PHARMACY BASED LIPID MANAGEMENT WORKSHEET

Patient name: ______SS# Last 4 ______

Patient Information

Age / Gender
Height (in) / Smoker:
Weight (lbs) / Allergies/ADR
BMI / Waist Cir.
BP / FBG
Date: / Date: / Date:
SGPT
SGOT
Alk Phos
Gamma-GTP
SCr
TSH
CPK

STEP 1 Determine lipoprotein levels – obtain complete lipoprotein profile after 9- to 12- hour fast.

  • LDL (calculated by lab) cholesterol = ______
  • LDL (direct serum level) = ______(only if triglycerides >400mg/dL)
  • VLDL cholesterol = Triglycerides/5 = ______
  • Categorize results
  • ATP III Classification of LDL, Total, and HDL Cholesterol and Triglycerides (mg/dL)

LDL Cholesterol: Primary Target of Therapy

 <100 Optimal

 100-129 Near optimal/above optimal

 130-159 Borderline high

 160-189 High

 ≥190 Very high

Total Cholesterol

 <200 Desirable

 200-239 Borderline high

 ≥240 High

HDL Cholesterol

 <40 Low

 ≥60 High

Triglycerides

 <150Normal

 150-199 Borderline high

 200-499 High

 ≥500 Very high

Any secondary causes of hyperlipidemia?

 Chronic renal failure /  Hypothyroidism
 Nephrotic syndrome /  Obstructive liver disease
 Diabetes /  Drug therapy

*Medications That Cause Alterations in Lipoproteins

Drug / LDL / HDL / Triglycerides / Patient Med/Dose
Amiodarone /
Anabolic Steroids / /
Beta Blockers / / /
Thiazide Diuretics / /
Corticosteroids / /
Cyclosporine /
Protease Inhibitors / / /
Progestins / /
Retinoids / / /
Antipsychotics / /

Benefit of drugs usually outweighs the risk of altering the lipid profile. Use caution in recommending discontinuation of medications

STEP 2 Identify presence of clinical atherosclerotic disease or other conditions that confer high risk for CHD events (CHD risk equivalents)

  • Determine presence of established CHD

 A history of acute myocardial infarction

 Evidence of silent myocardial infarction or myocardial ischemia

 History of unstable angina or stable angina pectoris

 History of coronary procedures (coronary angioplasty, coronary artery surgery)

  • Determine presence of other clinical atherosclerotic conditions

 Abdominal aortic aneurysm

 Peripheral arterial disease

 Symptomatic carotid artery disease, defined as a transient ischemic attack,

stroke of carotid origin, or >50% stenosis on angiography or ultrasound

  • Determine presence of diabetes

 Symptoms of diabetes plus casual plasma glucose concentration ≥200mg/dL

 Fasting plasma glucose ≥126mg/dL

 A 2-hour postload glucose ≥200mg/dL during an oral glucose tolerance test

(using a glucose load containing the equivalent of 75 g anhydrous glucose

dissolved in water)

CHD or CHD risk equivalents present?

 Yes (skip to Step 5)

 No (proceed to Step 3)

STEP 3 Determine presence of major risk factors (other than LDL

cholesterol) that may modify LDL goals)

  • Identify positive risk factors

Present ? / Risk Factor / Definition
 / Cigarette smoking /
  • Any cigarette smoking in the past month

 / Hypertension /
  • Systolic blood pressure ≥140 mmHg, or
  • Diastolic blood pressure ≥90mmHg or
  • Taking antihypertensive medication

 / Low HDL cholesterol /
  • <40 mg/dL

 / Family history of premature CHD /
  • CHD in male first-degree relative <55yrs
  • CHD in female first-degree relative <65yrs

 / Age /
  • ≥45 yrs in men
  • ≥55 yrs in women

Total # positive risk factors: ______

  • Identify negative risk factor

Present? Risk Factor Definition

 High HDL cholesterol • ≥60 mg/dL

  • Sum positive risk factors; subtract negative risk factor

Risk factor total: ______

Does patient have ≥2 risk factors*?

