DOCSLIB.ORG

Managing Hyperlipidemia: an Evidence-Based Approach

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Managing Hyperlipidemia: an Evidence-Based Approach Managing Hyperlipidemia: An Evidence-Based Approach John Varras, MD For a CME/CEU version of this article please go to http://www.namcp.org/cmeonline.htm, and then click the activity title. Summary To best manage patients with hyperlipidemia, clinicians need to use an evidence- based approach. Based on the evidence, statins are the medications of choice for most patients who need lipid lowering therapy. The presence of various risk factors will determine the appropriate LDL goal for a particular patient. Some patients can benefit from aggressive lipid lowering. Key Points • Lifestyle changes are an important part of hyperlipidemia treatment. • Statins are the drug of choice for most patients with elevated LDL. • Side effects with statins are uncommon, but they do occur more frequently at higher doses. • It is optimal to have an LDL goal of less than 70 in high-risk patients and less than 100 in moderately high-risk patients. • Diabetic patients, those with acute coronary syndrome, and those with multiple or uncontrolled risk factors are at high risk for cardiovascular events and should be treated aggressively. AGGRESSIVELY TREATING HYPERLIPIDEMIA is a major secondary cause, especially of hyper- is an area where the biggest differences have been made triglyceridemia and low HDL.With hypothyroidism, in cardiovascular disease in the last few years. Lipids treating the thyroid disease may revert the lipids back play a significant role in the atherosclerotic process.1,2 to normal. Medications also can be a factor in elevated Low density lipoprotein (LDL) particles become locat- lipids.As an example, thiazides and beta-blockers can ed within the intima of the artery at areas of hemody- worsen lipid control. namic stress. The LDL particles undergo oxidative The National Cholesterol Education Program modification, which leads to uptake by the endothelial (NCEP) guidelines are used in the United States to cells and expression of inflammatory markers, which manage lipids disorders. 3 The most recent update to increases the likelihood of thrombus formation. these guidelines was published in 2004.4 According Inflammation induces the plaque to be unstable.When to these guidelines, patients are stratified based on unstable plaque ruptures, a thrombus forms. cardiac risk factors and coronary heart disease equiv- High-density lipoprotein (HDL) cholesterol has alents into low risk, moderate risk, moderately high the opposite effect. It has anti-atherogenic properties and high risk categories (Exhibit 3). 3,4 Each category and reverses cholesterol transports, helps in endothelial has individual goals. dysfunction, and reduces thrombosis. High HDL People at low risk for developing heart disease are cholesterol is a good thing, and when risk factors are the easiest to manage. One is considered low risk if he evaluated, providers can actually subtract a cardiac or she has zero to one risk factor in addition to a lipid risk factor if the patient has high HDL cholesterol. disorder.The goal LDL is less than 160 gm/dL. If the Treatment is not started based on one lipid measure- LDL is > 160 mg/dL, the patient is started on thera- ment. Two lipid measurements at least two weeks peutic lifestyle changes. Because lifestyle changes are apart and baseline tests to rule out secondary causes unlikely to produce a sufficient decline, medication is and to monitor liver function are needed. started if the LDL is greater than 190 mg/dL. Secondary causes of hyperlipidemias need to be Patients are considered to be at moderate risk for ruled out and treated if present (Exhibit 2). Diabetes developing heart disease if they have two or more www.namcp.org | Vol. 11, No. 2 | Journal of Managed Care Medicine 17 Exhibit 1: Atherosclerotic in the Human Artery Exhibit 2: Secondary Causes A C Thrombus 1. DM Thrombus Endothelium Smooth Ruptured cap muscle cell 2. Hypothyroidism Lipid-rich core B 3. Obstructive liver disease Proteases, prothrombotic 4. Chronic renal failure, nephrotics syndrome T cell factors Mast cell 5. Medications: progestins, estrogen, androgens, Macrophage corticosteriods, thiazides, beta-blockers, Microbes, protease inhibitors, isotretinoin, alcohol autoantigens, and tobacco inflammatory molecules risk factors in addition to a lipid issue. Their goal from their baseline lipids. This is achievable with LDL is less than 130 mg/dL. Therapeutic lifestyle standard doses of the statins. changes are started if LDL is greater than 130 and When treating patients with lipid disorders, LDL medication if greater than 160 mg/dL. cholesterol is the number one goal by the guidelines. The next group is patients at moderately high risk. Once LDL is controlled, non-HDL cholesterol can These are people with two plus risk factors, and an be addressed. Non-HDL cholesterol is total cholesterol estimated risk of developing heart disease in the next minus HDL. The patient’s non-HDL goal is their 10 years of 10 to 20 percent.Their