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Division of General Internal Medicine
Drug Therapy for Lipid Disorders
Practical Strategies and Cost Considerations
Gordon Schectman, MD
General Internal Medicine
Medical College of Wisconsin
Digital Pager: 414 778-8811
Revised January, 2000
Table of Contents
- General Principles of Drug Therapy
- Treatment Strategies
- Type IIa: (High LDL, triglycerides ok)
- Refractory Hypercholesterolemia
- The role for LDL-apheresis
- Type IIb: (High LDL & high triglycerides)
- Type IV & V: (High triglycerides, LDL ok)
- Trouble Treating Triglycerides!
- Isolated Low HDL-C
- Diabetes
- Using the Drugs
- Niacin
- Sequestrants
- Statins
- Comparing the Statins
- Fibrates
- Combination Drug Therapy
- Laboratory Monitoring
- Yearly Cost of Drug Therapy
- Talking with Patients
- Explaining Hypertriglyceridemia: The "Rambler Engine" Story
- Explaining Cardiovascular Risk: The "Missing Snake" Story
- Final Advice
This handout is designed to help you use the lipid lowering drugs effectively. Although there are many different "correct" approaches to successful lipid disorder management, the approaches outlined here emphasize both effectiveness and simplicity. Be aware that differing opinions may exist among some lipidologists regarding treatment issues discussed in this handout.
Our underlying theme is that use of more than one lipid lowering drug will be necessary to achieve goal lipid levels in many patients, and therefore familiarity with all of the drugs is necessary for success. Helpful hints to improve tolerance to niacin and sequestrants are provided, in addition to information on the 'statins' and gemfibrozil.
A word about lipid goals. Establishing lipid goals with each patient is an extremely important part of lipid disorder management. The National Cholesterol Education Program (NCEP) provides useful guidelines. For example, for a patient with coronary heart disease, drug therapy is recommended if the LDL cholesterol remains >130 mg/dl despite diet, to achieve an ideal LDL goal of <100 mg/dl.
Unfortunately, this ideal may not be realistic in many patients, particularly those with moderate to severe LDL elevations. On the other hand, a more reasonable target may be an initial LDL goal of <130 mg/dl, with a secondary target of <100 mg/dl for patients successfully achieving the initial goal. You may wish to adopt similar initial goals for patients (without heart disease) with two or more risk factors (160 mg/dl) and less than two risk factors (190 mg/dl). The ideal goal suggested by the NCEP would be 30 mg/dl less than these "initial" goals.
The NCEP Guidelines Simplified
or
After Diet, When Should I Start Drugs?
Initiate Drugs Treat to Achieve
Patient Category
if LDL-C: LDL-C of:
CHD or PVD*
>130
<100
>2 CHD risk factors
>160
<130
<2 CHD risk factors
>190
<160
Young† and no risk factors >220
<190
*CHD-Coronary heart disease; PVD-peripheral vascular disease
†Males < 35; Females < 45 years.
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The NCEP Risk Factors: A Refresher Course
Positive Risk Factors
- Age (Male > 45; Female > 55)
- Family history of premature CHD
- (Male first-degree relative <55; Female first-degree relative < 65)
- Current cigarette smoking
- Hypertension
- Low HDL-C (< 35 mg/dl)
- Diabetes
Negative Risk Factor*
- High HDL-C (>60 mg/dl)
*If HDL-C is high, than subtract one from the positive risk factor total.
Drug
Therapy for Hyperlipidemia
or
What to do if diet fails!
General Principles
- Establish baseline lipids with at least two determinations.
- Obtain baseline laboratory (LFT, TFT, Urinalysis for protein) to screen for secondary causes of hyperlipidemia.
- Reinforce continued adherence to proper diet.
- Determine the lipid abnormalities to be corrected: (LDL, triglycerides, or both).
- Choose drug according to lipid abnormalities.
- After drug initiated, check lipids and appropriate chemistries at 1-2 month intervals until goal achieved.
- After goal lipids achieved, check lipids and appropriate chemistries at 6 month intervals.
- If goal lipoprotein targets are not achieved, then ACT:
- Advance dose of drug, or...
- Change to another drug, or...
- use Two or Three drugs Together, or...
- Refer to Lipid Specialist!