 Yes (proceed to Step 4)

 No (skip to Step 5)

*Other than CHD or CHD risk equivalents

Page 1 of 9

(Adapted by Ted D. Williams from White City VA Template by Don Lockwood)

PHARMACY BASED LIPID MANAGEMENT WORKSHEET

STEP 4 If ≥2 risk factors (other than LDL) are present without CHD or

CHD risk equivalent, assess 10-year (short-term) CHD risk by

using the Framingham tables on the next page

  • Use appropriate Framingham chart (different charts for men and women)

Patient’s 10-year risk: ______

  • Determine patient’s level of risk:

 >20%--CHD risk equivalent

 10% to 20%

 <10%

MEN / WOMEN
Estimate of 10-Year Risk for Men / Estimate of 10-Year Risk for Women

STEP 5 Determine patient’s risk category to establish LDL goal of therapy

and determine need for treatment

  • Determine risk category

 High risk: CHD or CHD risk equivalent (10-year risk >20%)

 Moderately high risk: ≥2 risk factors and 10-year risk 10%-20%

 Moderate risk: ≥2 risk factors and 10-year risk <10%

 Lower risk: 0-1 risk factor (10-year risk <20%)

  • Determine LDL cholesterol goal and need for therapy

LDL Cholesterol Goals and Cutpoints for Therapeutic Lifestyle Changes and Drug Therapy in Different Risk Factors (ATP III Update 2004)

Risk Category / LDL cholesterol Goal (mg/dL) / Initiate TLC / Consider Drug Therapy
High risk: CHD or CHD risk equivalent (10-year risk >20%) / <100 mg/dL (Optional goal <70 mg/dL) / ≥100 mg/dL / ≥100 mg/dL
(<100 mg/dL; Consider drug options)
Moderately high risk: 2+ risk factors (10 year risk 10% to 20%) / <130 mg/dL (Optional goal <100 mg/dL) / ≥130 mg/dL / ≥130 mg/dL
(100-129 mg/dL; Consider drug options)
Moderate risk: 2+ risk factors (10-year risk <10%) / <130 mg/dL / ≥130 mg/dL / ≥160 mg/dL
Lower risk: 0-1 risk
factor / <160 mg/dL / ≥160 mg/dL / ≥190 mg/dL
(160-189 mg/dL LDL- lowering drug optional)

Patient’s LDL cholesterol goal:______

Initiate TLC? Yes

 No

Consider drug therapy? Yes (with TLC)

 Yes (in 3 months)

 No

STEP 6 Initiate Therapeutic Lifestyle Changes if LDL cholesterol is

above goal

  • Continue/start therapeutic lifestyle changes:

 Saturated fats <7% of total calories

 Dietary cholesterol <200 mg/day

 Plant stanols/sterols: 2g/day

 Increased viscous (soluble) fiber: 10-25 g/day

 Increased physical activity

 Weight management or reduction

 Limit alcohol consumption

 Smoking cessation

STEP 7 Consider adding drug therapy if LDL cholesterol exceeds levels

shown in Step 5 table

Patient’s LDL – goal LDL x 100 = ______

Patient’s LDL

Initial Therapy Recommended / Current Dose
 Statin
 Bile acid sequestrant
 Niacin
 Fibric acid derivative
 Cholesterol absorption inhibitor
 Omega-3 Fatty Acids

Approximate Degree of LDL Lowering Expected at Different Doses of Statins

Statin 10 mg 20 mg 40 mg 80 mg
Atorvastatin / 38% / 46% / 51% / 54%
Fluvastatin / … / 17% / 23% / 29%
Lovastatin / … / 29% / 31% / 48%
Pravastatin / 19% / 24% / 34% / 37%
Rosuvastatin / 51% / 57% / 63% / …
Simvastatin / 28% / 35% / 41% / 46%


Drugs That Affect Lipoprotein Metabolism

Effects on Lipoproteins / When to Use / Major Adverse Effects / Contraindications
HMG CoA reductase inhibitors (statins)
LDL ↓ 18%-55%
HDL ↑ 5%-15%
TG↓ 7%-30% /
  • First-line monotherapy in most patients
/
  • Myopathy
  • Increased liver enzymes
/ Absolute
  • Active or chronic liver disease
  • Pregnancy and breast-feeding
Relative
  • Concomitant use of certain drugsa

Bile acid sequestrants (BAS)
LDL ↓ 15%-30%
HDL ↑ 3%-5%
TG No change, or ↑ /
  • Particularly useful in combination with statins to achieve major reductions in LDL levels
  • May be used as monotherapy:
- In younger persons
- In pregnant women (or women considering pregnancy)
- When only modest LDL lowering is needed /
  • Constipation
  • GI distress
  • Decreased absorption of other drugs
/ Absolute
  • Dysbetalipoproteinemia
  • TG >400 mg/dL
Relative
  • TG >200 mg/dL

