DYSLIPIDEMIA

Dharma Lindarto

Div: Endokrinologi-Metabolik. Departemen Ilmu Penyakit Dalam FK USU/RSUP. H Adam Malik Medan

Introduction
Dyslipidemia is a general term associated with high cholesterol and/or high triglyceride (TG) levels in plasma. Combined Dyslipidemias is both cholesterol (>200 mg/dL) and TGs are elevated. Cholesterol and triglycerides are normally present in the body and needed for normal cell function. (steroids, digestion, cell membranes) Two major clinical sequlae of hyperlipidemia are acute pancreatitis and atherosclerosis.

Lipoprotein Subclasses
0.95 VLDL Chylo-

microns

Density (g/ml)

1.006

IDL
1.02 LDL 1.06 1.10 1.20 HDL2 Lp(a) Chylomicron Remnants

HDL3
5 10 20 40 60 80 1000

Diameter (nm)

Functions of the Plasma Lipoproteins

ChylomicronTransport of dietary triglyceride VLDL Transport of endogenous triglyceride IDL -LDL precursor LDL Major cholesterol transport lipoprotein (BAD) HDL Reverse cholesterol transport (GOOD)

Released into lymph, and reach circulation through thoracic duct

Apolipoproteins
ApoA-I, which is synthesized in the liver and intestine, is found on virtually all HDL1 particles. ApoA-II is the second most abundant HDL apolipoprotein. ApoB is the major structural protein of chylomicrons, VLDL2, IDL3, and LDL4; apoB-48 (chylomicrons) or apoB-100 (VLDL, IDL, or LDL), ApoE is present in multiple copies on chylomicrons, VLDL, and IDL and plays a critical role in the metabolism and clearance of triglyceride-rich particles. ApoC-series (apoC-I, -II, and -III) also participate in the metabolism of triglyceride-rich lipoproteins.

Atherosclerosis
Atherosclerosis is the deposit of plaques containing cholesterol and lipids on the innermost layer of the walls of arteries. Atherosclerosis is the leading cause of death for both sexes in the US. (MI, hypertension,, brain infarct, death)

A key risk factor in the development of atherosclerosis is high blood cholesterol.

Among non-Hispanic whites age 20 and older, the ageadjusted prevalence of total blood cholesterol levels over 200 mg/dL is 48.9 percent of men and 52.1 percent of women. *
* National Health and Nutrition Examination Survey (NHANES), 1999-2002, Centers for Disease Control/National Center for Health Statistics.

Pathogenesis of Atherosclerotic Plaques

Endothelial damage Protective response results in production of cellular adhesion molecules (ICAM) Monocytes and T lymphocytes attach to sticky surface of endothelial cells Migrate through arterial wall to subendothelial space

Macrophages take up oxidised LDL-C

Lipid-rich foam cells Fatty streak and plaque

The inflammatory atherosclerotic process

Lumen of blood vessel
endothelium sdLDL Artery wall
Inflamm markers, CRP

sdLDL

monocyte
MMP-9

PLAQUE RUPTURE

Inflamm cytokines, IL-6, TNFa NFB O2- ROS ox-LDL foam cell
mf

MCP-1 ICAM-1

fatty streak

chemotaxis

Complex (vulnerable) plaque

differentiation

Smooth muscle cells

Lipid Levels in ATP III

Disorder Lipoprotein metabolisme

1. 2. Hypertriglyceride Primary Hypertriglyceridemia Secondary Hypertriglyceridemia Primary Familial Hypercholesterolemia Familial Hypercholesterolemia Familial combined Hyperlipidemia Lp (a) hyperlipoproteinemia

3.

Secundary Hypercholesterolemia Obesity, Diabetes, Hypothyroid, Cushing disease, renal disease

I. Primary Triglyceridemias High triglyceride (TG) levels have been epidemiologically linked with increased risk of coronary disease. Often linked with elevated VLDL and chylomicron levels. TG clearance is dependent on lipoprotein lipase. When plasma levels of TGs reach levels reach 800mg/dl or higher, lipoprotein lipase becomes saturated, individuals above that level must be treated to prevent acute pancreatitis.

Niacin and fibric acid derivatives are effective treatments.

