KEEPING ABREAST OF THE CHAOS WITH LIPID GUIDELINES

KEEPING ABREAST OF THE

CHAOS WITH LIPID

GUIDELINES

ROSHNI S. PATEL, PHARMD, BCPS

ASSISTANT PROFESSOR OF PHARMACY PRACTICE

JEFFERSON COLLEGE OF PHARMACY

DISCLOSURES

No conflicts of interest to disclose.

LEARNING OBJECTIVES

1. Compare and contrast the lipid lowering guidelines

published by the American College of

Cardiology/American Heart Association, American

Association of Clinical Endocrinologists, and the

National Lipid Association

2. Describe how emerging evidence has affected lipid

guidelines and clinical practice

3. Develop a patient-centered approach to the treatment of

dyslipidemia

QUESTION #1

Which set of clinical practice guidelines do you follow for the

management of dyslipidemia?

A. American College of Cardiology/American Heart

Association

B. American Association of Clinical Endocrinologists

C. National Lipid Association

D. Hybrid Approach – how?

E. I don’t use guidelines

TIMELINE OF EVENTS

National Cholesterol Education

Program’s Adult Treatment Panel III

(NCEP ATP III) ACC/AHA

ACC Expert

Consensus Decision

Pathway for Non-

statin Therapies

ACC Focused

update of 2016

consensus

pathway

May

2001

November

2013

June

2016 September

2017

Updated NLA Recommendations for

Use of PCSK9 Inhibitors

May 2017

NLA Recommendations

for Patient-Centered

Management of

Dyslipidemia: Part 1

September 2014

NLA Recommendations for

Patient-Centered Management

of Dyslipidemia: Part 2

November 2015

AACE Guidelines for

Management of Dyslipidemia &

Prevention of

Atherosclerosis

March 2012

AACE Guidelines for

Management of Dyslipidemia

& Prevention of

Atherosclerosis

April 2017

AHA

Statement

on TG

May 2011

NCEP ATP

III Update

July 2004

2001 NCEP ATP III GUIDELINES

Lipid Goals & Framingham Risk Stratification

Risk Category LDL-C Goal

LDL-C Level at Which to

Initiate Therapeutic

Lifestyle Changes (TLC)

LDL-C Level at Which

to Consider Drug

Therapy

CHD or CHD Risk

Equivalents

(10-year risk > 20%)

< 100 mg/dL ≥ 100 mg/dL

≥ 130 mg/dL

(100-129 mg/dL: drug

optional)

2+ Risk Factors

(10-year risk ≤ 20%) < 130 mg/dL ≥ 130 mg/dL

10-year risk 10-20%:

≥ 130 mg/dL

10-year risk <10%:

≥ 160 mg/dL

0-1 Risk Factor < 160 mg/dL ≥ 160 mg/dL

≥ 190 mg/dL

(160-189 mg/dL: LDL-

lowering drug optional)

NCEP. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection,

Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 2002;106:3143-421.

2004 NCEP ATP III UPDATE

Lipid Goals & Framingham Risk Stratification

Risk Category LDL-C Goal

LDL-C Level at Which to

Initiate Therapeutic

Lifestyle Changes (TLC)

LDL-C Level at Which

to Consider Drug

Therapy

CHD or CHD Risk

Equivalents

(10-year risk > 20%)

< 100 mg/dL

(optional: < 70

mg/dL)

≥ 100 mg/dL

≥ 100 mg/dL

(< 100 mg/dL: drug

optional)

2+ Risk Factors

(10-year risk ≤ 20%)

< 130 mg/dL

(optional < 100

mg/dL)

≥ 130 mg/dL

10-year risk 10-20%:

≥ 130 mg/dL

10-year risk <10%:

≥ 160 mg/dL

0-1 Risk Factor < 160 mg/dL ≥ 160 mg/dL

≥ 190 mg/dL

(160-189 mg/dL: LDL-

lowering drug optional)

NCEP Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. Circulation 2004;110:227-39.

NCEP ATP III GUIDELINES

Treatment:

• HMG CoA Reductase Inhibitors (statins) – usually first

• Starting dose of statin is dependent upon baseline level of

LDL-C

• Increase the dose of statin if LDL-C target goals not

achieved

• Bile acid sequestrants

• Nicotinic acid

• Fibric acids

• Omega 3 fatty acids

NCEP. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection,

Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 2002;106:3143-421.

