CT CASE 2:

HYPERLIPIDEMIA
De Guzman, Fernando, Jimenez, Lingat, Piperno
Section 3D
 CASE
Patient MG, a 53 year old male; family
and Setting medicine clinic

Chief Patient reports an elevated

cholesterol at a health fair
Complaint screening 2 weeks ago

Told at health fair screening to

HPI notify physician about elevated
cholesterol
 Type 2 Diabetes Mellitus for 5 years
GLYBURIDE, 10mg BID
PMH Hypothyroidism for 20 years -
LEVOTHYROXINE , 0.15 mg QD

Father: died of MI- 53 y/o

Family History Brother: MI- 44y/o

Salesman, travels frequently, golf

Social History Follows a good diabetic diet, non smoker, drinks

3-4 glasses of wine with evening meals and at
frequent occassion
 VITAL SIGNS:
BP: 138/88
HR: 85
RR: 18
Wt: 83 kg
Ht: 180 cm

SOURCE: ADAPTED FROM WHO,

1995, WHO, 2000 AND WHO 2004.
 National Cholesterol Education Program, Adult
Treatment Panel III (NCEP ATP III)

LAB RESULTS:

LDL = 4.14 (160mg/dL)

Total chol = 6.03 (233mg/dL)
HDL = 0.83 (32mg/dL)
TG = 2.3 (201mg/dL)
 LAB RESULTS

Glucose -7.5
HbA1c- 7%

TSH- 4.2 mU/L

NORMAL
 BASIS FOR OUR DIAGNOSIS

Patients History
PMH, Family and Social History
Physical Exam
Laboratory Results
 PATIENT BASED CORRELATION
HYPERLIPEDEMIA SECONDARY TO HYPERLIPIDEMIA SECONDARY TO DM
HYPOTHYROIDSIM
Hyperinsulinemia due to insulin
Due to elevation of LDL cholesterol resistance
levels.
Decrease LPL levels
Decrease LPL activity Decrease HDL cholesterol
Promotes LDL oxidation
HYPERLIPIDEMIA
SECONDARY TO
DIABETES MELLITUS
EFFECTS OF TYPE 2 DM ON FAT METABOLISM
(1) a decrease in lipoprotein lipase (LPL)
activity resulting in reduced catabolism of
chylomicrons and VLDLs

(2) an increase in the release of free fatty

acid from the adipose tissue

(3) an increase in fatty acid synthesis in the

liver

(4) an increase in hepatic VLDL production

HYPERLIPIDEMIA
SECONDARY TO
HYPOTHYROIDISM
Reduction in hepatic LDL
receptor function

Delayed clearance of
LDL due to the defect in
both hepatic and
extrahepatic tissues
Increased plasma
responsible for levels of LDL,
endocytosis of LDL triglycerides and IDL

Decreased LDL receptor

mediated catabolism

Decrease in lipoprotein
lipase activity
 PROBLEM #1
HYPERLIPIDEMIA
53 y.o. male
BMI: 25.6 OVERWEIGHT
Laboratory Test Results:
Total cholesterol: 233 BORDERLINE HIGH
HDLC: 32 LOW
LDLC: 160 HIGH
Triglycerides: 201 HIGH
 BASIS OF TREATMENT DECISIONS
Patients LDL level
Risk factor status
Present of Known CHD or CHD risk equivalents
Framingham Risk Projection
 RISK FACTORS FOR DEVELOPING CHD
Positive Risk Factors
Age Men 45 y/o, women 55 y/o
Family History of CHD in male 1st deg relative < 55 y/o
Premature CHD CHD in female 1st deg relative < 65 y/o