II. Familial Hypercholesterolemia

Is an autosomal dominant trait, a defect in the high affinity LDL receptor. Homozygous individuals can have serum cholesterol levels as high as 1000mg/dl, leading to childhood development of coronary disease. Niacin and Atorvastatin are beneficial, but binding resins have from little to no effect in this disorder, depending on LDL receptor activity.

III. Familial Ligand-Defective Apolipoprotein B

Defect in ligand region of apo B100 region of LDL Impairs the endocytosis of LDL, leading to moderately severe hypercholesterolemias. Statins have variable effects, since even with upregulation of LDL receptors, defective LDL still cant taken up by cells. Niacin produces beneficial effects by reducing vLDL plasma levels.

IV. Familial Combined Hyperlipidemia

(The Phenotypic Classification of the Hyperlipoproteinemias based upon serum electrophoresis are: Types I, IIA, IIB, III, IV and V) Type I Hyperlipidemia chylomicrons (triglycerides) results LPL or apo C-II,
Type IIA Hyperlipidemia LDL. Type IIB Hyperlipidemia : of both LDL cholesterol and triglycerides. Type III Hyperlipidemia defect in VLDL remnant clearance

 Type IV Hyperlipidemia - Hypertriglyceridemia 250 and 500 mg/dl.

Type V Hyperlipidemia - chylomicrons and VLDL.

Coronary event, Eruptive xanthomas and pancreatitis

Symptoms of Hyper Cholesterolemia

High cholesterol rarely causes symptoms. It is usually detected during a regular blood test The first symptom of coronary artery disease (CAD) is often chest pain (angina). Unless the person has a transient ischemic attack (TIA), it is rare to have any warning signs of an oncoming stroke. Some people with lipid disorders or familiall hypercholesterolemia symptoms such as deposits of excess cholesterol in the skin or eye tissue, nodules in tendons in the hands or feet or rarely yellow streaks in the hands.

Eye signs in Hyperlipidaemia

CORNEAL ARCUS

XANTHELASMATA

Secundary Hypercholesterolemia
Diabetes Mellitus (1) LPL catabolism of chylomicrons, VLDL. (2) release of FFA from the adipose tissue (3) FFA synthesis in the liver, (4) hepatic VLDL production. Hypothyroid - hepatic LDL receptor function and clearance of LDL. Cushing Syndrome - VLDL synthesis and hypertriglyceridemia. Regular alcohol consumption - oxidation FFA hepatic syntesis VLDL

CHD Risk Factors

Smoking HTN >140/90 or on HTN Meds HDL < 40 mg/dl Family Hx of Premature CHD 1st degree Male < 45 yo 1st degree Female < 55 yo Age Men > 45 yo Women > 55 yo DM HDL 60 mg/dl counts as negative Risk Factor

Risk Equivalents

CHD
MI Angina Angioplasty Bypass Surgery

Non-coronary Atherosclerotic Disease

Peripheral Artery Disease Carotid Artery Disease

DM

TREATMENT OPTIONS FOR DYSLIPIDEMIA

Lifestyle Changes include: -reduce CAD risk include smoking cessation, -dietary changes, -weight loss, -and regular physical activity. Dietary changes include: - reducing the intake of saturated fats to less than 7% of the diet, - reducing cholesterol to <200 mg/dL, - increasing the intake of soluble fiber (10-25 g/d).

Diet Therapy for High Blood Cholesterol

(Data from National Cholesterol Education Program [NCEP]. Second Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults [Adult Treatment Panel II]. NIH Publication N. 93-3095. Bethesda, MD; National Institutes of Health. National Heart, Lung, and Blood Institute, 1993.) * Calories from alcohol not included.

Treatment Paradigm

Lipid Lowering Drugs

Lipoprotein Effects of Lipidmodifying Therapy

Statins
LDL 18%-55%

Nicotinic acid
5%-25%

Fibrates
5%-20%

HDL
Triglycerides Small, dense LDL Effect on insulin resistance

5%-15%
7%-30% No effect None

15%-35%
20%-50% Decrease

10%-20%
20%-50% Decrease

May increase May increase

Anti-hyperlipidemic Drugs
A. Niacin (Nicotinic Acid)
Treats combined dyslipidemias

Decreases LDL levels and vLDL levels.

Pharmacokinetics
Rapid absorption, Plasma T1/2- (20-40min) Water soluble Vitamin B3 which is converted in the body into nicotinamide adenine dinucleotide (NAD). Excreted unchanged as well as a number of metabolites.