goal LDL is 130 LDL goal plus 30. mg/dL. By the recent guideline updates, it is an Therapeutic lifestyle changes (TLC) are important option to treat these patients more aggressively to an in controlling lipids. All patients that are above goal LDL goal of less than 100.4 Patients with moderately cholesterol or even those with just multiple risk factors high risk and multiple risk factors or severe risk factors should be begun on TLC. that are uncontrolled would benefit from more In general, the patient should consume less than 25 aggressive treatment. to 30 percent of the calories from fat. Saturated fat The highest risk group already has coronary disease intake should be reduced and dietary cholesterol or one of its equivalents or two plus risk factors and should be less than 200 milligrams a day. Patient can an estimated ten year risk of greater than 20 percent. reduce their lipids by reducing fat intake, increasing The goal LDL for this group in general is an LDL fiber to 20 to 30 grams a day, adding plant stanols and less than 100, but there is the therapeutic option of sterols in their diet, losing weight, and exercising aer- treating them more aggressively to less than 70. obically at least 30 minutes the majority of days of Medications should be started in these patients if the the week. Patients with maximal TLC can lower LDL is greater than 100. If they are within the 70 to their LDL by 25 to 30 percent, which can get some 100 range,it also is an option to start them on treatment patients to their goal. then. Certain patients within this highest risk group For a lot of patients, medications will be necessary should be treated most aggressively. Patients who to achieve goal lipid values.The statins work by partially have acute coronary syndrome (ACS) are at the inhibiting HMG-CoA reductase, which is the rate- highest risk of having a cardiovascular event in the limiting step in cholesterol synthesis.They lower LDL near future. Patients with multiple risk factors or by 20 to 60 percent and increase HDL relatively severe poorly controlled risk factors also benefit from modestly (5 to 15 percent), and lower triglycerides. aggressive treatment. These medications reduce coronary events, cardiac The risk of coronary heart disease is log linear deaths, and the need for cardiovascular procedures. It associated with LDL cholesterol. For every 1 percent is unknown if the LDL lowering effect of statins pro- reduction in LDL, there is a relative risk reduction of vides the mortality benefit or if it is the other effects 1 percent.Trials show that this occurs even at LDLs of these agents.They have anti-inflammatory effects, of less than 100.The updated guidelines recommend enhance fibrinolysis, and reduce platelet function.The now that not only should patients get to their goal statins are the only lipid lowering class that has been LDL, they should have a 30 to 40 percent reduction shown to improve total mortality in primary and 18 Journal of Managed Care Medicine | Vol. 11, No. 2 | www.namcp.org secondary prevention.This is why statins are the drug niacin is available (Advicor®). Because it is an older of choice in patients with elevated LDL. medication, the outcomes based data is not as good as Although the agent of choice, they do have some that with statins. There are trials that show reduced adverse effects. Overall, statins are usually very well tol- coronary events, possible reduced total mortality in erated.The one-year discontinuation rate secondary to secondary prevention, and possibly reduced progression adverse effects is about 15 percent.This is much better of carotid disease when niacin is added to a statin. than for the other classes of lipid lowering agents. Unfortunately,there can be a lot of adverse effects. One of the biggest concerns with statins is myositis In general, niacin has a 46 percent discontinuation or muscle inflammation. Myalgias (muscle aches) rate for adverse effects.The biggest reason patients do occur in about 2 to 10 percent of patients, and in trials not tolerate niacin is flushing. Special formulations, this was fairly similar to placebo. slow dose adjustments, and aspirin can be used to Myositis is rare. It is seen in less than 0.5 of patients reduce the flushing. Hepatotoxicity has been report- and the worst case of this, rhabdomyolysis with acute ed. It is especially important for people not to take renal failure, is seen in less than 0.1 percent of over-the-counter niacin preparations because the patients. Rhabdomyolysis occurs most frequently in long acting over-the-counter preparations have been patients that are taking a statin combined with an associated with higher rates of hepatotoxicity. interacting medication. The fibric acid derivatives, gemfibrozil (Lopid®) and Elevated liver function tests are the other major fenofibrate (Tricor®), are another class of lipid lowering concern.With medium dose statins, the rate is prob- agents.They work as ligands for peroxisome profilera- ably about 1 percent of patients, and in high dose tor-activated receptors, which are similar to the mech- statins about 3 percent.