Niacin
LDL ↓ 5%-25%
HDL ↑ 15%-35%
TG↓ 20%-50%
Lp(a) ↓ ~30% /
  • Used in combination with statins if additional LDL lowering is required (esp. in persons who do not tolerate BAS)
  • Good choice if increases in HDL and decreases in triglycerides and Lp(a) are needed in addition to LDL lowering
/
  • Flushing
  • Hyperglycemia
  • Hyperuricemia (or gout)
  • Upper GI distress
  • Hepatotoxicity
/ Absolute
  • Chronic liver disease
  • Severe gout
Relative
  • Diabetes
  • Hyperuricemia
  • Peptic ulcer disease

Fibric acid derivatives
LDL ↓ 5%-20%b
HDL ↑ 10%-20%
TG↓ 20%-50% /
  • Used in combination with statins only when patients cannot tolerate a BAS or niacin
  • May be useful in patients with atherogenic dyslipidemia
/
  • Dyspepsia
  • Gallstones
  • Myopathy
/ Absolute
  • Severe hepatic disease
  • Severe renal disease

Cholesterol absorption inhibitor (Ezetimibe)
LDL ↓ 18%
HDL ↑ 1%
TG↓ 1.7% /
  • Used primarily in combination with statins to achieve major reductions in LDL cholesterol levels
/
  • None
/ Absolute
  • Active liver disease
  • Unexplained persistent elevations in serum transaminases
Relative
  • Concomitant use of cyclosporine or fibrates

Omega-3 fish oils
LDL ↑ 25%-31%
VLDL↓ 30%-40%
HDL ↑ 11%-13%
TG↓ 20%-45%
Apo(B)↑ 7% /
  • Used for the treatment of hypertriglyceridemia, particularly chylomicronemia
/
  • Mild GI disturbances (burping)
/ Relative
  • Persons on strict calorie restricted diets

aCyclosporine, macrolide antibiotics, various antifungal agents, and cytochrome P-450 inhibitors (fibrates and niacin should be used with appropriate caution).
bMay be increased in patients with elevated triglycerides.

Specific drug therapy recommendation (drug and dosage):

Significant Drug Interactions and mediation strategies:

STEP 8 Identify metabolic syndrome treat, if present, after 3 months of TLC

Clinical Identification of the Metabolic Syndrome- Any 3 of the Following:

Present? Risk FactorDefining Level

 Abdominal obesity Waist circumference

Men>40 in (>102 cm)

Women>35 in (>88 cm)

 Triglycerides≥150 mg/dL

 HDL cholesterol

Men<40 mg/dL

Women <50 mg/dL

 Blood pressure≥130 mm Hg systolic &/or

≥85 mm Hg diastolic

 Fasting blood glucose≥100 mg/dL

Does patient have ≥3 risk factors?  Yes  No

  • Therapeutic interventions needed:

 Intensify weight management

 Increase physical activity

 Treat hypertension

 Use aspirin for CHD patients to reduce prothrombotic state

 Treat elevated triglycerides and/or low HDL (as shown in Step 9)

STEP 9 Treat elevated triglycerides and low HDL cholesterol

  • Patient’s triglycerides level is:

 ≥150 mg/dL

 200-499 mg/dL

 ≥500 mg/dL

  • Therapeutic interventions to consider:

≥150 mg/dL

 Intensify weight management

 Increase physical activity

200-499 mg/dL

 Set secondary goal for non-HDL cholesterol

Non-HDL cholesterol = Total cholesterol – HDL cholesterol = ______

Non-HDL goal (30 points higher than LDL goal) = ______

 Intensify therapy with LDL-lowering drug

 Add niacin or fibrate, and/or omega-3 fish oils

≥500 mg/dL (patient is at increased risk for acute pancreatitis, and triglyceride

lowering becomes primary goal)

 Keep total fat ≤15% of total calories

  • If HDL cholesterol is <40 mg/dL, reach LDL goal first, then:

 Intensify weight management

 Increase physical activity

 If triglycerides are 200-499 mg/dL, achieve non-HDL goal

 If triglycerides are <200 mg/dL (isolated low HDL) in patient with CHD or CHD

risk equivalent, consider niacin or fibrate, and/or omega-3 fish oils

Page 1 of 9

(Adapted by Ted D. Williams from White City VA Template by Don Lockwood)