2013 ACC/AHA GUIDELINES

• No target goals

• New Pooled Cohort Equation to Identify Primary ASCVD

risk

• 4 Major Statin Benefit Groups

1. Clinical ASCVD

2. Primary elevations of LDL-C ≥ 190 mg/dL

3. Diabetes aged 40 to 75 years with LDL-C 70 to 189

mg/dL and without clinical ASCVD

4. Without clinical ASCVD or diabetes with LDL-C 70 to 189

mg/dL & estimated 10-year ASCVD risk ≥ 7.5%

2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation. Published online November 12, 2013. doi: 10.1161/ 01.cir.0000437738.63853.7a

Clinical ASCVD: ACS, history of MI, stable or unstable angina, coronary or

other arterial revascularization, stroke, TIA, or PAD

POOLED COHORT EQUATION

STATIN INTENSITY

Low Intensity Moderate Intensity High Intensity

Daily dose lowers LDL-C on average by <30%

Daily dose lowers LDL-C on average by 30% to <50%

Daily dose lowers LDL-C on average by ≥50%

Simvastatin 10 mg Pravastatin 10-20 mg Lovastatin 20 mg Fluvastatin 20-40 mg Pitavastatin 1 mg

Atorvastatin 10 (20) mg Rosuvastatin 5 (10) mg Simvastatin 20-40 mg Pravastatin 40 (80) mg Lovastatin 40 mg Fluvastatin XL 80 mg Fluvastatin 40 mg BID Pitavastatin 2-4 mg

Atorvastatin 40-80 mg Rosuvastatin 20 (40) mg

Bolded = specific statin + dose evaluated in RCT Italicized = specific statin + dose approved by FDA but not evaluated in RCT


Based on

LDL-C

lowering

potential

rosuvastatin atorvastatin simvastatin = pitavastatin pravastatin = lovastatin fluvastatin

P

O

T

E

N

C

Y

APPROACH TO THE PATIENT

Age ≤ 75: High Intensity Statin

Age > 75: Mod Intensity Statin

High Intensity Statin

Mod Intensity Statin ASCVD risk ≥ 7.5%:


Mod Intensity Statin

No action or need to increase statin

< 70 mg/dL

Not in definite benefit group

ASCVD 10 year risk q 4-6 yr

yes

≥ 190 mg/dL

70 - 189 mg/dL

Age 40 – 75?

yes

yes

no

T1 or T2 DM?

≥ 7.5%

Clinical ASCVD?

LDL

< 7.5%

Consider other factors: a.LDL > 160 mg/dL b.Family hx c.High CRP d.CAC score e.ABI < 0.9 f.Lifetime ASCVD risk


no

no


LIPID PANELS

**Use LDL–C reduction thresholds as an indicator of efficacy to assess response to therapy and adherence

Baseline fasting lipid panel

2nd fasting lipid panel after 4-12 weeks

q 3 to 12 months as clinically indicated


CAVEAT INCLUDED

“in those already on a statin, in whom baseline LDL-C is unknown, an LDL-C

level < 100 mg/dL was observed in most individuals receiving high-intensity

statin therapy”

Nonetheless, LCL-C < 100 mg/dL should not be used as a fixed-target.

Example:

• Patient 1 with ASCVD on low intensity statin achieves an LDL-C of < 100

mg/dL

• Patient 2 with ASCVD on high intensity statin achieves an LDL-C of < 100

mg/dL

• Outcome data suggests high intensity statin (if tolerated) provides

greater reduction in ASCVD events than low intensity statin


AFTER STATINS

“less evidence to support the use of non-statin drugs for

ASCVD prevention”

Safety recommendations provided for:

• Bile acid sequestrants

• Nicotinic acid

• Fibric acids

• Cholesterol absorption inhibitors

• Omega 3 Fatty Acids


2016 ACC CONSENSUS PATHWAY

FOR NON-STATIN THERAPIES

High risk patients who…

1. Have a less-than-anticipated response to statins

[% reduction in LDL-C from baseline (may consider LDL-C

targets of < 70 mg/dL or <100 mg/dL)]

2. Are unable to tolerate a less-than-recommended intensity

of a statin

3. Are completely statin intolerant

**Use drugs that have been shown in RCTs to provide ASCVD risk-reduction benefits that outweigh the potential for adverse effects and drug-drug interactions,

and consider patient preferences

2016 ACC expert consensus decision pathway on the role of non-statin therapies for LDL-cholesterol lowering in the management of atherosclerotic cardiovascular disease risk. J Am Coll Cardiol. 2016;68(1):92-125.

