2002 CLINICAL PRACTICE GUIDELINES MANAGEMENT OF LIPID ABNORMALITIES
2002 CLINICAL PRACTICE G UIDELINES MANAGEMENT OF LIPID ABNORMALITIES OVERVIEW The Management of Lipid Abnormalities guideline is based on the recommen...
2002 CLINICAL PRACTICE G UIDELINES MANAGEMENT OF LIPID ABNORMALITIES OVERVIEW The Management of Lipid Abnormalities guideline is based on the recommendations outlined in the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP III). The purpose of the guideline is to improve management strategies for primary prevention of coronary heart disease (CHD) and LDL cholesterol (LDL-C) control in people with CHD. Additionally, the guideline seeks to foster and improve adherence to evidence-based medicine and practice in lipid and cholesterol management. THE PHYSICIAN’S CLINICAL JUDGMENT MUST ULTIMATELY DETERMINE THE APPROPRIATE TREATMENT FOR EACH INDIVIDUAL CLASSIFICATION OF LDL, TOTAL, AND HDL CHOLESTEROL (MG/DL ) A complete nine- to 12-hour fasting lipoprotein analysis measuring total cholesterol, LDL-C, highdensity lipoprotein (HDL) cholesterol, and triglyceride should be performed every five years. Level Primary Target of Therapy LDL-Cholesterol 190 Very high Total Cholesterol 240 High HDL Cholesterol 60 High DETERMINE RISK FACTORS AND CATEGORY Risk Factors: • Cigarette smoking • Hypertension (BP >140/90 mmHg or on anti-hypertensive medication) • Low HDL cholesterol (20%* *See 10-year risk assessment tool on page 6. Three levels of 10-year risk: • >20% - CHD risk equivalent • 10-20% • 130mg/dL. EVIDENCE STATEMENTS: Persons with type 1 diabetes have increased risk for coronary heart disease. However, some persons with type 1 diabetes have a 10-year risk for CHD less than 15-20 percent (i.e., young persons without other risk factors). Nevertheless, such persons will have a high long-term risk for CHD. Moreover, there is no reason to believe that the benefits of LDL reduction are different in persons with type 1 and type 2 diabetes. RECOMMENDATIONS: The intensity of LDL-lowering therapy in persons with type 1 diabetes should depend on clinical judgment. Recent on-set type 1 diabetes need not be designated a CHD risk equivalent; hence reduction of LDL-cholesterol to 130 mg/dL (100-129 mg/dL: drug therapy is optional) 10-year risk 10-20%: >130 mg/dL 10-year risk 160 mg/dL >190 mg/dL (160-189 mg/dL: LDL-lowering drug is optional)
2002 CLINICAL PRACTICE G UIDELINES MANAGEMENT OF LIPID ABNORMALITIES LIPID LOWERING THERAPY: THERAPEUTIC LIFESTYLE COUNSELING (TLC) Lipid lowering therapy can be approached through therapeutic lifestyle changes or drug therapy. The TLC approach focuses on reduction of saturated fat (200 mg/dL Absolute: • Chronic liver disease • Severe gout Relative: • Diabetes • Hyperuricemia • Peptic ulcer disease Absolute: • Severe renal disease • Severe hepatic disease
*Cyclosporine, macrolide antibiotics, various anti-fungal agents, and cytochrome P-450 inhibitors (fibrates and niacin should be used with appropriate caution).
2002 CLINICAL PRACTICE G UIDELINES MANAGEMENT OF LIPID ABNORMALITIES
DRUG THERAPY IN PRIMARY PREVENTION
Initiate LDLlowering drug therapy
Start statin or bile acid sequestrant or nicotinic acid
6 wks s
If LDL goal is not achieved, intensify LDLlowering therapy
Consider higher dose of statin or add a bile acid sequestrant or nicotinic acid
6 wks
If LDL goal is not achieved, intensify drug therapy or refer to a lipid specialist
6 wks
Monitor response and adherence to therapy
If LDL goal achieved, treat other lipid risk factors
STRATEGIES TO IMPROVE PATIENT ADHERENCE TO DRUG THERAPY • • • • • • • • •
Simplify medication regimens Provide explicit patient instruction and use good counseling techniques to teach the patient how to follow the prescribed treatment Encourage the use of prompts to help persons remember regimens Use systems to reinforce adherence and maintain contact with the patient Encourage the support of family and friends Reinforce and reward adherence Increase patient visits for persons unable to achieve treatment goal Increase the convenience and access to care Involve patients in their care through self-monitoring
2002 CLINICAL PRACTICE G UIDELINES MANAGEMENT OF LIPID ABNORMALITIES 10-YEAR RISK CALCULATOR (Framingham Point Scores) MEN
