AntiHyperlipidemic

1. See Also
   1. Hyperlipidemia
   2. Hypertriglyceridemia
   3. Low Fat Diet
2. Indications
   1. Hyperlipidemia
   2. Prevention of Ischemic Stroke
   3. CAD Risk Management
3. Management: General Measures
   1. See Low Fat Diet
   2. Aerobic Exercise for at least 120 minutes per week (900 kcal expended per week)
      1. Raises HDL Cholesterol linearly with cummulative amount of aerobic Exercise
      2. Lowers Total Cholesterol 3.9%, LDL Cholesterol 3.9% and serum Triglycerides 7.1%
      3. Halbert (1999) Eur J Clin Nutr 53(7):514-22
   3. Weight loss in Obesity (11 kg or 24 lb)
      1. Lowers LDL 10%, Triglycerides 24%, raises HDL 8%
      2. Katzel (1995) Metabolism 44:307-14
4. Management: Medication Selection
   1. General
      1. Guidelines push for lower LDL Cholesterol
         1. LDL Cholesterol <70 mg/dl in coronary disease and Diabetes Mellitus
      2. Guidelines may require high dose and combinations
         1. Most potent agents: Zocor, Lipitor, Crestor
            1. Doubling dose lowers LDL Cholesterol 6%
         2. Combined with: Niacin, Cholestyramine, zetia
            1. Lowers LDL Cholesterol additional 10-15%
            2. However neither Zetia or Niacin have shown added benefit beyond Statin alon
      3. References
         1. (2004) Prescriber's Letter 11(8):43
   2. Serum Triglyceride <150 mg/dl (Primarily LDL Disorder)
      1. First: HMG-CoA Reductase Inhibitor (Statin)
      2. Second: Niacin or Ezitimibe
         1. However neither has been shown to improve outcomes over Statin alone
      3. Third: Bile Binding Resin (Cholestyramine)
         1. Consider adding Colesevelam (Welchol) in Diabetes Mellitus
      4. Adjunctive: Plant Sterols and stanols
   3. Serum Triglyceride 150 to 400 mg/dl (combined disorder)
      1. First: HMG-CoA Reductase Inhibitor (Statin)
      2. Second: Niacin
      3. Third: Cholesterol absorption inhibitor (Ezitimibe)
      4. As noted above, neither Niacin nor Ezetimibe have been shown to improve outcomes over Statin alone
   4. Serum Triglyceride >400 mg/dl: See Hypertriglyceridemia
      1. First choices
         1. Fibric Acid Derivative (Gemfibrozil)
         2. Nicotinic Acid (Niacin)
      2. Adjuncts
         1. HMG-CoA Reductase Inhibitor
         2. Fish oil
   5. Coronary Artery Disease Prevention
      1. HMG-CoA Reductase Inhibitor (Statin)
   6. Medication not recommended if only HDL Cholesterol low
      1. Raise HDL Cholesterol with non-medication measures
      2. Focus medication use on lowering LDL Cholesterol
      3. Birjmohun (2005) J Am Coll Cardiol 45:185-97
   7. Hyperlipidemia in age over 65 years
      1. Low HDL increases MI risk in age over 65 years
      2. Other Hyperlipidemia does not predict MI risk age >65
      3. Psaty (2004) J Am Geriatr Soc 52:1639-47
5. Management: Adjuvant Therapy
   1. Garlic
      1. Stevinson (2000) Ann Intern Med 133:420-9
   2. Plant Sterols and stanols (e.g. Benecol, Promise Activ)
      1. Dose 2 grams daily lowers LDL by 10%
   3. Fish oils (Omega-3 Fatty Acids)
      1. Lowers Triglycerides (4%: 1 g/day, 10-40%: 2-4g/day)
      2. Unfortunately raises LDL Cholesterol 5-10%
      3. Marginal effect on HDL Cholesterol
   4. Soluble Dietary Fiber
      1. Lowers LDL Cholesterol 7% for 10 grams of fiber
      2. Sources
         1. Psyllium, Barley, Beans
         2. Oat bran (e.g. cheerios, oatmeal)
      3. Brown (1999) Am J Clin Nutr 69:30-42
   5. Dietary Soy Proteins 25 grams per day (4% lowering)
      1. Anderson (1995) N Engl J Med 333:276-82
   6. Unsaturated fat nuts (pistachios, almonds)
   7. Glucophage (Metformin)
   8. Rosiglitazone or Pioglitazone
   9. Orlistat (Xenical)
   10. Policosanol (sugar cane derivative)
   11. Red-yeast rice
       1. Contains natural HMG-CoA reductase agent
       2. Currently unregulated and dose not standardized
       3. Not recommended until standardized dosing available
       4. May be an alternative for patients not tolerant to Statin medications
          1. Example Monocolin K 5-10 mg daily
6. Management: Measures that are not effective (not recommended)
   1. Estrogen Replacement Therapy
      1. No longer recommended for CAD prevention
      2. Recent studies suggest increased cardiovascular risk
         1. See Hormone Replacement for details
      3. Lipid effects
         1. LDL lowered (15%)
         2. HDL raised (15%)
         3. Triglycerides
            1. Raised: Oral Estrogen Replacement (considerably)
            2. No effect: Transdermal Estrogen
   2. Antioxidants do not affect lipid levels
      1. No benefit with Vitamin E, C, Beta Carotene, Selenium
      2. Brown (2001) N Engl J Med 345:1583-92
7. Management: Combination Regimens
   1. General
      1. Combination regimens can lower LDL 40-50%
   2. Combinations without risk
      1. HMG-CoA Reductase Inhibitors and Bile Binding Resin
      2. HMG-CoA Reductase Inhibitors and Ezetimibe (Zetia)
         1. Early studies suggest benefit with low toxicity
         2. Allows lipid control at lower Statin dose
   3. Combinations to use with caution
      1. Statin and Nicotinic Acid (Niacin)
         1. Risk of Myopathy, Hepatitis And Rhabdomyolysis
         2. Zocor + Niacin lowered LDL 42% and raised HDL 26%
         3. Brown (2001) N Engl J Med 345:1583-92
      2. Advicor (Niacin and Lovastatin)
         1. Appears relatively safe and well tolerated
            1. Limited Myopathy and hepatitis risk
         2. Efficacy
            1. Lowers LDL up to 32-47%
            2. Lowers Triglycerides 24-45%
            3. Raises HDL 18-40%
   4. Contraindicated combinations
      1. Statin and Gemfibrozil (Lopid)
         1. Risk of severe Myopathy and Rhabdomyolysis
         2. Fenofibrate appears safer with Statins
8. References
   1. McKenney (2002) Am J Cardiol 90(suppl):8K-20K
   2. Stein (2002) Am J Cardiol 89(suppl):50C-57C