Low HDL < 40 mg/dL

Hypertension BP 140/90 mm Hg or on antiHTN meds
Cigarette Smoking Current smoker

Negative Risk Factor

High HDL 60 mg/dL (subtract a positive risk factor)
RISK FACTORS FOR DEVELOPING
HYPERLIPIDEMIA
Other Risk Factors
Male>Female Cushings Syndrome
Overweight/Obesi Obstructive Liver
ty Disease
Physical Inactivity Nephrotic Syndrome
Alcoholism
Diet high in fat
Diabetes Mellitus
Hypothyroidism
 III. CHD RISK EQUIVALENTS
Risk Equivalent Comments
Other forms of Peripheral arterial
atherosclerotic Disease disease, abdominal
aortic aneurysm, and
symptomatic carotid
artery disease
Diabetes
Multiple Risk Factors that
confer a 10-y risk for
CHD >20%
 IV. FRAMINGHAM RISK PROJECTION
Age (6), Total Cholesterol (3), HDL Cholesterol (2), Systolic
Blood Pressure (1), Smoking Status (0)
Add up the points: 12
Point Total 10-y Risk Point Total 10-y Risk
0-4 1% 12 10%
5-6 2% 13 12%
7 3% 14 16%
8 4% 15 20%
9 5% 16 25%
10 6% 17 30%
11 8%
RISK CATEGORIES FOR DEVT OF CHD
High Risk Known CHD
(+) CHD Risk
Equivalents
Moderately High Risk cholesterol levels
2 or more risk factors
Framingham 10-y risk of
10%-20%
Moderate Risk 2 or more risk factors
Framingham 10-y risk
below 10%
Low Risk cholesterol levels
0-1 risk factor
 TREATMENT OBJECTIVES
To lower the levels of cholesterol, triglyceride, and
lipids within normal levels
To reduce the risk of developing coronary heart
disease
 PHARMACOLOGIC THERAPY
Bile Acid
Niacin Statins
Resins
Bind bile acids Reduce release of Inhibits HMG-
in the intestine fatty acids from Coa
MOA and promote stores and reduce Reducatase
their excretion hepatic uptake of
in the stool FFA
Fast Intermediate Intermediate
Onset

24 hours 24 hours 12-24 hours

Duration
 Sterol Absorption
Fibrates
Inhibitor
Peroxisome proliferator Inhibit absorption of
activated receptor-alpha cholesterol leading to
MOA (PPAR-) agonists decrease delivery to the
liver
Intermediate Intermediate
Onset

3-24 hours 24 hours

Duration
Drugs Efficacy Safety Suitability Cost (30-day
treatment)
Bile-acid ++ ++ ++ +
Resins TC & LDL serum TG (1000-
(15-30%) (7% acutely & 2000Php)
HDL (3-5%) 2-3%
prolonged tx)

Niacin +++ ++ +++ +++

LDL (5-25%) elevation of OTC (300-500 Php)
TG (20-50%) blood glucose
HDL (15- levels
35%)
Statin +++ +++ +++ +++
LDL (18- Check liver (320-3000
58%) function Php)
TG (8-30%) before use
HDL (2-16%)
Drugs Efficacy Safety Suitability Cost (30-day
treatment)
Fibrates ++ ++ + ++
LDL (20%) Can cause (11.31php/cap)
HDL (10-20%) arrythmia
serum TG (20-
30%)

Sterol +++ + ++ ++
Absorption LDL (18%) serum TG (1509.91
Inhibitor TG (6%) Php/pack)
(Ezetimibe)

Drug Group of choice: Statins

Drug Class: Efficacy Safety Suitability Cost
Statins
Atorvastatin +++ ++ +++ +++ (Php 34-
50/pc)
Fluvastatin ++ +++ ++ ++(Php 52 -
60/pc)
Lovastatin ++ ++ + ++(950-1500 )
(international)
Pravastatin + +++ ++ +++(Php 16-
24/pc)
Rosuvastatin +++ ++ +++ +(Php 57-91/pc)
Simvastatin ++ +++ + +++(Php 19-
30/pc)

Drug of Choice: Atorvastatin

 ATORVASTATIN
Indication: reduction of total and LDL cholesterol, apolipoprotein B and
triglycerides and increase HDL cholesterol
Dosage: 10-80 mg once daily (start with 10 mg/day)
Administration: with or without food
Contraindication: active liver disease or elevated serum transaminases > 3x
upper limit; pregnancy and lactation

Source: MIMS Philippines. 124th Ed. 2010

 ATORVASTATIN
Special Precautions: monitor for creatine phosphokinase
and transaminase elevations; avoid alcohol
consumption;
Adverse Reactions: gastrointestinal s/s, myalgia;
hypo/hyperglycemia, anorexia; thrombocytopenia,
weight gain, dizziness, skin manifestations, etc.
Drug Interactions: risk of myopathy if taken with
cyclosporin, fibric acid derivatives, niacin, erythromycin;
conc. w/ erythromycin, diltiazem HCl and grapefruit juice

Source: MIMS Philippines. 124th Ed. 2010

 TREATMENT
Dietary ( intake of sat fat and cholesterol, use plant sterols
and fiber)
Weight Reduction
physical activity
Treat secondary causes of hyperlipidemia (hypothyroidism,
diabetes) and measure impact of treatment on lipid profile
before starting hyperlipidemia treatment
 MAUVECATE PIPERNO M.D.
FEU-NRMF MEDICAL CENTER
REGALADO AVENUE WEST FAIRVIEW Q.C.
MON-WED-FRI (1-3 PM)
TEL: 9610631

