact Sheet. 2016. Available at: http://www.cdc.gov/dhdsp/data_statistics/fact_sheets /fs_heart_disease.htm Center for Disease Control. About High Cholesterol. 2015. Available at: http://www.cdc.gov/cholesterol/about.htm. Center for Disease Control. LDL and HDL: “Bad” and “Good” Cholesterol. 2015. Available at: http://www.cdc.gov/cholesterol/ldl_hdl.htm References (cont.) Stone, NJ, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation. 2013;01.cir.0000437738.63853.7a, originally published November 12, 2013. Atorvastatin. Lexicomp Online® Lexi-Drugs® , Hudson, Ohio: Lexi-Comp, Inc.; November 2, 2016. Cholestyramine. Lexicomp Online® Lexi-Drugs® , Hudson, Ohio: Lexi-Comp, Inc.; November 2, 2016. Gemfibrozil. Lexicomp Online® Lexi-Drugs® , Hudson, Ohio: Lexi-Comp, Inc.; November 2, 2016. Ezetimibe. Lexicomp Online® Lexi-Drugs® , Hudson, Ohio: Lexi-Comp, Inc.; November 2, 2016. References (cont.) Niacin. Lexicomp Online® Lexi-Drugs® , Hudson, Ohio: Lexi-Comp, Inc.; November 2, 2016. American Heart Association. Lifestyle Changes and Cholesterol. 2016. Available at: https://www.heart.org/HEARTORG/Conditions/Choleste rol/PreventionTreatmentofHighCholesterol/LifestyleChanges-and-Cholesterol_UCM_305627_Article.jsp# Ubiquinone. Lexicomp Online® Natural Products Database , Hudson, Ohio: Lexi-Comp, Inc.; November 2, 2016. Omega-3 Fatty Acids. Lexicomp Online® Lexi-Drugs® , Hudson, Ohio: Lexi-Comp, Inc.; November 2, 2016. References (cont.) Red Yeast Rice. Lexicomp Online® Natural Products Database , Hudson, Ohio: Lexi-Comp, Inc.; November 2, 2016. Mayo Clinic. Red wine and resveratrol: Good for your heart? 2016. Available at: http://www.mayoclinic.org/diseases-conditions/heartdisease/in-depth/red-wine/art-20048281 United States Preventive Services Task Force. Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Preventive Medication. 2016. Available at: https://www.uspreventiveservicestaskforce.org/Page/D ocument/UpdateSummaryFinal/statin-use-in-adultspreventive-medication1. Questions? HHQI Cholesterol Resources Cholesterol management & Smoking cessation Best Practice Intervention Package (BPIP) – Current American College of Cardiology/American Heart Association (ACC/AHA) guidelines – Clinician & Patient tools Patient Tools Patient Tools (cont.) Medication Adherence Assessment HHQI Underserved Population BPIP – Morisky Medication Adherence Scale & Tip Sheet HHQI Medication Management Focused BPIP – Guiding Patients Toward Medication Adherence Continuing Education Steps Follow these steps to get your CE certificate: 1. Register/log in to HHQI University. You will be automatically redirected to this website when you exit this webinar. Continuing Education Steps 2. Click on the Cholesterol: The Good, the Bad, and the Ugly course in the Cardiovascular Health course catalog. 3. Click on Enroll under the icon. 4. Click on My Account to launch the course. 5. Click on the icon next to the course in the View column. Continuing Education Steps 6. Click on the to Lesson 1. icon in the Action column next • Complete the reflective question and evaluation 7. After completing the evaluation, you can print your certificate from the My Account area in HHQI University. Questions? Thank You! [email protected] www.HomeHealthQuality.org This material was prepared by Quality Insights, the Medicare Quality Innovation Network-Quality Improvement Organization supporting the Home Health Quality Improvement National Campaign, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The views presented do not necessarily reflect CMS policy. Publication number 11SOW-WV-HH-MMD-111516A