Load more

Recommended publications
  • Genetic Testing for Familial Hypercholesterolemia AHS – M2137
    Corporate Medical Policy Genetic Testing for Familial Hypercholesterolemia AHS – M2137 File Name: genetic_testing_for_familial_hypercholesterolemia Origination: 01/01/2019 Last CAP Review: 07/2021 Next CAP Review: 07/2022 Last Review: 07/2021 Description of Procedure or Service Definitions Familial hypercholesterolemia (FH) is a genetic condition that results in premature atherosclerotic cardiovascular disease due to lifelong exposure to elevated low-density lipoprotein cholesterol (LDL-C) levels (Sturm et al., 2018). FH encompasses multiple clinical phenotypes associated with distinct molecular etiologies. The most common is an autosomal dominant disorder caused by mutations in one of three genes, low-density lipoprotein receptor (LDLR), apolipoprotein B-100 (APOB), and proprotein convertase subtilisin-like kexin type 9 (PCSK9) (Ahmad et al., 2016; Goldberg et al., 2011). Rare autosomal recessive disease results from mutation in low-density lipoprotein receptor adaptor protein (LDLRAP) (Garcia et al., 2001). Related Policies Cardiovascular Disease Risk Assessment AHS – G2050 ***Note: This Medical Policy is complex and technical. For questions concerning the technical language and/or specific clinical indications for its use, please consult your physician. Policy BCBSNC will provide coverage for genetic testing for familial hypercholesterolemia when it is determined the medical criteria or reimbursement guidelines below are met. Benefits Application This medical policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this medical policy. When Genetic Testing for Familial Hypercholesterolemia is covered 1. Genetic testing to establish a molecular diagnosis of Familial Hypercholesterolemia is considered medically necessary when BOTH of the following criteria are met: A.
    [Show full text]
  • Commonly Used Lipidcentric ICD-10 (ICD-9) Codes
    Commonly Used Lipidcentric ICD-10 (ICD-9) Codes *This is not an all inclusive list of ICD-10 codes R.LaForge 11/2015 E78.0 (272.0) Pure hypercholesterolemia E78.3 (272.3) Hyperchylomicronemia (Group A) (Group D) Familial hypercholesterolemia Grütz syndrome Fredrickson Type IIa Chylomicronemia (fasting) (with hyperlipoproteinemia hyperprebetalipoproteinemia) Hyperbetalipoproteinemia Fredrickson type I or V Hyperlipidemia, Group A hyperlipoproteinemia Low-density-lipoid-type [LDL] Lipemia hyperlipoproteinemia Mixed hyperglyceridemia E78.4 (272.4) Other hyperlipidemia E78.1 (272.1) Pure hyperglyceridemia Type 1 Diabetes Mellitus (DM) with (Group B) hyperlipidemia Elevated fasting triglycerides Type 1 DM w diabetic hyperlipidemia Endogenous hyperglyceridemia Familial hyperalphalipoproteinemia Fredrickson Type IV Hyperalphalipoproteinemia, familial hyperlipoproteinemia Hyperlipidemia due to type 1 DM Hyperlipidemia, Group B Hyperprebetalipoproteinemia Hypertriglyceridemia, essential E78.5 (272.5) Hyperlipidemia, unspecified Very-low-density-lipoid-type [VLDL] Complex dyslipidemia hyperlipoproteinemia Elevated fasting lipid profile Elevated lipid profile fasting Hyperlipidemia E78.2 (272.2) Mixed hyperlipidemia (Group C) Hyperlipidemia (high blood fats) Broad- or floating-betalipoproteinemia Hyperlipidemia due to steroid Combined hyperlipidemia NOS Hyperlipidemia due to type 2 diabetes Elevated cholesterol with elevated mellitus triglycerides NEC Fredrickson Type IIb or III hyperlipoproteinemia with E78.6 (272.6)
    [Show full text]
  • Hyperlipidemia