Always Maintain
- Step I or Step II diet (as tolerated)
If LDL cholesterol > 20% above goal:
- Use statin first
- Followed by addition of sequestrant or niacin
If LDL cholesterol < 20% above goal:
- Use sequestrant, niacin or statin first
- Substitute alternative not initially selected
Refractory Hypercholesterolemia
The role for LDL-Apheresis
LDL-apheresis provides a means for you to manage your patients with severe hypercholesterolemia refractory to conventional initial therapy. The most common reasons for using LDL-apheresis are failure of patients to tolerate or respond optimally to statin therapy.
LDL-apheresis:
Background-
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Most common system: Liposorber LA-15 (Kaneka).
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Concept similar to plasmapheresis.
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Apo B absorbed on dextran sulfate cellulose column.
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FDA approved.
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Processes 1.5-2 plasma volumes.
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Treatment duration: 3-4 hours; Frequency: twice monthly.
Cost-
• Approximately $10,000 monthly. Insurance usually pays most.
Efficacy-
-
Lowers LDL-C by 70-80% (40-50% average over time).
-
Lowers Triglycerides and Lp(a) by 30%, without affecting HDL-C.
-
Uncontrolled studies have documented angiographic regression.
Indications-
Following adequate trials of diet and combination drug therapy, LDL- apheresis is indicated if:
-
LDL-C persist above 200 mg/dl in patients with CHD or PVD.
-
LDL-C persist above 300 mg/dl in patients without CHD or PVD.
Don't Forget!
Continue to encourage non-pharmacologic therapy including diet and exercise. Also consider rescreening for secondary causes of hypercholesterolemia.
Nearest LDL-apheresis unit to Milwaukee: Chicago, IL.
Milwaukee Blood Center expected to purchase a unit shortly.
Always Maintain Step I or Step II diet (as tolerated)
Triglycerides >300 mg/dl
Correct triglycerides first with either
- Niacin, or
- Fibrates (gemfibrozil or fenofibrate)
If LDL-C remains above goal, then add:
- Statin
- Niacin, or
- Sequestrants
Triglycerides <300 mg/dl
Correct LDL-C first using a statin
If TG remain above goal, then add:
- Niacin, or
- Fibrates (gemfibrozil or fenofibrate)
If blood triglycerides > 600 mg/dl:
- Caloric and fat restriction of primary importance!! (~20% total calories from fat)
Also consider drug therapy:
- Fibrate as initial agent
- Followed by niacin
- Fish Oil-the last resort!
If blood triglycerides < 600 mg/dl:
- Step I or Step II diet (as tolerated)
- Fibrate or niacin as initial agent
- Followed by alternative agent
Once TG corrected, evaluate and treat LDL-C, if elevated.
Trouble Treating Triglycerides?
-The patient with refractory hypertriglyceridemia despite proper initial management-
This algorithm provides a means for you to manage your patients with severe hypertriglyceridemia refractory to conventional initial therapy. In this algorithm, LDL-C is treated even if blood triglyceride levels remain sub-optimal.
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Stress compliance with diet therapy. Many patients with severe hypertriglyceridemia will not respond well to drug therapy unless they show some compliance with diet. Refer back to dietitian with prescribed diet restricted in both fat and calories. See the "Rambler Engine Story" of this handout to help provide motivational insight into this metabolic problem for your patient.
-
Intensify treatment for secondary disorders, such as diabetes.
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Consider using niacin in addition to a fibrate if the patient is non-diabetic.
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Evaluate patient for surreptitious alcohol abuse.
-
Determine LDL-C:
-
Evaluate need for LDL-C lowering therapy. Add statin if LDL-C elevated. If triglycerides are usually above 300 mg/dl, consider obtaining direct LDL-C measurements routinely to follow response to therapy. Titrate LDL-C lowering therapy to achieve LDL-C goal, even if triglycerides remain elevated.
Triglycerides above 400 mg/dl?
Yes: Obtain direct LDL-C measurement (your lab may need to send this out [cost <$60])
No: Determine LDL-C using standard calculation.
If patient has CHD or is young with a very strong family hx:
•Try non-pharmacologic measures
Also consider one of the following:
•If LDL-C elevated, use statins to reduce LDL-C to below 90-100 mg/dl
•If TG> 200 mg/dl, consider gemfibrozil
•Consider trial of niacin & maintain if HDL increased by > 15%
If patient doesn't have CHD or a very strong family hx:
•Always try non-pharmacologic measures
•Use statins to reduce the LDL-C to below 130-160 mg/dl
•Data to suggest benefit of treatment to raise HDL-C for primary prevention currently lacking
Dyslipidemia Therapy in Diabetes
General Comments:
High TG, Low HDL may be due to poor glycemic control.