CHOICE FOR NON-STATIN

THERAPY

S T A T I N B E N E F I T G R O U P S

Group #1 (Clinical ASCVD)

Group #2 LDL-C ≥ 190 mg/dL

1st line

Add ezetimibe

2nd line

Add PCSK9i

or

Replace ezetimibe

with PCSK9i

or

Add bile acid

sequestrant

1st line

Add PCSK9i

or

Add ezetimibe

2nd line

Add bile acid

sequestrant

Group #3 40-75 y/o (w/o ASCVD)

+ DM + LDL-C 70-189

mg/dL

1st line

Add ezetimibe

2nd line

Add bile acid

sequestrant

Group #4 ASCVD risk > 7.5%

1st line

Add ezetimibe

2nd line

Add bile acid

sequestrant


IMPROVE-IT TRIAL

Cannon et al. N Engl J Med 2015;372:2387-97.

Population:

Patients with recent acute MI with or without

ST elevation, or high-risk UA

Treatment arms:

Simvastatin 40 mg + ezetimibe 10 mg

Simvastatin 40 mg + placebo

Primary outcome:

Composite of death from CVD, a major

coronary event, or nonfatal stroke

Results:

32.7% vs. 34.7%, p=0.016


THERAPY




1st line

Add ezetimibe

2nd line

Add PCSK9i

or

Replace ezetimibe

with PCSK9i

or

Add bile acid

sequestrant

1st line

Add PCSK9i

or

Add ezetimibe

2nd line

Add bile acid

sequestrant


+ DM + LDL-C 70-189

mg/dL

1st line

Add ezetimibe

2nd line

Add bile acid

sequestrant


1st line

Add ezetimibe

2nd line

Add bile acid

sequestrant


HPS2-THRIVE TRIAL

**ACC: No clear indications for routine use of niacin preparations as additional non-statin therapy (based on evidence of non-efficacy and potential harm)

HPS2-THRIVE Collaborative Group. N Engl J Med 2014;371:203-12.


THERAPY




1st line

Add ezetimibe

2nd line

Add PCSK9i

or

Replace ezetimibe

with PCSK9i

or

Add bile acid

sequestrant

1st line

Add PCSK9i

or

Add ezetimibe

2nd line

Add bile acid

sequestrant


+ DM + LDL-C 70-189

mg/dL

1st line

Add ezetimibe

2nd line

Add bile acid

sequestrant


1st line

Add ezetimibe

2nd line

Add bile acid

sequestrant


PCSK9 INHIBITORS

PCSK9

LDLR

Head to the

surface to

receive chlyo-

remnants, IDL,

and LDL

nucleus

ϒ ϒ

Mechanism of Action:

• Human monoclonal antibody inhibiting PCSK9 protein

COMPARATIVE EFFECTS OF LIPID-

LOWERING DRUG THERAPIES

Class Generic Brand Dose/day LDL-C HDL-C TG

HMG-CoA

Reductase

Inhibitors

(Statins)

Lovastatin Mevacor 20-80mg 20-40% 6-10% 7-12%

Simvastatin Zocor 5-40 mg 26-47% 7-12% 10-24%

Pravastatin Pravachol 10-80mg 22-34% 7-12% 15-24%

Fluvastatin Lescol 20-80 mg 22-24% small small

Atorvastatin Lipitor 10-80 mg 39-60% 5-9% 19-37%

Rosuvastatin Crestor 5-40 mg 45-63% 8-14% 10-35%

Pitavastatin Livalo 1-4 mg 32-43 5-7% 15-19%

PCSK9 Inhibitorsƚ Alirocumab Praluent Footnote 32-62% small 1-17%

Evolocumab Repatha Footnote 55-70% small 6-31%

Bile acid

sequestrants

Cholestyramine Questran 4-24 gm 10-20% 3-5% May

Cholestipol Colestid 5-30 gm 10-20% 3-5% May

Colesevelam Welchol 3.75 gm 9-18% 3-5% May

Nicotinic Acid IR/SR Niacin Niacor/Slo-Niacin

variable 10-25% 10-35% 10-50%

ER-Niacin Niaspan 9-17% 15-26% 11-35%

Fibric Acids derivatives Gemfibrozil Lopid 1200 mg 10-15% 10-15% 20-50%

Fenofibrate Tricor 48-145 mg 17-29% 0-15% 38%-57%

Cholesterol Absorption

Inhibitor Ezetimibe Zetia 10 mg 18% 1% 10%

Fish Oil Omega 3-FAs Lovaza

Vascepa 2-4 gm variable variable Up to 50%

MTP Inhibitor Lomitapide Juxtapid 5-60 mg 40% 7% 45%

ApoB Antisenseǂ Mipomersen Kynamro Footnote 25% 15% 18%

ƚAlirocumab dosed 75/150 mg every 2 weeks or 300 mg every 4 weeks; evolocumab dosed 140 mg every 2 weeks or 420 mg once monthly ǂMipomersen dosed 200 mg once weekly