    Hyperlipidemia Overview Hyperlipidemia (HLP) is a condition in which there are high levels of lipid (or fat) in the blood. The two main types of fat that are found in the blood are cholesterol and triglycerides. Nutrition and lifestyle factors such as maintaining a healthy weight, limiting alcohol consumption, avoiding tobacco, and adequate physical activity play a role in both the prevention and treatment of hyperlipidemia. Hyperlipidemia is the most common risk factor for the development of cardiovascular disease, which is why it is important to manage your blood lipid levels by implementing a heart healthy lifestyle. LDL Cholesterol Cholesterol is an essential component found in all human cell membranes and is required for healthy bodily functions. Your body makes all the cholesterol it needs to function and therefore the amount consumed in the diet should be limited. High levels of cholesterol in the blood increases your risk for heart disease by sticking to the walls of your arteries and causing plaque to build-up. Over time, this plaque can narrow your arteries and prevent adequate blood flow. This condition is called atherosclerosis and it is one of the primary causes of heart attack and stroke. There are two types of cholesterol, low-density lipoprotein (LDL) or “bad” cholesterol, and high-density lipoprotein (HDL) or “good” cholesterol. High levels of LDL are associated with the formation of atherosclerotic plaque. High levels of HDL have been shown to decrease the risk for heart disease and stroke by removing excess cholesterol from the bloodstream. Triglycerides Triglycerides are the most common type of fat in the body.
    [Show full text]
  • Familial Combined Hyperlipidemia: Current Knowledge, Perspectives
    REVISTA DE INVESTIGACIÓN CLÍNICA Contents available at PubMed www .clinicalandtranslationalinvestigation .com PERMANYER Rev Invest Clin. 2018;70:224-36 BRIEF REVIEW Familial Combined Hyperlipidemia: Current Knowledge, Perspectives, and Controversies Omar Yaxmehen Bello-Chavolla1,2, Anuar Kuri-García1, Monserratte Ríos-Ríos1, Arsenio Vargas-Vázquez1,2, Jorge Eduardo Cortés-Arroyo1,2, Gabriela Tapia-González1, Ivette Cruz-Bautista1,3,4 and Carlos Alberto Aguilar-Salinas1,3,4* 1Metabolic Diseases Research Unit and 3Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico; 2MD/PhD (PECEM) Program, Facultad de Medicina, Universidad Nacional Autónoma de México; 4Tec Salud, Instituto Tecnológico y de Estudios Superiores de Monterrey, Monterrey, N.L., México ABSTRACT Familial combined hyperlipidemia (FCHL) is the most prevalent primary dyslipidemia; however, it frequently remains undiagnosed and its precise definition is a subject of controversy. FCHL is characterized by fluctuations in serum lipid concentrations and may present as mixed hyperlipidemia, isolated hypercholesterolemia, hypertriglyceridemia, or as a normal serum lipid profile in combination with abnormally elevated levels of apolipoprotein B. FCHL is an oligogenic primary lipid disorder, which can occur due to the interaction of several contributing variants and mutations along with environmental triggers. Controversies surround- ing the relevance of identifying FCHL as a cause of isolated hypertriglyceridemia and a differential diagnosis of familial hyper- triglyceridemia are offset by the description of associations with USF1 and other genetic traits that are unique for FCHL and that are shared with other conditions with similar pathophysiological mechanisms. Patients with FCHL are at an increased risk of cardiovascular disease and mortality and have a high frequency of comorbidity with other metabolic conditions such as type 2 diabetes, non-alcoholic fatty liver disease, steatohepatitis, and the metabolic syndrome.