While treating lipids, intensify anti-diabetic diet and drug therapy.
Even in diabetics without CHD, event rates are very high; a LDL-C goal of <100 mg/dl is frequently appropriate.
Diet:
Cholesterol lowering and diabetic diets are equivalent!
i) Attain ideal body weight.
ii) Maintain high complex carbohydrate diet.
iii) Keep <30% total calories from fat.
Drug Therapy:
Statins: First choice for elevated LDL-C.
Fibrates: First choice for elevated TG > 300 mg/dl.
Bile acid sequestrants: Second choice for elevated LDL-C.
Monitor closely for high TG/constipation.
Niacin: Consider only when glycemic control is excellent;
Must monitor closely.
Drug Management of Lipid Disorders
High LDL-C; TG ok:
Start statin, add sequestrant if necessary
High TG, LDL-C ok:
Start fibrate, add statin if LDL-C becomes elevated.
High LDL-C; High TG:
Start statin, add fibrate if TG remain elevated.TG<300:
TG>300:
Start fibrate, add statin (or sequestrant) if necessary.
Dose Range: (Immediate Release): 1 to 3 grams.
(Niaspan [Sustained Release Preparation]): 1 to 2 grams.
Indications: IIa, IIb, IV, V hyperlipidemia
Approximate Effectiveness
(Percent Change from Basal)
Dose TG HDL-C LDL-C
1.0g -10 (-15) +15 (+15) -7 (-10)
1.5g -15 (-20) +20 (+20) -10 (-12)
2.0g -20 (-30) +25 (+25) -15 (-15)
3.0g -30 (---) +25 (---) -20 (---)
-Lipid response to Niaspan shown in parentheses-
Consider using Niaspan:
-Extended release niacin; FDA approved and requires prescription.
-As effective as immediate release niacin.
-Flushing less frequent than immediate release niacin.
-No increase in hepatotoxicity or myopathy.
-Disadvantage: More expensive.
Adverse effects:
Not Serious: Flushing, pruritis, rash/urticaria, [Less with Niaspan].
Potentially Serious: Hepatitis, gastritis/GI bleeding, hyperglycemia, gout, myalgias, myositis.
Relative Contraindications: Diabetes, active gout, peptic ulcer disease/severe gastritis, liver function abnormalities.
Laboratory Monitoring: LFT, glucose, uric acid (optional).
Getting Used to Niacin
Train staff to advise patient about cutaneous side effects:
- Start slowly and build up gradually
- Always take with meals
- Use aspirin judiciously
- Avoid simultaneous hot beverages
- Effects are "transient"
- Use drug information sheet
You can advise patient about other adverse effects:
- Hyperglycemia
- LFT abnormalities
- Gout
- Rash/Acanthosis Nigricans
- Avoid OTC sustained release preparations
Niacin Alert
Five Questions to Ask Before Starting Niacin!
1) Is patient diabetic (fasting glucose > 125-140 mg/dl)?
Greater than 50% chance of worsening glycemic control with niacin.
2) Does patient have active gout or peptic ulcer disease?
Treat the gout or ulcer first before starting niacin: may use niacin after active disease has resolved > six months.
3) Does the patient have liver disease?
Active liver disease is an important contraindication to niacin use.
4) Is the patient a previous niacin failure?
He/she is unlikely to tolerate a rechallenge, but it may be worthwhile to try anyway. Consider using Niaspan.
5) Is the patient willing and able?
The patient must be cooperative to withstand the initiation of niacin therapy!
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[For Niaspan, use dosing schedule noted above] Nicotinic acid is a medication which lowers cholesterol levels! How to take: Take three times a day with meals. Initial Dosing Schedule: Two doses will be prescribed: Low dose: 100 mg tablets Treatment is always started at low doses as follows: First week: One low dose tablet (100 mg) three times daily. Side Effects: Common: Flushing (prevented by aspirin). Suggest:
For any problems, call us!! We want to talk about these side effects with you! Mr/Ms _____________________, Phone__________________. Dr ________________________, Phone__________________.