PCSK9

INHIBITORS

Navarese et al. Ann Intern Med 2015;163:40-51.

LDL-C Percentage of

Change from Baseline

PCSK9 INHIBITORS

Available Products:

• Alirocumab (Praluent®) 75 mg/150 mg SUBUTANEOUSLY every 2

weeks or 300 mg every 4 weeks

• Evolocumab (Repatha®) 140 mg SUBCUTANEOUSLY every 2

weeks OR 420 mg monthly

ADEs:

• Injection site reactions

• Nasopharyngitis and influenza

• Small incidence of elevations in liver enzymes and CK


THERAPY




1st line

Add ezetimibe

2nd line

Add PCSK9i

or

Replace ezetimibe

with PCSK9i

or

Add bile acid

sequestrant

1st line

Add PCSK9i

or

Add ezetimibe

2nd line

Add bile acid

sequestrant


+ DM + LDL-C 70-189

mg/dL

1st line

Add ezetimibe

2nd line

Add bile acid

sequestrant


1st line

Add ezetimibe

2nd line

Add bile acid

sequestrant


2017 ACC UPDATE




1st line

Add PCSK9i

or

Add ezetimibe

2nd line

Add bile acid

sequestrant

1st line

Add PCSK9i

or

Add ezetimibe

2nd line

Add bile acid

sequestrant


+ DM + LDL-C 70-189

mg/dL

1st line

Add ezetimibe

2nd line

Add bile acid

sequestrant


1st line

Add ezetimibe

2nd line

Add bile acid

sequestrant

2017 Focused Update of the 2016 ACC Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk: A Report of the American College

of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol 2017;70:1785-1822.

OSLER 1 & 2 TRIALS

Population:

Patients who previously completed 1 of 12 phase 2 or 3

trials (“parent trials”)

Treatment arms:

Evolocumab 140 mg every 2 weeks + standard therapy

Evolocumab 420 mg every month + standard therapy

Standard therapy alone

Exploratory analysis (outcome):

Composite of CV death, myocardial infarction, unstable

angina requiring hospitalization or coronary

revascularization, stroke, TIA, and heart failure requiring

hospitalization

Results:

0.95% vs. 2.18%, p=0.003

Sabatine et al. N Engl J Med 2015;372:1500-09.

FOURIER TRIAL

Sabatine et al. N Engl J Med 2017;376:1713-22.

Population:

Patients with ASCVD and LDL-C > 70 mg/dL

on statin therapy

Treatment arms:

Evolocumab 140 mg every 2 weeks

Evolocumab 420 mg every month

Matching placebo

Primary outcome:

Composite of CV death, myocardial infarction,

stoke, hospitalization for unstable angina, or

coronary revascularization

Results:

9.8% vs. 11.3%, p<0.001

MI, stroke, and coronary revascularization

were all lower in the evolocumab group

SPIRE 1 & 2 TRIALS

Population:

Patients with previous CV event or a history of

diabetes, CKD, or PVD with additional CV risk

conditions or a history of FH

Treatment arms:

Bococizumab 150 mg every 2 weeks

Matching placebo

Primary outcome:

Composite of nonfatal myocardial infarction,

nonfatal stroke, hospitalization for unstable

angina requiring urgent revascularization, or

CV death

Results:

Spire 1 (lower risk, shorter duration):

2% in each group

HR 0.99 (95% CI 0.80 to 1.22, p=0.99)

Spire 2 (higher risk, longer duration):

3.4% vs. 4.2%

HR 0.79 (95% CI 0.65 to 0.97, p=0.02)

Ridker et al. N Engl J Med 2017;376:1527-39.