    [Show full text]
  • LIPITOR® (Atorvastatin Calcium) Tablets for Oral Administration Hypothyroidism, and Renal Impairment
    HIGHLIGHTS OF PRESCRIBING INFORMATION ----------------------WARNINGS AND PRECAUTIONS-----------------------­ These highlights do not include all the information needed to use Skeletal muscle effects (e.g., myopathy and rhabdomyolysis): Risks increase LIPITOR safely and effectively. See full prescribing information for when higher doses are used concomitantly with cyclosporine, fibrates, and LIPITOR. strong CYP3A4 inhibitors (e.g., clarithromycin, itraconazole, HIV protease inhibitors). Predisposing factors include advanced age (> 65), uncontrolled LIPITOR® (atorvastatin calcium) Tablets for oral administration hypothyroidism, and renal impairment. Rare cases of rhabdomyolysis with Initial U.S. Approval: 1996 acute renal failure secondary to myoglobinuria have been reported. In cases of myopathy or rhabdomyolysis, therapy should be temporarily withheld or discontinued (5.1). ----------------------------INDICATIONS AND USAGE--------------------------- LIPITOR is an inhibitor of HMG-CoA reductase (statin) indicated as an Liver enzyme abnormalities and monitoring: Persistent elevations in hepatic adjunct therapy to diet to: transaminases can occur. Monitor liver enzymes before and during treatment • Reduce the risk of MI, stroke, revascularization procedures, and angina (5.2). in patients without CHD, but with multiple risk factors (1.1). • Reduce the risk of MI and stroke in patients with type 2 diabetes without A higher incidence of hemorrhagic stroke was seen in patients without CHD CHD, but with multiple risk factors (1.1). but with stroke
    [Show full text]
  • UMHS Guideline Screening and Management of Lipids
    Guidelines for Clinical Care Quality Department Ambulatory Lipid Therapy Screening and Management of Lipids Guideline Team Team Leader Patient population: Adults age 20–79 years without familial or severe dyslipidemias or chronic Audrey L. Fan, MD kidney disease (CKD). (In patients with CKD, see UMHS Management of Chronic Kidney Disease.) General Medicine Objective: Primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD) Team Members through lipid screening, determining treatment benefit and risk, and providing appropriate treatment. Jill N. Fenske, MD Family Medicine Key Points R. Van Harrison, PhD Obtain a screening / baseline lipid profile Medical Education Patients. Men age ≥ 35 and women age ≥ 45 years. Also men age 20–35 and women age 20–45 who are Melvyn Rubenfire, MD at increased risk for ASCVD [IC*]. Can also consider a screening or baseline lipid profile in adults Cardiology age ≥ 20 when assessing traditional ASCVD risk factors (age, sex, total cholesterol, HDL-C, systolic Marie A. Marcelino, BP, use of antihypertensive therapy, diabetes, and smoking) [IIC*]. PharmD Fasting/non-fasting. Screening lipid profile can be obtained fasting or non-fasting. Pharmacy Services Prior to considering drug treatment for dyslipidemias at any age exclude secondary causes (Table 1). Consultant, 2020 revision Assess ASCVD risk. Does the patient have any of the following risk factors? Trisha D. Wells, PharmD Clinical ASCVD. This includes stroke/TIA, carotid and peripheral arterial disease, and clinical evidence Pharmacy Services of coronary heart disease. Initial Release LDL-C ≥ 190 mg/dL and age ≥ 20, not caused by drugs or an underlying medical condition (Table 1). May 2000 Diabetes mellitus type 1 or 2, and age 40–75 years, with LDL-C 70–189 mg/dL.