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Cholestyramine [Questran] One Scoop=4g
Colestipol [Colestid] One Scoop=5g
Dose Range: 1 to 6 scoops daily
Indications: IIa hyperlipidemia
Approximate Effectiveness
(Percent Change from Basal)
Dose TG HDL-C LDL-C
1 Scoop +6 +2 -12
2 Scoops +12 +3 -20
4 Scoops +12 +4 -25
6 Scoops +20 +5 -30
Adverse effects:
Not Serious: Sandy taste, constipation, abdominal gas and cramping..
Potentially Serious: None.
Relative Contraindications: Hypertriglyceridemia, severe constipation, polypharmacy.
Laboratory Monitoring: None.
Getting Used to Bile Acid Sequestrants
Avoid Adverse Effects:
1) Suggest low doses (two scoops q PM).2) Suggest several preparations to improve tolerance.
3) Provide support for side effects, i.e.
Constipation:
- Stool softeners (If stool hard)
- Fiber
- Increase water intake
- Mineral Oil
4) Suggest dosing schedules if taking other Rx.
5) Use Drug Information Sheet.
Sequestrant Alert
Five Questions to Ask Before Starting Sequestrants!
i) Are fasting triglycerides above 250 mg/dl?
Triglycerides will worsen by 10-50% with sequestrants! Consider lowering triglycerides to below 200 mg/dl before using sequestrants.
ii) Is patient currently constipated?
It will only get worse! Consider fiber, stool softeners, and/or mineral oil to treat the constipation.
iii) Is patient currently taking 3 or more other drugs?
Scheduling of sequestrants to separate them properly from other medications will be a problem.
iv) Is patient a previous sequestrant failure?
He/she will be unlikely to tolerate a rechallenge, but you might try a different sequestrant preparation (i.e. Questran Light instead of Questran, or Colestid tablets
v) Is the patient willing and able?
The patient must be cooperative to withstand
initiation and maintenance of sequestrant therapy.
SEQUESTRANT Information Sheet Colestipol [cholestyramine] is a medication which lowers cholesterol levels! How to take: 1. Always mix with other foods. For example, try mixing with juices, milk, applesauce, or cereals to see which has the best taste! 2, Take twice daily, just before or during the breakfast and evening meals. 3. Take other medications either one hour before or 4 hours after the colestipol. Initial Dosing Schedule: We start with low doses! First Week:
1 scoop daily with supper.
SIDE EFFECTS:
For any problems, call us!! We want to talk about these side effects with you! Mr/Ms _____________________, Phone__________________. Dr ________________________, Phone__________________.
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Dose Range
Atorvastatin (Lipitor) 10 to 80mg
Cerivastatin (Baycol) 0.2 to 0.4mg
Fluvastatin (Lescol) 20 to 40mg
Lovastatin (Mevacor) 10 to 40mg
Pravastatin (Pravachol) 10 to 40mg
Simvastatin (Zocor) 10 to 80mg
Indications: IIa, IIb hyperlipidemia
Note: Statins not indicated unless LDL-C is elevated!
Approximate Effectiveness of Simvastatin (Atorvastatin)
Percent Change from Basal
Dose TG* HDL-C LDL-C
10mg -10 (-15) +3 (+3) -27 (-34)
20mg -15 (-20) +5 (+5) -34 (-41)
40mg -20 (-25) +6 (+6) -41 (-48)
80mg -25 (-30) +8 (+6) -48 (-55)
*TG reductions unlikely if TG levels initially > 400 mg/dl!
-Lipid response to atorvastatin shown in parentheses-
Adverse effects:
Hepatitis (particularly at higher doses), myalgias, myopathy.
Relative Contraindications:
Renal disease, other meds may potentiate rhabdomyolysis, including gemfibrozil, cyclosporine (and other immunosuppressives), erythromycin.Absolute Contraindications:
Active liver disease.Laboratory Monitoring:
LFT, CK (if symptoms).Take-Home Message
1) To reduce toxicity and cost, keep statin doses as low as possible.
2) True for all statins: Doubling the dose reduces LDL by only 7%!
Statin Alert
Five Questions to Ask Before Starting a Statin!
i) Are fasting triglycerides above 300 mg/dl?
Although statins do lower triglycerides by 10-40%, this generally holds true only when they are not initially elevated. Do not use a statin unless triglycerides are below this level.
ii) Is patient already taking a fibrate or cyclosporine?