2017 ACC UPDATE




1st line

Add PCSK9i

or

Add ezetimibe

2nd line

Add bile acid

sequestrant

1st line

Add PCSK9i

or

Add ezetimibe

2nd line

Add bile acid

sequestrant


+ DM + LDL-C 70-189

mg/dL

1st line

Add ezetimibe

2nd line

Add bile acid

sequestrant


1st line

Add ezetimibe

2nd line

Add bile acid

sequestrant

2017 Focused Update of the 2016 ACC Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk: A Report of the American College

of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol 2017;70:1785-1822.

2017 AACE GUIDELINES

Risk Category Risk factors/10-year risk Treatment Goals

LDL-C Non-HDL-C Apo-B

Extreme risk

- Progressive ASCVD including unstable

angina in patients after achieving an

LDL-C < 70 mg/dL

- Established clinical cardiovascular

disease in patients with DM, CKD 3/4,

or HeFH

- History of premature ASCVD (<55

male, <65 female)

<55 mg/dL <80 mg/dL <70 mg/dL

Very high risk

- Established or recent hospitalization

for ACS, coronary, carotid, of

peripheral vascular disease, 10-year

risk > 20%

- Diabetes of CKD 3/4 with 1 or more

risk factor(s)

- HeFH

<70 mg/dL <100 mg/dL <80 mg/dL

High risk

- ≥2 risk factors and 10-year risk 10-

20%

- Diabetes or CKD 3/4 with no other risk

factors

<100 mg/dL <130 mg/dL <90 mg/dL

Moderate risk ≤2 risk factors and 10-year risk <10% <100 mg/dL <130 mg/dL <90 mg/dL

Low risk 0 risk factors <130 mg/dL <160 mg/dL NR

2017 AACE and ACE Guidelines For Management of Dyslipidemia and Prevention of Cardiovascular Disease. Endocr Pract 2017;23:1-87.

QUESTION #2

How low is too low for LDL-C?

A. <55 mg/dL is too low

B. <40 mg/dL is too low

C. <25 mg/dL is too low

D. There is no such thing as “too low”

2017 AACE GUIDELINES

Assessment of 10-year Risk for a Coronary Event:

• Framingham Risk Assessment Tool

• Multi-Ethnic Study of Atherosclerosis (MESA) 10-year ASCVD

Risk with Coronary Artery Calcification Calculator

• Reynolds Risk Score

• United Kingdom Prospective Diabetes Study Risk Engine to

Calculate ASCVD Risk in Individuals with T2DM


TREATMENT

• Statins primary pharmacologic agent to achieve target LDL-C

• BAS may be considered for reducing LDL-C and Apo B

• Nicotinic acid adjust for reducing TG

• Fibric acids for severe hypertriglyceridemia

• CAI may be considered as monotherapy for reducing LDL-C and

Apo B, specially in statin-intolerant patients

• O3FA for severe hypertriglyceridemia

• PCSK9i for use in combination with statin therapy for LDL-C lowering in

patients with FH, for patients with CVD unable to reach LDL-

C/non-HDL-C goals with maximally tolerated statin therapy


NLA’S TAKE ON “GOALS”

Treatment goals are useful as means to ensure that the

aggressiveness of therapy to lower atherogenic cholesterol is matched

to absolute risk for an event.

Treatment goals facilitate effective communication between patients

and clinicians, providing an easily interpretable means through which

the clinician can communicate progress toward meeting treatment

objectives, thus supporting efforts to maximize long-term adherence to

the treatment plan.

National Lipid Association Recommendations for Patient-Centered Management of Dyslipidemia: Part 1—Full Report. J Clin Lipidol 2015; 9:129-69.

NLA GUIDELINES

Risk

Category Criteria

Treatment Goals

LDL-C Non-HDL-C Apo-B

Low - 0-1 major ASCVD risk factors

- Consider other risk indicators, if known <100 mg/dL <130 mg/dL <90 mg/dL

Moderate - 2 major ASCVD risk factors

- Consider quantitative risk scoring

- Consider other risk indicators

<100 mg/dL <130 mg/dL <90 mg/dL

High - ≥3 major ASCVD risk factors

- Diabetes mellitus (type 1 or 2)

- 0-1 other major ASCVD risk factors

and

- No evidence of end organ damage

- CKD 3B or 4

- LDL-C ≥190 mg/dL

- Quantitative risk score reaching the high-

risk threshold

<100 mg/dL <130 mg/dL <90 mg/dL

Very High - ASCVD

- Diabetes mellitus (type 1 or 2)