    [Show full text]
  • Hypobetalipoproteinemia and Developmental Abnormalities in Mice (Embryonic Stem Cells/Gene Targeting/Hydrocephalus/Exencephalus/Atherosclerosis) GREGG E
    Proc. Natl. Acad. Sci. USA Vol. 90, pp. 2389-2393, March 1993 Medical Sciences Targeted modification of the apolipoprotein B gene results in hypobetalipoproteinemia and developmental abnormalities in mice (embryonic stem cells/gene targeting/hydrocephalus/exencephalus/atherosclerosis) GREGG E. HoMANICS*, TERRY J. SMITH*t, SUNNY H. ZHANG*, DENISE LEE*, STEPHEN G. YOUNGf, AND NOBUYO MAEDA*§ *Department of Pathology, The University of North Carolina at Chapel Hill, CB #7525, Chapel Hill, NC 27599-7525; and tGladstone Foundation Laboratories for Cardiovascular Disease, Cardiovascular Research Institute, Department of Medicine, The University of California, San Francisco, CA 94110-0608 Communicated by Oliver Smithies, December 17, 1992 (receivedfor review November 10, 1992) ABSTRACT Familial hypobetalipoproteinemia is an auto- proteins (for reviews, see refs. 7 and 8). Such mutations cause somal codominant disorder resulting in a dramatic reduction in familial hypobetalipoproteinemia (HBL), a condition char- plasma concentrations of apolipoprotein (apo) B, cholesterol, acterized by a reduction in circulating apoB, cholesterol, and and ,-migrating lipoproteins. A benefit of hypobetalipopro- ,-lipoproteins. Humans homozygous for "null alleles" have teinemia is that mildly affected individuals may be protected a complete absence of apoB-containing lipoproteins and can from coronary vascular disease. We have used gene targeting be severely affected with symptoms of intestinal fat malab- to generate mice with a modified Apob allele. Mice containing sorption, fat-soluble vitamin deficiency, and neurological this allele display all of the hallmarks of human hypobetali- problems. The phenotypes of individuals homozygous for poproteinemia: they produce a truncated apoB protein, mutant APOB alleles leading to the synthesis of truncated apoB70, and have markedly decreased plasma concentrations apoB proteins are variable (7-10).
    [Show full text]
  • Hypertriglyceridemia
    J Am Board Fam Med: first published as 10.3122/jabfm.19.3.310 on 3 May 2006. Downloaded from EVIDENCED-BASED CLINICAL MEDICINE Hypertriglyceridemia Rade N. Pejic, MD, and Daniel T. Lee, MD Hypertriglyceridemia is a commonly encountered lipid abnormality frequently associated with other lipid and metabolic derangements. The National Cholesterol Education Program recommends obtaining a fasting lipid panel in adults over the age of 20. The discovery of hypertriglyceridemia should prompt an investigation for secondary causes such as high fat diet, excessive alcohol intake, certain medica- tions, and medical conditions (eg, diabetes mellitus, hypothyroidism). In addition, patients should be evaluated for other components of the metabolic syndrome. These include abdominal obesity, insulin resistance, low high-density lipoprotein (HDL), high triglyceride, and hypertension. Hypertriglyceride- mia is classified as primary hypertriglyceridemia when there are no secondary causes identified. Pri- mary hypertriglyceridemia is the result of various genetic defects leading to disordered triglyceride me- tabolism. It is important to treat hypertriglyceridemia to prevent pancreatitis by reducing triglyceride levels to <500 mg/dL. Furthermore, lowering triglycerides while treating other dyslipidemias and com- ponents of the metabolic syndrome will reduce coronary events. However, it is controversial how much isolated hypertriglyceridemia correlates directly with coronary artery disease and further studies are needed to clarify whether treatment for this condition leads to meaningful clinical outcomes. Therapeu- tic lifestyle changes (TLC) are the first line of treatment for hypertriglyceridemia. These changes include a low saturated fat, carbohydrate-controlled diet, combined with alcohol reduction, smoking cessation, and regular aerobic exercise. High doses of omega-3 fatty acids from fish and fish oil supplements will lower triglyceride levels significantly.