If so, be sure to keep the statin dose low and instruct patient to stop both drugs if myalgias and/or muscle weakness develops.
iii) Does the patient have liver disease?
Active liver disease is an important contraindication to statin use.
iv) Does the patient have severe renal insufficiency?
Statin metabolites may be cleared by the kidney; severe renal impairment heightens the risk of rhabdomyolysis.
v) Is patient a previous statin failure?
He/she will be unlikely to tolerate a rechallenge even with a different statin. Rechallenge is worth a try particularly if adverse effects weren't necessarily caused by previous statin.
Comparing the Statins
I. Differences Between Drugs
Atorvastatin Simvastatin Pravastatin Cerivastatin
Lipitor Zocor Pravachol Baycol
Standard Starting Dose (mg) 10 10 20 0.2
Maximum Dose (mg) 80 40 40 0.4
LDL Reduction at Max Dose 56% 40% 34% 30%
Price* (Relative to cerivastatin) 4.5 2.4 2.4 1.0
*Shown for maximum dose. Prices taken from website: drugstore.com
II. Similarities between drugs
1) Adverse effect profile (note that LFT abnormalities and most other adverse effects are dose dependent).
2) Potential to interact with other medications (fibrates, niacin and cyclosporin)
3) Effect on triglycerides and HDL cholesterol levels.
III. Take-Home Message
1) Atorvastatin is the most effective LDL lowering agent; a small triglyceride lowering benefit is observed only at the highest doses, which may be more hepatotoxic.
2) Cerivastatin and fluvastatin are the least potent LDL cholesterol lowering agents.
3) Cerivastatin and fluvastatin are the least expensive statins.
IV. The Bottom Line
1) For severe LDL cholesterol elevations, particularly in patients with cardiovascular disease: Consider atorvastatin.
2) For mild LDL cholesterol elevations, particularly where drug costs are an issue: Consider cerivastatin.
3) For moderate LDL cholesterol elevations: Choose simvastatin, pravastatin, or lower dose atorvastatin.
4) Monitor LFTs carefully when using atorvastatin 40-80mg (q 6 wks for 3 months, then q 3-6 months). "Periodic" (q 6-12 mo) monitoring appropriate for other statins.
Gemfibrozil (Lopid)- Dose 1200mg (600 mg bid)
Fenofibrate (Tricor)- Dose 67-200 mg q day
Indications: IIb, IV hyperlipidemia
Note: Fibrates not indicated unless triglycerides are elevated!
Percent Change from Basal
Drug TG HDL-C LDL-C
Gemfibrozil -50 +15 -2
Fenofibrate -45 +15 -15
Note: Studies directly comparing the two drugs not currently available.
Adverse effects:
Not Serious:
Epigastric discomfort, dyspepsia, abdominal pain.Potentially Serious:
Cholelithiasis, myopathy, hepatitis, neutropenia.Relative Contraindications:
Hepatic or severe renal disease; gallstones; current therapy with a statin.Laboratory Monitoring:
CBC shortly after drug started; periodic LFTs.Take-Home Message
1) Consider fenofibrate when treating combined dyslipidemia requiring LDL-C reductions.
2) Consider gemfibrozil when treating isolated
hypertriglyceridemia (much less expensive).
3) Consider gemfibrozil in patients with CHD, 'normal' LDL cholesterol and HDL < 40 (HDL Intervention Trial, NEJM 1999; 341:410-418)..
Fibrate Alert
Four Questions to Ask Before Starting a Fibrate!
i) Are fasting triglycerides below 250 mg/dl?
Fibrates are indicated primarily when triglycerides are elevated. If triglycerides are below 250 mg/dl, re-evaluate whether a fibrate is really needed.
ii) Is LDL-C also elevated above goal levels?
A great triglyceride lowering drug, gemfibrozil will probably NOT also reduce the LDL cholesterol. Consider using fenofibrate, but be prepared to add an additional lipid lowering drug if LDL remains elevated.
iii) Is patient already taking a statin? Cyclosporine??
If so, try to keep the statin dose low and instruct patient to stop both drugs if myalgias and/or muscle weakness develops. Fenofibrate should be used at low doses and with great caution in patients taking cyclosporine.
iv) Does the patient have severe renal or liver disease?
Fibrates are excreted primarily by kidney; toxicity is much more likely if creatinine clearance is less than 50 cc/hr.
Facts
1) Lipid lowering effects are additive.