Mechanism primarily involves the inhibition of vLDL secretion thereby reducing LDL levels!!. Also lowers both triglycerides and Lp(a) levels.

Niacin (cont)
Side Effects:
Flushing, tachycardia, atrial arrhythmias, dry skin, nausea, hyperuricemia, diarrhea, peptic ulcer disease, glucose intolerance, hepatic dysfunction.

Contraindications
Peptics ulcers, cardiac arrhythmias, liver disease, gout and diabetes mellitus

Drug Interactions
Works synergistically with ganglionic blockers leading to orthostatic hypotension.

B. Fibric Acid Derivatives

Gemfibrozil and Fenofibrate
Reduces vLDL levels and increases the activity of

lipoprotein lipase!!!.
Typically used to treat hypertriglyceridemias in which vLDL predominate and in dysbetalipoproteinemia.

Lowers triglycerides and raises HDL. Pharmacokinetics

absorbed from the GI tract & undergoes enterohepatic circulation. Most (70%) is eliminated unchanged through the kidneys. Half life is 1.5 hrs.

Fibric Acid Derivatives (cont)

Side Effects:
rare cases of rash, GI symptoms, myopathy, arrhythmias, hypokalemia & high aminotransferase or

alkaline phosphatase levels, risk of cholesterol gallstones.

Major drug interactions:

fibric acid derivatives increase the anticoagulant effect of coumarin & indanediones.

Contraindications
patients with hepatic or renal dysfunction, patients with biliary tract disease

C. Bile Acid Binding Resins

Colestipol and Cholestyramine
Decrease LDL levels, increase HDL and TGs

Mechanism of Action:
Colestipol binds bile acids in the intestine forming a complex that is excreted in the feces. This nonsystemic action results in a partial removal of the bile acids from the enterohepatic circulation, preventing their reabsorption. The increased fecal loss of bile acids due to colestipol hydrochloride administration leads to an increased oxidation of cholesterol to bile acids. *** This results in an increase in the number of lowdensity lipoprotein (LDL) receptors, thereby decreasing serum LDL levels

Bile Acid Binding Resins (cont)

Pharmacokinetics:
Not absorbed!!!

Side Effects
Constipation, may cause an increase in vLDL
necessitating the addition of a 2nd agent such as niacin. Bad tasting may lead to compliance issues. Ineffective in homozygous familial cholesteremia due to lack of LDL receptor.

Drug interactions:
may delay or reduce the absorption of other concomitant oral medications Because these resins bind bile acids they may interfere with normal fat digestion and absorption and thus may prevent absorption of fat soluble vitamins such as A, D, E, and K.

D. HMG-CoA Reductase Inhibitors

Statins
They are structural analogues of hydroxy-methyl-glutaryl coenzyme A (HMG-CoA) and are competitive inhibitors of HMG-CoA reductase!!. Used primarily for the reduction of LDL levels. Seems to also have an effect on C-reactive protein (CRP) levels as well. Mechanism HMG-CoA reductase mediates the first committed step in sterol biosynthesis. ***This leads to an induction of high affinity LDL receptors, thus lowering serum LDL levels. Increasing LDL receptors is the impt. part of mechanism! Due to the high first pass metabolism, the main effect of these drugs is on the liver.

Statins (cont)
Pharmacokinetics
Lovastatin (Mevacor) and simvastatin (Zocor*) are inactive prodrugs and are activated in the GI tract, all others are active drug. Absorption varies between 40-75%, with fluvastatin (Lescol*) being nearly completely absorbed. High first pass metabolism by Cytochrome P450 (CYP 3A4 or CYP2C9) (grapefruit juice) Mainly excreted in the bile with 5-20% excreted in urine. T1/2 ranges from 1 to 3 hours, except atorvastatin (Lipitor*) T1/2=14 hrs.

Statins (cont)
Side Effects
Elevations of serum aminotransferase activity up to 3x commonly occur and generally do not result in hepatotoxicity. In ~2% of patients (some of whom have underlying liver disease or alcohol abuse) may have > 3x elevations in aminotransferase levels, may indicate severe

hepatotoxicity, statin treatment should discontinue immediately.

Rare side effect include myositis (muscle pain), marked by elevated creatine kinase activity. If the drug is not discontinued, rhabdomyolysis may occur producing myoglobinemia that may lead to acute renal failure.

