Hyperlipidemia Advances

1. Management
of
Dyslipidemia

2. CONTENTS
• Introduction to lipoproteins and dyslipidemia
• Non pharmacological management
• Pharmacological management
• Scenario

3. Lipoproteins
• Atherogenic
• Non
atherogenic
• Lp(a) ?

4. Composition

5. Lipidprofiling
• Lipoprotein measurement – ApoB
• Lipid profile
• Fasting or not ?
Total Cholesterol 120-200
Triglycerides 10-150
HDL Cholesterol 40-60
LDL Cholesterol <130
VLDL Cholesterol Upto 30

6. DYSLIPIDEMIA
• Dyslipidemias are
generally characterized
clinically by increased
plasma levels of
cholesterol, TGs, or
both, variably
accompanied by
reduced levels of HDL
cholesterol
Dyslipidemia
Familial/Genetic
Secondary

7. Familialdyslipidemias

9. When tosuspect?

10. Acquired

11. Dyslipidemia as a cause ofAtherosclerosis

13. Non
Pharmacological
Management
• Clinical studies – 30% to 40% reduction
of serum cholesterol, LDL, and TGs
with the combination of diet, lifestyle
modifications, and nutritional
supplements in most patients.

16. HYPOLIPIDEMIC
DRUGS

17. STATINS
• HMG-CoA
reductase
HMG-CoA
Reductase
inhibition
Reduction in
intracellular
cholesterol
increased
LDL
receptor
increased
uptake of
LDL

18. • Metabolism through the CYP system except pravastatin,
rosuvastatin and pitavastatin
• Gemfibrozil enhances the risk of myopathy

20. Intensity oftherapy

21. Cholesterol absorption inhibitors
inhibiting cholesterol
absorption at intestine
upregulating LDLR
expression increased clearance of LDL
Ezetimibe- monotherapy at 10 mg/day reduces LDL-C by 15
to 22% - with statin additional 21 to 27%.
Adverse Effects: diarrhea, respiratory infections, fatigue

22. Bile acidsequestrants
Blocks EHC
Need to increase more
cholesterol synthesis
More LDL receptors
• Reduction in LDL-C of 18 to 25%
• 24 g of cholestyramine OD
• 20 g of colestipol OD
• 4.5 g of colesevelam OD – best of class
• To be taken 4hr before or 1 hr after other drugs
• Adverse effects
1. GI -------- low dose, ample fluid
2. Increase TG

23. PCSK9 inhibitors
Mabs against PCSK9 –
1. Alirocumab 75mg s/c once 2 weekly
2. Evolocumab 140 mg s/c once 2 weekly
• Reduce LDL by 46 to 73%
• Reduce TG by 26% in phase 2 trials
• Reduce Lp(a) 30 to 40% in phase 2
Adverse Effects
1. Local
2. Flu like symptoms
3. Immunological

24. Microsomal TGtransfer proteininhibitor
• Lomitapide – oral daily 5mg to max 60 mg
- taken 2hrs before meals
• Reduction of LDL by 50%
• Used in HoFH studies
• Cyp3A4 metabolism so Interactions
Adverse effects-
GI side effects limiting
Fatty liver, raised enzymes

25. MIPOMERSEN
• Antisense Oligonucleotide to mRNA of ApoB100
• 200 mg weekly s/c injection
• Metabolised by tissue endo and exo nucleases
• Used mostly in HoFH
Adverse Effects
1. Local
2. Steato-hepatitis – 3 monthly LFT monitoring
3. Flu like symptoms
Hybridization in liver
Degradation by RNAse H
Low ApoB100

26. • Drugs –
1. Gemfibrozil 600mg tab bid
2. Fenofibrate 40mg, 120mg once daily tab
• Effects
1. 50% reduction in TG
2. <20% reduction in LDL
3. <20% increase in HDL
• Increased risk of myopathy if prescribed along with statins-
less with Fenofibrate
• Adverse Effects- GI, skin rash, pancreatitis, Cholelithiasis
• Monitor : S.Creatinine, SGPT, CK-MB if prescribed along with
statins

27. Newer Drugs
• CETP Inhibitors - Anacetrapib –
1. raises HDL-C and ApoA-I levels (by 104 and 36%,
respectively)
2. lowers LDL-C and ApoB (by 17 and 18%, respectively)
• Only Anacetrapib has shown reduced coronary events by
9%
• Apolipoprotein A1 mimetic – D-4Fpeptide - uptake
• Thromimetic – Sobetirome, Eprotirome