2) Drug combinations reduce toxicity when used together in low doses.
Combinations Evaluated for Efficacy and Safety in Clinical Trials
1) Niacin and Sequestrants 4) Statins and Sequestrants
2) Niacin and Statins 5) Statins and Fibrates*
3) Niacin and Fibrates 6) Sequestrants and Fibrates
*Question: Can statins and fibrates be prescribed together safely?
Yes.......but be careful! Incidence of severe (yet reversible!) myopathy 1-3% [data available only for gemfibrozil].
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Important hints for combined statin/fibrate therapy
1) Keep statin doses low: (lovastatin/pravastatin/fluvastatin <40mg, simvastatin, atorvastatin <20mg)
2) Avoid using combination in:
Renal failure
Immunosuppressives, especially cyclosporine
?niacin-anecdotal data may not be convincing
3) Tell patient to stop therapy first if new onset myalgias or weakness, then contact you.
4) Obtain CK in presence of symptoms.
LFT Glucose Uric Acid CK CBC
Niacin √ √ optional
Sequestrants
Statins √ Symptoms
Fibrates √ Symptoms √*
Notes
LFT One transaminase is sufficient; Discontinue drug if elevated 3 times above baseline
CK Routine monitoring not clearly helpful, but would check in presence of symptoms (myalgias/muscle weakness). Drug should be stopped in the presence of significant symptoms regardless of the CK level.
Uric Acid Uric acid monitoring optional in absence of symptoms of gout.
*CBC One post-therapy CBC recommended to screen for leukopenia.
Dose Lab Monitoring Pharmacy Total
Niacin 3000mg $100 $120 $220
Niaspan 2000mg $100 $600 $700
Sequestrants 2 scoops $0 $650 $650
Gemfibrozil (generic) 1200mg $80 $150 $380
Fenofibrate 200mg $80 $940 $1,020
Statins (Cerivastatin) 0.4mg $50 $480 $530
Statins (Simvastatin) 80mg $50 $1,140 $1,190
Statins (Atorvastatin) 20mg $50 $890 $940
Statins (Atorvastatin) 80 mg $50 $2,130 $2,180
*Lab Monitoring-performed twice yearly.
Explaining Hypertriglyceridemia to your Patients:
The "Rambler Engine" Story
(This story is most appropriate for overweight
individuals with triglycerides ≥250 mg/dl)
1) All food goes from the stomach to the blood.
2) Therefore, dietary fat, such as in a stick of margarine, quickly ends up in the blood. Doctors then call it triglycerides.
3) We all have a (metabolic) engine which has to remove all food, including this fat, from the blood. Some of the food is stored as fat, some is burned as energy, and some is used to build muscles.
4) Most people are born with an engine that has a lot of reserve to deal with food "emergencies": for example, after eating 10 pieces of cheesecake, their engine would work extra hard to quickly remove all of the cheesecake from the blood. A blood test taken 12 hours later would reveal no trace of the cheesecake [triglycerides] in their blood. These people were born with a "Cadillac" engine!
5) You, on the other hand, were born with an engine that doesn't have this reserve. If you ate even 1/2 of one piece of cheesecake, your engine would have trouble removing it quickly from the blood. We call this engine that you were born with a "Rambler"!! [If patient ≤ 40 years old, substitute "Hyundai", or something similar].
6) This fat, now called triglycerides, may travel in your blood for days and sometimes even weeks before your Rambler can get around to removing it. The triglycerides can sometimes build up to levels in the thousands (normal is less than 200).
7) Individuals with a Cadillac engine can eat whatever they want! Their engine has the reserve to clear all of the fat and other food out of the blood! However, your engine doesn't have that reserve!
8) As you know, a Rambler can work fine if it is treated properly. But for your Rambler to run properly, you must take better care of it compared to a Cadillac.
9) To help your Rambler, you must take several steps.
a) Give your Rambler a "vacation"! Everything you eat represents work for your Rambler, which is already overloaded and unable to effectively clear what you are already eating from the blood. By eating less food (and especially fat), you will be reducing the workload on your Rambler, allowing it to finally get to all the backwork which has been building up in your blood. By eating less food, even for a short period of time (1-2 months), your Rambler will be better rested and better able to function more efficiently to handle the food that you are eating. Sometimes we recommend very strict diets (less than 1000 calories/day) for a relatively short period of time to help your Rambler engine rest and quickly get back on track. This is the most important part of the treatment!!! It is like finally unhitching a two ton trailer from your Rambler- this will certainly help your Rambler to run better and more efficiently!
b) Give your Rambler a "tune-up". There are two ways to tune-up your Rambler. The first is by aerobic exercise. Exercising 20-45 minutes 3-7 times weekly will effectively tune-up your Rambler, allowing it to run better and more efficiently clear your food from the blood. The second way to tune-up your engine is with medication such as gemfibrozil, fenofibrate or niacin. In addition to diet and exercise, your doctor may want to consider medication to tune-up your engine.
