Transcript Dyslipidemia case#6

Dyslipidemia
case#6
Husam 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
Neuro
o 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 cholesterollowering 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
Questions and Answers
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
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