Manuel Gelvezon, Age 53 May 07, 2013

Blk 13 Lot 8 Mozart St.
Casa Milan, Quezon City

Rx
Atorvastatin 10 mg tablets #30
(Lipitor)

Sig: Take 1 tablet daily at evening meal or at bedtime

Mauvecate Piperno, MD
Lic. No. 12345
PTR No.6789
PROBLEM 2: DIABETES
MELLITUS
Fernando, Joan Grace B.
3D
 Problem #2
DIABETES MELLITUS
BASIS OF DIAGNOSIS
53 year-old male
With Type II Diabetes mellitus for 5 years
Golfs on weekends; otherwise no exercise
Drinks 3-4 glasses of wine with evening meal and at
frequent social occasions
Takes glyburide 10mg BID, Levothyroxine 0.15mg OD
Wt: 83kg, Ht: 180cm, BMI: 25.62 (Overweight)
Glucose: 7.5 mmol/L (135 mg/dL)
HbA1c: 7%
AACE DIABETES CARE PLAN GUIDELINES, ENDOCR PRACT;17 (SUPPL 2) 7
 TREATMENT OBJECTIVES
To control blood sugar levels within normal or near-normal
levels and prevention of complications associated with the
disease thru
a. Promotion of healthy lifestyle (diet modification, increase
physical activities, weight reduction)
b. Pharmacologic intervention
c. Treatment of other physiologic derangements
 Drug Class MOA Safety Suitability

Insulin activates insulin receptors

PHARMACOLOGIC
AE: hypoglycemia,
weight gain,
not suitable; SQ

INTERVENTIONS
lipodystrophy

Insulin Close K+ channels in beta cells AE: hypoglycemia, suitable; it has no

Secretagogue increase insulin release weight gain drug interaction, PO,
available

Biguanides reduces hepatic glucose AE: GIT Suitable; no drug

production symptoms,may interaction, PO,
impairs renal gluconeogenesis, cause lactic available
slows of glucose absorption acidosis,
from GIT contraindicated for
Stimulates glycolysis in tissues, patients with Hx of
increased glucose removal MI
from blood, and reduction of
plasma glucagon levels.
 Drug Class MOA
a-Glucosidase competitive inhibitors of the
Inhibotors intestinal -glucosidases and
reduce post-meal glucose
excursions by delaying the
digestion and absorption of
starch and disaccharides
Safety Suitability
AE:hypoglycemia, GI not suitable: may
symptoms; may cause antagonize
hepatotoxicity when effect of insulin
combined with anti- secretagogue
hyperlipidimic agents

Thiazolidinediones promote glucose uptake and AE: fluid retention, not suitable: may
utilization edema, anemia, cause
modulate synthesis of lipid weight gain, macular hepatotoxicity
hormones or cytokines and edema when combined
other proteins involved in with anti-
energy regulation hyperlipidimic
regulate adipocyte agents
apoptosis and differentiation.
 Drug Class MOA Safety Suitability
Incretin-based Potentiate glucose- AE: not suitable: not
drugs mediated insulin hypoglycemia available in the
secretion, suppression of and GIT Philippines
postprandial glucagon symptoms,
release through as-yet anorexia
unknown mechanisms,
slowed gastric emptying,
and a central loss of
appetite.

Amylin suppresses glucagon AE: not suitable: not

Analogue release via undetermined hypoglycemia available in the
mechanisms, delays and GIT Philippines
gastric emptying, and has symptoms,
central nervous system- anorexia
mediated anorectic
effects.
 Drug Class Efficacy Safety Suitability cost

DI Ad S A

Insulin ++ ++ + + + ++
Sulfunylureas 2nd gen +++ +++ + + + + +++

Insulin Meglitinide +++ +++ + + + ++

secretagogue
D-phenylalanine +++ +++ + + +
derivative

Biguanides +++ +++ + + + + +++

a-glucosidase inhibitors ++ + + + + ++

Thiazolidinediones +++ + + + + ++
Incretin-based drugs ++ + + +
Amylin analogue ++ +++ + +
 2nd Gen Effica Safety Suitability Cost
Sulfunylureas cy
Glyburide +++ +++ DI A S A
d
+ + + + +++
Glipizide ++ +++ + + + + ++

