Lipid Management Protocol

RISK GOALS FOR CLINICAL MANAGEMENT LIFESTYLE CATEGORIES THERAPY INTERVENTIONS MODIFICATIONS

Evaluate for ten (10) Initial Assessment: Recommendations years CVD risk. • Assess fasting lipid panel (FLP) for • Encourage weight loss/ baseline. LDL is primary focus. management. Risk Factors include: • Smoking • If LDL-C cannot be calculated due to • Promote increased daily • Hypertension elevated triglyceride level, order LDL-C physical activity. • Dyslipidemia direct measurement or calculate Non-HDL • Low HDL (Exclusive cholesterol. • Referral for medical of LDL) nutrition therapy (covered • Diabetes • FLP within 24 hours of hospitalization for by most payers) • Obesity an acute event and recheck FLP in 12 • Family History weeks. - Limit diet to <7% • Age saturated fats and <200 Men ≥ 45 • Periodically recheck FLP thereafter until mg/dL of cholesterol Women ≥ 55 goal values are met. from total calories.

Metabolic Syndrome* • Consider fasting glucose on all initial - Increased consumption protocols and prn. of monounsaturated fatty acids (olive/ peanut/ canola oils, RISK CATEGORIES nuts/peanut butter, avocado, olives). 0-1 Low Risk (<10% in 10 yrs) LDL<160 and • If LDL is ≥ 130 mg/dL (Baseline or on - Include 6 oz. of fish/wk, Non-HDL<190 treatment) start or intensify lipid lowering specifying tuna, herring Ideal <130 therapy to reach goal (statin preferred). or salmon or 1000 mg and Non- (If patient is hospitalized, start statin.) fish oil per day. HDL<160 2 + Moderate Risk • If LDL 100-129 mg/dL (Baseline or on - Encourage increased (10 - 20% in 10 yrs) treatment): consumption of complex LDL<130 and - Start lipid lowering therapy (statin carbohydrates. Non-HDL<160 preferred). Ideal<100 and - Consider combined drug therapy (statin - Encourage decreased Non-HDL<130 + fibrate or niacin if low HDL or high TG). consumption of simple Preferred fibrate is fenofibrate (Tricor or carbohydrates. Advise 30-40% Lofibra) with lower dose statin. reduction - Encourage increased consumption of fiber.

MISC-106 mps 05/04/05 Lipid Management Protocol

RISK GOALS FOR CLINICAL MANAGEMENT LIFESTYLE CATEGORIES THERAPY INTERVENTIONS MODIFICATIONS

High Risk or LDL<70 and • If LDL 100-129 mg/dL (Baseline or on CHD equivalent Non-HDL<100 treatment): (≥ 20% risk in 10 yrs) - Start lipid lowering therapy (statin Advise 30-50% preferred). reduction - Consider combined drug therapy (statin + fibrate or niacin if low HDL or high TG). Preferred fibrate is fenofibrate (Tricor or *Metabolic Syndrome Lofibra) with lower dose statin. (3 of the following): * Fasting Glucose High Triglycerides Treatment Options: ≥100 • If TG > 500 mg/dL: - Treat TG first to prevent pancreatitis. * Abdominal Obesity - Initiate fibrate and lifestyle Men - Waist management. circumference - Initiate/resume lipid-lowering therapy > 102 cm /40 in. (statin preferred). - Tricor or Lofibra is preferred fibrate in Women - Waist combination with lower dose statin. circumference > 88 cm /35 in. • If TG 200-499 mg/dL: - Start fibrate or niacin. * Blood Pressure - Initiate lifestyle management ≥ 130/85 - Tricor or Lofibra is preferred fibrate in combination with lower dose statin. * Triglycerides ≥ 150 - If triglycerides >150 consider FBS - Aggressive treatment of diabetes * HDL - Consider Actos (pioglitazone) Men < 40 Women < 50 Low HDL Therapy Options:· • If HDL ≤40 mg/dL for men or ≤50 mg/dL for women: - First attain LDL goal - Consider the addition of Niaspan Consider fibrates - Consider Actos (pioglitazone) in diabetes - Intensify weight management and physical activity.

Note: This practitioner’s tool was developed to provide guidance to providers and is not intended to replace or preclude clinical judgement. References: Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Cholesterol in Adults (ATP III) NIH Publication No. 02 - 5215 September 2002 Cardiovascular Associates of Northern Wisconsin Clinical Based Guidelines, David K. Murdock, M.D. NCEP Report: Implications of Recent Clinical Trials for the national Cholesterol Education Program ATP III Guideline Circulation. 2004; 110:227-234

MISC-106 mps 05/04/05