    [Show full text]
  • Hyperlipidemia: Etiology and Possible Control
    IOSR Journal of Dental and Medical Sciences (IOSR-JDMS) e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 14, Issue 10 Ver. VI (Oct. 2015), PP 93-100 www.iosrjournals.org Hyperlipidemia: Etiology and Possible Control Onwe PE* ., Folawiyo MA., Anyigor -Ogah CS., Umahi G., Okorocha AE and Afoke AO *Department of Medical Physiology, Faculty of Medicine, Ebonyi State University, Abakaliki, Nigeria. Abstract: Hyperlipidemia is a condition characterized by an elevation of any or all lipid profile and/or lipoproteins in the blood. Although elevated low density lipoprotein cholesterol (LDL) is thought to be the best indicator of atherosclerosis risk, (Amit et al., 2011) dyslipidemia (abnormal amount of lipids in the blood) can also describe elevated total cholesterol (TC) or triglycerides (TG), or low levels of high density lipoprotein cholesterol (HDL).Hyperlipidemia is the major precursor of lipid related ailment such as atherosclerosis, coronary artery disease and also involved in sudden death syndrome. The main cause of hyperlipidemia includes changes in lifestyle habits in which risk factor is mainly poor diet i.e. with a fat intake greater than 40 percent of total calories, saturated fat intake greater than 10 percent of total calories; and cholesterol intake greater than 300 milligrams per day or treatable medical conditions (Durrington, 1995). The pathophysiology of hyperlipidemia can be studied under the two basic classification of hyperlipidemia - primary and secondary hyperlipidemia. The pathophysiology of primary hyperlipidemia involve the idiopathic hyperchylomicronemia in which defect in lipid metabolism leads to hypertriglyceridemia and hyperchylomicronemia caused by a defect in lipoprotein lipase activity or the absence of the surface apoprotein CII31.
    [Show full text]
  • The Role of Nonstatin Therapy in Managing Hyperlipidemia This Is One in a Series of Pro/Con Editorials Dis- JONATHAN R
    Editorials The Role of Nonstatin Therapy in Managing Hyperlipidemia This is one in a series of pro/con editorials dis- JONATHAN R. MURROW, MD, Medical College of cussing controversial issues in family medicine. Georgia—University of Georgia Medical Partnership, ▲ Athens, Georgia See related editorial on page 1063. about these ADD A AAFP members may post comments COMMENT editorials at http://www.aafp.org/afp/2010/1101/ Hyperlipidemia is a potent biomarker for predicting the p1056.html. development of cardiovascular disease.1,2 Reducing low- density lipoprotein (LDL) cholesterol levels with statin use improves morbidity and mortality.3,4 Although of 20 clinical trials found that fibrate therapy for hyper- statins are generally safe, up to 10 percent of patients lipidemia offers a reduction in nonfatal MI, although who are prescribed statin therapy experience toxicity overall mortality is not affected.10 that leads to the discontinuation of therapy.5 In other Niacin lowers LDL cholesterol levels by influencing patients, optimal statin dosing fails to achieve lipid- very-low–density lipoprotein metabolism. In the Coro- lowering goals.3 Accordingly, when treating hyper- nary Drug Project, patients with coronary heart disease lipidemia, physicians often face the question of the receiving niacin were followed over 15 years, and were clinical value of nonstatin drugs, including bile acid found to have a lower all-cause mortality rate compared sequestrants, fibrates (fibric acid derivatives), niacin, with those receiving placebo (52 versus 58 percent; and cholesterol-absorption inhibitors. This editorial P < .001; number needed to treat = 16).11 When com- highlights the most prominent trial data and examines bined with simvastatin (Zocor), extended-release niacin the merit of these drugs in the primary and secondary has been shown to attenuate progression of subclini- prevention of heart disease.