Glimepride +++ +++ + + + ++

Biguanides

Metformin +++ +++ + + + + ++

 NON-PHARMACOLOGIC
INTERVENTIONS
Increase physical activities
Modify patients diet
Weight reduction
Promote self-monitoring blood glucose
Educate patient about the disease to increase compliance
 JOAN GRACE B. FERNANDO, MD
INTERNAL MEDICINE
FEU-NICANOR REYES MEDICAL FOUNDATION MEDICAL HOSPITAL
MON-WED (8:00AM-11:00AM)
TEL: 775432

(Glucophage forte) 500mg tablet

 PROBLEM #3
HYPOTHYROIDISM
BASIS:
- Diagnosed with Hypothyroidsm for 20 years
- Medication:
- Levothyroxine, 0.15 mg QD
- Lab Tests: TSH 4.2 mU/L (EUTHYROID)
NORMAL TSH VALUES: 0.5-4.6mU/L
 OBJECTIVES
Maintain TSH level within normal values
Ensure patient follows continuous medication
regimen
Prevent the occurrence of overtreatment
symptoms
 HYPOTHYROIDSM
decrease in production and secretion of thyroid hormones by the thyroid gland

From Katzung and Trevors Pharmacology, 9th Edition

 PHARMACOLOGIC INTERVENTION

According to Clinical Practice Guidelines for Hypothyroidism in Adults by AACE,

Levothyroxine is the recommended treatment for Hypothyroidism

Potency
Cost effectiveness
Lack of foreign protein antigenicity
Ease of dosing due to long acting
effect increase patients
compliance
 PHARMACOLOGIC INTERVENTION
DRUG Efficacy Safety Suitability Cost
++++ +++ +++ +++
- long half life - no protein - once daily dosing - relatively
Levothyroxine - stable smooth antigenicity - various drugs can inexpensive
-synthetic T4 action - overtreatment may affect absorption
produce symptoms and metabolism
of hyperthyroidism
Liothyronine ++ + + +
- synthetic T3
-greater potency -greater cardiotoxicity -multiple dosing -expensive
-rapid absorption potential
- difficult monitoring
 DRUG Efficacy Safety Suitability Cost

L-thyroxine &
L-Triiodothyronine
combination (Liotrix)
- combination of synthetic
T3 and T4
++ ++ + +
-stable and overtreatment may - expensive
predictable potency produce symptoms of
-lack of therapeutic hyperthyroidism
rationale ( T4 is
peripherally
converted to T3)

+ + + ++++
- Variable Possible allergic - Potency
- Cheap
hormone reaction deteriorate with
Desiccated content and Not easily monitored storage
T4/T3 ratios No controlled trials
Thyroid overtreatment may
-from animal thyroid
produce symptoms
glands
of hyperthyroidism
 LEVOTHYROXINE
With uncomplicated hypothyroidism:
- synthetic T4 preparation which 1.6 g/kg
is the choice hormone
Approx: 100-150g
replacement therapy for
Older adults: 50-100 g
Hypothyroidism

Dose adjustments are after 4-8 weeks

Daily dosage is dependent on:
Age Change of 12.5-25 g/day
severity and duration of the hypothyroidism
presence of underlying cardiac disease
Levothyroxine therapy may exacerbate angina by increasing myocardial contractility and
heart rate.

With underlying cadiac disease, long standing Hypothyroidism:

12-25 g/day
If initial dose is tolerated after 1 week, the dose can be increased in
by 25 g every 1 to 2 weeks until therapeutic levels are achieved.

PATIENTS CURRENT DOSE: THYROID STATE:

150 g / 0.15mg EUTHYROID
 SERUM TSH MONITORING
PERIODIC SERUM TSH MEASUREMENT: NORMAL TSH VALUES:
0.5-4.6mU/L

4-8 weeks after Tx

initiation Monitoring is important to prevent
overtreatment that may cause
subclinical signs of hyperthyroidism.
Once adequate dose
is established PRINCIPAL ADVERSE
CONSEQUENCES:
- Cardiovascular (arrhythmias)
6 months after - Sketelal (osteoporosis)
- Affective Disturbances

Every 12 months
ADMINISTRATION:
best taken with water 30 60 minutes before breakfast or at bedtime 4 hours after the last
meal
Do not use with substances and meds that interact with Levothyroxine