28. Bempedoic acid inhibits cholesterol synthesis by inhibiting the action of ATP citrate
lyase
Small interfering RNA (siRNA) molecule Inclisiran— inhibits the synthesis of
PCSK9—reduced LDL-C by up to 50%
Evinacumab is monoclonal antibody that is an inhibitor of angiopoietin-like 3 which
regulates lipid metabolism by increasing triglycerides
Volanesorsen is an antisense oligonucleotide - binds to apoC-III mRNA - leading to its
degradation and preventing translation of apoC-III protein, which inhibits triglyceride
metabolism and hepatic clearance of chylomicrons

29. Miscellaneous Phytosterols 1.6 to 3.0 g/d in divided doses with food
Red yeast rice 2400 mg per night
Pantethine: 300 mg 3 times per day
Niacin various forms at 500 to 3000
mg/d Soy
γ-/δ-Tocotrienols: 200 mg per night with food
ω-3 Fatty Acids: at 3 to 5 g/d at a ratio of 3
parts EPA, 2 parts DHA, and GLA

30. Scenario

31. What arewe
trying to do
with these
drugs?
ASCVD
Major ASCVD events includes
1. Recent ACS (within the past 12 mo)
2. History of MI (other than recent
ACS event listed above)
3. History of ischemic stroke
4. Symptomatic peripheral arterial
disease

32. High-Risk Conditions include
1. Age ≥65 y
2. Heterozygous familial hypercholesterolemia
3. History of prior CABG or PCI outside of the major ASCVD event(s)
4. Diabetes mellitus
5. Hypertension
6. CKD (eGFR 15-59 mL/min/1.73 m2)
7. Current smoking
8. Persistently elevated LDL-C (LDL-C ≥100 mg/dL)
9. History of congestive HF
Very High-Risk Conditions include
1. Multiple major events
2. 1 Major plus multiple high risk conditions

33. SECONDARY
PREVENTION

35. •High dose statin therapy is initiated or
continued as early as possible
•Goal 50% reduction of LDL-C, to <55 mg/dL
•Initial Ezetimibe then PCSK9 inhibitors
•Loading with high dose statins before PCI.
•Intensive statin therapy after TIA & Stroke

36. PRIMARY
PREVENTION

37. Risk
calculators

39. Raised LDL

40. DIABETES
• IA--- > 40 to 75 years age with diabetes– moderate intensity
Statins
• II A---- assess ascvd risk and If multiple RFs – higher intensity
Statins to reduce ldl by 50 %
• II A ---- > 75 years-old, if on statins- continue
• II B --- Adults with diabetes with ascvd risk >20% -add
ezetimibe.
• II B----- >75 years old with DM, not on statins – start based
on risk- benefit ratio

41. Old age
•For given TC higher risk in elderly.
•Multiple co-morbities, Medications
•Different pharmacokinetics and dynamics
•Statins to be started at low doses and
titrate.

42. Children
• Family history of early CVD & hypercholesterolemia –
screening from 2 years
• With obesity and Metabolic syndrome- testing
• Lifestyle changes and caloric restrictions.
• >190 or >160 mg/dL with FH after failure of above
• Reverse cascade of screening.

43. WOMEN
•Statins are preferred.
•OCPs ? >160mg/dL
•Oestrogen Replacing therapy ?
•Pregnancy and lactation: BAS and lipid apheresis

44. CKD
• Increased risk of both
atherosclerotic vascular
disease and structural
heart disease
• Specifically rise of TG,
Lp(a)

45. CKD contd

46. Inflammatory conditions
• Rheumatoid arthritis (RA), glomerulosclerosis, or pulmonary
fibrosis
• CVD has been cited as the top cause of death in people with RA
• HIV - Immune dysregulation, Systemic inflammation, Antiretroviral
therapy & Dyslipidemia
• Role of hs-CRP, CAC, intimal thickness.
• Assess Risk score and start based on score
• Start on low doses and check for drug interactions.

47. Raised TG
• TGs are associated but not causal for ASCVD
• Drugs used are statins, fibrates, niacin, ω-3 Fatty Acids
• Treatment to be started If > 200 mg/dL
• Lifestyle and dietary modifications
• 885-1000:Lipid apheresis and insulin infusion till 500

49. Dyslipidemia as a cause ofPancreatitis

50. Lipoprotein (a)
• Screen if Premature ASCVD, Familial
• Limited evidence in reducing ascvd on lowering levels
• Drugs – PCSK9 inhibitors, Niacin
• Statins increase

51. Thankyou