Statins (cont)
Major drug interactions:
Drugs that inhibit or compete for CYP 3A4 or CYP2C9 will increase the plasma concentrations of statins. Drugs that induce CYP will reduce plasma statin levels (see below). Concomitant use of amiodarone or verapamil causes an increased risk of myopathy.

Contraindications
Pregnancy due to potential teratogenicity

E. EZETIMIBE (Zetia*)
Prodrug (liverglucuronide) Decreases GI Uptake of cholesterol Both dietary and biliary secreted cholesterol Reduces tightly regulated cholesterol pool in liver resulting in increased synthesis of high affinity LDL receptors and subsequent removal of LDL from blood LOWERS SERUM LDL and TRIGLYCERIDES!! INDICATIONS: hypercholesterolemia TOXICITY: Well tolerated, but may increase hepatic toxicity with HMG CoA reductase inhibitors

Dyslipidemia Treatment Guideline

This algorithm is useful once a confirmatory 9-12 hour fasting lipoprotein profile is available and secondary dyslipidemia has been ruled out.
NCEP ATP III JAMA. 2001;285:2486-2497

Visit 2 TLC ONLY

(6 weeks later)
Check LDL response Intensify TLC Consider ordering labs for next visit

Visit 3 (6 weeks later)

Check LDL response Intensify TLC Consider drug therapy (Go to VISIT 2, TLC & Rx)

HDL 40

TG < 200

HDL < 40

Visit 1
Rule out secondary dyslipidemia* Assess CHD risk Identify CHD risk equivalents (DM, AAA, ASPVD, symptomatic carotid disease) Calculate 10-year risk -- see Framingham Risk Scoring Identify major risk factors (RF) (see reverse) If TG 400 treat to < 400$ Set LDL goal$ (Consider ordering labs for next visit now) Determine initial treatment plan$ (TLC alone or TLC + Rx) Begin Therapeutic Lifestyle Changes (TLC) if LDL > goal

and CHD or equivalent

Follow up Visit
(q 4-6 mos.) Monitor treatment response Maintain TLC Monitor for drug side effects

Meet LDL goal consider secondary treatment goals

Isolated low-HDL
TLC and Rx HDL (see reverse)

TG 200-499 Visit 2 TLC AND Rx

(6 weeks later)
Check LDL response Intensify TLC Initiate LDL drug therapy if LDL exceeds levels shown below. Consider ordering labs for next visit

Metabolic Syndrome 3 of 5
Waist Circumference Men > 40 Women > 35 Triglycerides 150 HDL Men < 40 Women < 50 Fasting glucose 110 Blood Pressure 130 / 85

Visit 3 (6 weeks later)

Check LDL response Maintain/Intensify TLC Intensify current med or initiate combination therapy as needed

*Secondary Dyslipidemia Diabetes Hypothyroidism Obstructive liver disease Chronic renal failure Drugs that LDL Progestins Anabolic steroids Corticosteroids

Primary

Treatment Goals (mg/dL) When TG 400, lab cant calculate LDL Treat: TG-specific TLC + Niacin/Fibrate When TG < 400; set LDL goals Framingham LDL Goal Consider 10-yr Risk (TLC if LDL above goal) Add Meds < 10% (0-1 RF) < 160 160 < 10% (2+ RF) < 130 160 10-20% < 130 130 > 20% < 100 130

Secondary Treatment Goals If TG 200 mg/dL non-HDL is 2 target Usually seen with metabolic syndrome LDL + VLDL = non-HDL-C = Total cholesterol HDL Normal VLDL = 30 mg/dL, therefore 10-yr Risk LDL Goal non-HDL Goal < 10% (0-1 RF) < 160 < 190 < 10% (2+ RF) < 130 < 160 10-20% < 130 < 160 > 20% < 100 < 130

Initial Approach
Major Risk Factors (RF)
Age/Gender Male 45 years Female 55 years BP 140/90 mm Hg or BP meds Cigarette smoking FH of CHD in 1 relative Male < 55 years Female < 65 years HDL < 40 mg/dL

Specific Dyslipidemias Therapeutic Lifestyle Changes (TLC)