- ≥2 other major ASCVD risk factors or

- No evidence of end organ damage <70 mg/dL <100 mg/dL <80 mg/dL


NLA HIGH RISK THRESHOLDS

• ATP III Framingham risk calculator:

≥10% 10-year risk for a hard CHD event (myocardial infarction

or CHD death)

• Pooled Cohort Equations (American College of

Cardiology/American Heart Association):

≥15% 10-year risk for a hard ASCVD event (myocardial

infarction, stroke, or death from CHD or stroke)

• Framingham long-term (30-year to age 80) risk calculator:

≥45% risk for CVD (myocardial infarction, CHD death, or

stroke)


NLA TREATMENT

1st line therapy: moderate or high intensity statin

• If cholesterol goals are not achieved, either increase statin

intensity or add on second agent

• References HPS2-THRIVE Trial

• References IMPROVE-IT Trial


2017 NLA EXPERT PANEL PCSK9

INHIBITOR RECOMMENDATIONS

Disorder LDL-C/Non-HDL-C

Threshold for Rx

(md/dL)

Strength of Evidence Quality of Evidence

ASCVD + additional risk factors ≥ 70 / ≥ 100 A High

Progressive ASCVD ≥ 70 / ≥ 100

B Moderate

LDL-C ≥ 190, age 40-79

(no uncontrolled RF or key

additional risk markers)

≥ 100 / ≥ 130

B Moderate

LDL-C ≥ 190, age 40-79

(uncontrolled RF or key

additional risk markers)

≥ 70 / ≥ 100 B Moderate

LDL-C ≥ 190, age 18-39

(uncontrolled RF or key

additional risk markers or FH

causing mutation)

≥ 100 / ≥ 130

E Low

HoFH phenotype ≥ 70 / ≥ 100 B Moderate

ASCVD + statin intolerance Clinical Judgement C Low

Update on the use of PCSK9 inhibitors in adults: Recommendations from an Expert Panel of the National Lipid Association. J Clin Lipidol 2017;11:880-90.

QUESTION #3

Which set of clinical practice guidelines will you follow for

the management of dyslipidemia?

A. American College of Cardiology/American Heart

Association

B. American Association of Clinical Endocrinologists

C. National Lipid Association

D. Hybrid Approach – how?

E. I will not be using guidelines

DOES IT REALLY MATTER?

Patient Case: MC is a 60 year old African American woman with HTN, dyslipidemia, CKD (stage I), migraines,

and osteoarthritis. She has been taking all of her medications for 2 years and reports 100% compliance

(which is confirmed by refill records and pill counts). Denies CP, SOB, s/sx of CVA. Denies ADEs to any of her

medications. FH is significant for T2DM and CVD. No tobacco use.

Medications:

Lisinopril 40 mg PO daily

Amlodipine 10 mg PO daily

Atorvastatin 20 mg PO daily

Aspirin 81 mg PO daily

Sumatriptan 50 mg PO PRN

Acetaminophen 650 mg PO TID

VS: BP 128/90 mmHg, HR 70 bpm

Labs:

Baseline FLP: TC 240 mg/dL, LDL-C 170 mg/dL, HDL 38 mg/dL, TG 160 mg/dL

Today’s FLP: TC 250 mg/dL, LDL-C 164 mg/dL, HDL 42 mg/dL, TG 220 mg/dL

ACC/AHA

AACE

NLA


Patient Case: MC is a 60 year old African American woman with HTN, dyslipidemia, CKD (stage I), migraines,

and osteoarthritis. She has been taking all of her medications for 2 years and reports 100% compliance

(which is confirmed by refill records and pill counts). Denies CP, SOB, s/sx of CVA. Denies ADEs to any of her

medications. FH is significant for T2DM and CVD. No tobacco use.

Medications:



Atorvastatin 20 mg PO daily


Sumatriptan 50 mg PO PRN

Acetaminophen 650 mg PO TID


Labs:



ACC/AHA

AACE

NLA


Patient Case: MC is a 60 year old African American woman with HTN, dyslipidemia, PAD, T2DM. She has

been taking all of her medications for 2 years and reports 100% compliance (which is confirmed by refill

records and pill counts). Denies CP, SOB, s/sx of CVA. Denies ADEs to any of her medications. FH is

significant for T2DM and CVD. No tobacco use.

Medications:



Rosuvastatin 40 mg PO daily



Labs:



ACC/AHA

AACE

NLA

Documents

KEEPING ABREAST OF THE CHAOS WITH LIPID GUIDELINES