DRUG INTERACTIONS:
DECREASE ABSORPTION: INCREASE CLEARANCE:
Malabsorption Syndromes Phenytoin
Calcium Rifampicin
Iron Phenobarbital
Bile Acid Sequestrants Carbamazepine
Raloxifene
aluminium containing antacids, PPI
Meal Intake
Various food products (Soy products, Coffee,
high fiber diet)
STORAGE:
- Stored at 20-25C, Protected from light and moisture

ADVERSE EFFECTS:
- Inform doctor if any of the following are experienced:
Finger tremor, Palpitation
Heart rhythm disturbances
excessive sweating, diarrhea
Weight loss
Sleeplessness or restlessness
Fever
vomiting
 ANGEL KHYM DA. JIMENEZ, MD
INTERNAL MEDICINE
FEU-NRMF DR. NICANOR REYES MEDICAL FOUNDATION MEDICAL CENTER
Marian Medical Arts Building, Rm 211

Mon-Wed, 9:00am 11:00am

Tel. No.: 9313549

Name: Mario Garcia...

Age:53.....Sex: M.. Date: ..............May 6, 2013.

Address: .Regalado Ave., West Fairview, Quezon City.....

\
Levothyroxine Na #30
(Levoxyl)
0.15 mg Tablet

Sig: Take 1 tablet with water 30 minutes before

breakfast daily

Angel Khym DA. Jimenez, MD

Lic. No._8912180____________

PTR no. _1122334___________

S2 no._____________________
PATIENT EDUCATION
 PROBLEM 1: HYPERLIPIDEMIA
Drug of Choice: Atorvastatin (Lipitor)

Take 1 tablet of 10 mg Atorvastatin in the evening or

at bedtime for one month.

Atorvastatin may be taken with or without food.

Take it at the same time each day. The drug must be
taken regularly for it to be effective even if there are
signs of improvement. Do not stop the drug unless
instructed. Store the drug at room temperature not
exceeding 25C.

Avoid excessive grapefruit juice consumption, it can

increase plasma levels of Atorvastatin .
 Do not take cyclosporine or fibric acid
derivatives while on Atorvastatin as this may
increase risk of myopathy.

Inform your doctor immediately if you

experience unexplained muscle pain,
weakness or tenderness especially if it is
accompanied by fever or malaise.

Liver function tests will be performed prior to

the initiation of treatment.
 Atorvastatin should be used with caution in
patients who consume substantial quantities
of alcohol or have a history of liver disease.

Other common side effects of Atorvastatin

include sore throat, stomach pain,
indigestion, constipation, headache and
difficulty sleeping.

Schedule a follow up after one month to test

for drug efficacy and evaluation of lipid
profile.
 It is important to also combine this
medication with appropriate diet by eating
lots of fruits and vegetables and reducing
intake of foods rich saturated fat and
cholesterol.

Increase physical activity, perform exercises

and control patients weight.

Avoid smoking and drinking alcoholic

beverages.
 PROBLEM 2: DIABETES MELLITUS
Drug of Choice: Metformin (Glucophage)
Take 1 tablet of 500 mg Metformin in the
evening with food for six weeks.

Always keep a source of sugar on hand in

case of hypoglycemia.
It may take up to 4 weeks to reach desired
effect.
Regular monitoring of kidney function is
needed.
 Patient may experience GI disturbances and
metallic taste. These are common adverse
effects of the drug.

Avoid alcohol consumption as this may cause

lactic acidosis.

Do not take with sulfonylureas, insulin, beta

blockers or ACE inhibitors this may cause
hypoglycemia.

Schedule a follow up after 6 weeks to measure

glucose level and evaluate drugs effectivity.
 Lifestyle modification:
Consuming a healthy balanced diet
Maintaining ideal body weight
Performing regular exercise
Stress management
Avoidance of tobacco
 PROBLEM 3: HYPOTHYROIDISM
Drug of choice: Levothyroxine Na (Levoxyl)
Take 1 tablet of 0.15 mg Levoxyl once a day 30 minutes
or 1 hour prior to breakfast for 3 months. Should be
taken on an empty stomach.
Store drug at room temperature and keep container
tightly closed to protect from moisture.
Inform patient that TSH levels will be re-evaluated
periodically
 Monitor for possible side effects such as:
Increased nervousness
Heat intolerance
Episodes of palpitations
Tachycardia
Unexplained weight loss

*Inform the doctor immediately if any of

these occur.
 Avoid consumption of food containing bran,
soy or coffee.

Avoid taking Levoxyl with the following

medications:
Cholestyramine
Ferrous sulfate
Sucralfate
Aluminum hydroxide antacids.
 END.
THANK YOU!