    [Show full text]
  • Primary Deficiency of Microsomal Triglyceride Transfer Protein in Human Abetalipoproteinemia Is Associated with Loss of CD1 Function
    Primary deficiency of microsomal triglyceride transfer protein in human abetalipoproteinemia is associated with loss of CD1 function Sebastian Zeissig, … , Nicholas O. Davidson, Richard S. Blumberg J Clin Invest. 2010;120(8):2889-2899. https://doi.org/10.1172/JCI42703. Research Article Immunology Abetalipoproteinemia (ABL) is a rare Mendelian disorder of lipid metabolism due to genetic deficiency in microsomal triglyceride transfer protein (MTP). It is associated with defects in MTP-mediated lipid transfer onto apolipoprotein B (APOB) and impaired secretion of APOB-containing lipoproteins. Recently, MTP was shown to regulate the CD1 family of lipid antigen-presenting molecules, but little is known about immune function in ABL patients. Here, we have shown that ABL is characterized by immune defects affecting presentation of self and microbial lipid antigens by group 1 (CD1a, CD1b, CD1c) and group 2 (CD1d) CD1 molecules. In dendritic cells isolated from ABL patients, MTP deficiency was associated with increased proteasomal degradation of group 1 CD1 molecules. Although CD1d escaped degradation, it was unable to load antigens and exhibited functional defects similar to those affecting the group 1 CD1 molecules. The reduction in CD1 function resulted in impaired activation of CD1-restricted T and invariant natural killer T (iNKT) cells and reduced numbers and phenotypic alterations of iNKT cells consistent with central and peripheral CD1 defects in vivo. These data highlight MTP as a unique regulator of human metabolic and immune pathways and reveal that ABL is not only a disorder of lipid metabolism but also an immune disease involving CD1. Find the latest version: https://jci.me/42703/pdf Research article Primary deficiency of microsomal triglyceride transfer protein in human abetalipoproteinemia is associated with loss of CD1 function Sebastian Zeissig,1 Stephanie K.
    [Show full text]
  • Acquired Lipoprotein Lipase Deficiency Associated with Chronic Urticaria. A
    European Journal of Endocrinology (1999) 141 502–505 ISSN 0804-4643 CLINICAL STUDY Acquired lipoprotein lipase deficiency associated with chronic urticaria. A new etiology for type I hyperlipoproteinemia Angel L Garcı´a-Otı´n1, Fernando Civeira1, Julia Peinado-Onsurbe2, Carmen Gonzalvo1, Miguel Llobera2 and Miguel Pocovı´1 1Departments of Biochemistry, Molecular Biology and Medicine, University of Zaragoza, Hospital Miguel Servet, Av. Isabel La Cato´lica 1–3, 50009, Zaragoza, Spain and 2Department of Biochemistry and Molecular Biology, University of Barcelona, Av. Diagonal 645, 08028, Barcelona, Spain (Correspondence should be addressed to F Civeira, Servicio de Medicina Interna, Hospital Miguel Servet, Av. Isabel La Cato´lica 1–3, 50009, Zaragoza, Spain; Email: [email protected]) Abstract Type I hyperlipoproteinemia (type I HLP) is a rare disorder of lipid metabolism characterized by fasting chylomicronemia and reduced postheparin plasma lipoprotein lipase (LPL) activity. Most cases of type I HLP are due to genetic defects in the LPL gene or in its activator, the apolipoprotein CII gene. Several cases of acquired type I HLP have also been described in the course of autoimmune diseases due to the presence of circulating inhibitors of LPL. Here we report a case of type I HLP due to a transient defect of LPL activity during puberty associated with chronic idiopathic urticaria (CIU). The absence of any circulating LPL inhibitor in plasma during the disease was demonstrated. The LPL genotype showed that the patient was heterozygous for the D9N variant. This mutation, previously described, can explain only minor defects in the LPL activity. The presence of HLP just after the onset of CIU, and the elevation of the LPL activity with remission of the HLP when the patient recovered from CIU, indicate that type I HLP was caused by CIU.
    [Show full text]