10) For advanced learners!!
The story is actually a little more complicated than presented above!! Your body can actually make fat itself, even if you are not eating it. If you have a Rambler engine, your body may misinterpret internal signals as messages to make fat, even if you are already overweight and therefore this extra fat is unnecessary!! For example, certain medications can send this signal to make fat. Therefore, you will want your doctor(s) to be familiar with all the medications that you are taking. Being overweight itself will also sometimes inappropriately trigger the body to make fat when not really necessary. However, when one cuts back on calories, the opposite signal is sent- the message to STOP making fat is then received. Therefore, caloric restriction must go hand in hand with fat restriction.Explaining Cardiovascular Risk to your Patients:
The "Missing Snake" Story
This story is most appropriate for hypercholesterolemic individuals who are contemplating the need for cholesterol lowering drug therapy. This story illustrates the importance of cardiovascular risk assessment to help determine whether elevated cholesterol levels should be treated. This story addresses the frequently asked question [asked by individuals with high cholesterol but few coronary heart disease risk factors]: "My cholesterol is elevated, why aren't you treating me with medication to reduce my risk for a heart attack!!" or the converse question [asked by individuals with only moderately elevated cholesterol but at high risk for future cardiac events]: "My cholesterol isn't all that high, why do you want to treat me with drug therapy?" The "Missing Snake" Story illustrates the need for cholesterol lowering therapy in those individuals at high risk for heart disease, while suggesting that drug therapy may not be necessary for individuals who are at low risk.
1) Suppose you were driving home from work and you heard on the radio that one snake escaped from the County Zoo. Would you be unduly concerned for your health?? Would you be afraid to drive to work the next day?? Would you stay inside your house out of fear that the snake might find you and bite you?? [The answer is usually no].
Next you heard on the radio an advertisement for a special snake vaccine that was available to protect you from the snake bite if you took it before getting bitten. It cost $1000 and reduced your chances of dying from the snakebite by about half (50%). Would you consider buying it?? [The answer is usually no].
2) The next day you were driving home from work and you heard an emergency news flash that 2000 poisonous snakes have just escaped from the County Zoo. Also imagine that both your home and place of work were located within a quarter mile of the zoo grounds!! In this instance, would you be afraid for your health?? Would you be afraid to drive to work the next day?? Would you stay inside your house out of fear that a snake might find you and bite you?? [The answer is usually yes!].
Next you heard on the radio an advertisement for a special snake vaccine that was available to protect you from the snake bite if you took it before getting bitten. It cost $1000 and reduced your chances of dying from the snakebite by about half (50%). Would you consider buying it now?? [The answer is usually yes!].
3) The same concepts apply for drug therapy for high cholesterol levels!! If your cholesterol is elevated, but your risk for heart disease is low (i.e. only one snake loose in the city), then it is really not worth it to treat you with expensive medication to reduce your risk for heart disease! This is because your risk for heart disease is already very low and not much to worry about. On the other hand, if your risk for heart disease is very high (i.e. 2000 poisonous snakes loose in the city), then reducing your risk for heart attacks because a very important priority for your health as there is a very real chance that it will save your life! In this setting of very high risk, intensive approaches to lower cholesterol become an important part of your health care.
1) Take the time to gain familiarity with niacin. It will serve you well in patients with both mild and severe lipid disorders!
2) Use low dose sequestrants freely in appropriate patients, adding to other lipid lowering drugs to achieve goal levels.
3) Set realistic goal lipid levels with your patient (based on NCEP recommendations). Consider multiple drug strategies, if necessary, to achieve these targets.
4) Identify a local "expert" in your area who is willing to informally discuss your problem patients. Consider referral if targets not achieved despite his/her advice.
5) Good luck!
9200 W. Wisconsin Ave.
Milwaukee, WI. 53226