Smoking cessation as needed Increase physical activity level Limit saturated fats, like dairy fats (e.g. butter) and palm and coconut oil (e.g. baked goods) Limit high-cholesterol foods, like egg yolks, organ meats (such as liver) and shellfish Eat more fruits and vegetables Eat more broiled or grilled fish and skinless chicken breasts Choose lean cuts when you eat beef, pork and lamb. Also eat smaller portions Eat a variety of fiber-rich foods, like oats, dark breads and apples Choose low-fat or nonfat dairy products Avoid fried foods
(Adopted from information found at www.familydoctor.org)

Low HDL (< 40 mg/dL)

Contributory factors
- Associated with insulin resistance - Elevated TG - Overfat - Physical inactivity - Type 2 diabetes - Cigarette smoking - High-carb diet (> 60% of calories) - Drugs: - B-blockers - Anabolic steroids - Progestins Treatment (usually for those with CHD or equivalent) - Treat LDL then TLC - HDL < 40 mg/dL + TG 200-499 mg/dL treat TG - HDL < 40 mg/dL + TG < 200 mg/dL HDL raising drugs

ATP III Lipid Classification

LDL Cholesterol
< 100 100-129 130-159 169-189 190 < 200 200-239 240 Optimal Above optimal Borderline high High Very high Desirable Borderline high High Low High Normal Borderline high High Very high

Total cholesterol (TC)

Very High LDL (>190 mg/dL)

Generally represents genetic hypercholesterolemia Important to identify in young adults Treatment: often requires combination therapy

HDL cholesterol
< 40 60 < 150 159-199 200-499 500

Elevated Triglyceride
Contributory factors
- Obesity and overfat - Physical inactivity - Cigarette smoking - Excess alcohol intake -High-carb diet (> 60% of calories) - Diseases - Type 2 diabetes - Chronic renal failure - Nephrotic syndrome - Drugs: - Corticosteroids - Estrogens - Retinoids Treatment (meet LDL goal, then) - TG 150-199 mg/dL TLC - TG 200-499 target non-HDL - Intensify statin therapy - Add nicotinic acid or fibrate - TG 500 lower TG before LDL - Very low-fat diet ( 15% of calories) - Fat reduction - Increased physical activity - Nicotinic acid or fibrate - When TG < 500 mg/dL lower LDL

Serum Triglycerides (TG)

Lipid Lowering Medication

Drug Class Statin Lipid Effect LDL 18-55% HDL 5-15% TG 7-30% LDL 15-30% HDL 3-5% TG no effect LDL 5-25% HDL 15-35% TG 20-50% LDL 5-20% HDL 10-20% TG 20-50% Side Effects Myopathy Increased LFTs Contraindications Absolute: liver disease Relative: concomitant use of some drugs Absolute: TG > 400 mg/dL Relative: TG > 200 mg/dL DoD Formulary Simvastatin (Zocor) start 20-40 mg after evening meal not approved for flyers Colestipol (Colestid) start 1-2 gms qd-bid work to 2-16 gms/day Niacin (Niaspan) start 250 mg q HS work to 1-2 gms bid-tid not approved for flyers Gemfibrozil (Lopid) 600 mg bid 30 min before meals not approved for all flyers

Bile Acid Sequestrant

GI distress; constipation Decreased absorption of other drugs Flushing; hyperglycemia upper GI distress liver toxic; uric acid

Nicotinic acid

Absolute: Chronic liver dz. severe gout Relative: diabetes; PUD

Fibric acid

Dyspepsia; gallstones myopathy; unexplained non-CHD deaths in studies

Absolute: severe renal dz severe hepatic dz.

Primary Prevention with Lipoprotein Analysis

(From National Cholesterol Education Program: Second Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). National Institutes of Health, NIH Publication No. 93-3095. Bethesda, MD: National Heart, Lung, and Blood Institute, 1993.)

2004, 2002 Elsevier Inc. All rights reserved.

Primary Prevention in Adults without Evidence of CHD: Initial Classification Based on Total Cholesterol and HDL Cholesterol

(From National Cholesterol Education Program: Second Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). National Institutes of Health, NIH Publication No. 93-3095. Bethesda, MD: National Heart, Lung, and Blood Institute, 1993.) HDL = high-density lipoprotein.

2004, 2002 Elsevier Inc. All rights reserved.

Reference - 1. Basic and Clinical Endocrinology 7th Edition - 2. 16th Edition HARRISONS PRINCIPLES OF Internal Medicine