Management of Dyslipidemia

The CDC reports that more than 73 million Americans currently live with cholesterol levels that are higher than recommended, a condition known as dyslipidemia. Although the number of people living with dyslipidemia declined substantially from 1999 to 2010, there has been little change in its prevalence in the years since.2 For adults aged 65 and older, the prevalence of the condition is reportedly more than 60%,1 with women being more likely to be affected than men.2 Older adults are at a significantly higher risk than other populations for complications associated with dyslipidemia, due to a high likelihood of comorbidities and a lifestyle that is often far less active than other demographics. High cholesterol levels often occur concomitantly with hypertension, and together, these conditions can double one’s risk of heart attack or stroke.1,3 Additionally, only about 1 in 3 Americans with high cholesterol have their cholesterol levels under control, while only half are receiving any treatment for the condition.1,4 A 2012 study reported that the total economic impact of nonadherence to medication for dyslipidemia was more than $100 billion.5 Treatment options for hypercholesterolemia have been somewhat limited, with statin therapies being the primary method treatment. Statins are effective for lowering cholesterol,6 but some users have complained of muscle pain.7 Additionally, a marginally increased risk of developing type 2 diabetes is associated with statin use.7 The National Lipid Association (NLA) has been on the forefront of developing new methods to treat and care for people with high cholesterol levels. Recently, Part 2 of the NLA Recommendations for Patient-Centered Management of Dyslipidemia (NLA Recommendations) were published. These recommendations serve as guidance for treating patients with dyslipidemia, with a focus on patient-centered management for special conditions and patient populations, including older adults. This document can by used as a tool for providers caring for older patients. We spoke with Carl E. Orringer, MD, president of the NLA to discuss the development of the recommendations and the unique considerations that are associated with treating dyslipidemia in long-term care. ALTC: Can you elaborate on the process for assembling the NLA Recommendations? What were some of the data sources that were used? Dr. Orringer: A panel of experts was convened to review the literature to identify the key studies with an emphasis on randomized controlled trials and meta-analyses of those trials, but the database also included selected observational epidemiologic studies, genetic studies, and metabolic and mechanistic studies. Based on this review, draft recommendations were written. Recommendations were summarized and reviewed and commented upon by the NLA Board, after which they were posted for public comment. Comments were solicited from the general public, NLA members, outside stakeholder organizations, and governmental agencies. These comments were incorporated, when appropriate, into the final document. Are any particular groups or individuals more likely to achieve adequate control of their cholesterol levels than others? Whether we are discussing older or younger patients, the key question that we, as clinicians, are asked to assess is the patient’s readiness to make a change in their lifestyle habits, and, if necessary, the patient’s readiness to accept the need for medical therapy in order to address his or her risk for complications related to their lipid disorder. As patients age, they are more likely to encounter family members, a spouse, or friends who have had one of these medical issues. When these medical disorders are personalized, they become more real to the patient, and often result in a willingness to consider making the changes advised by the health professional. You stressed the importance of patient-centered management, but how involved should the clinician, staff, and caregivers be in setting goals and enforcing these treatment methods? Patient-centered care is the central focus of the NLA Recommendations. We emphasize active engagement of the entire health care team with the patient. In some cases, that engagement may be with a solo health care provider or with that practitioner’s office staff. In other cases, the patient may receive counseling by a host of providers including physicians, nurses, nurse practitioners, dietitians, and exercise and behavioral change specialists. In all cases, the focus is on the individual set of issues that that patient brings to the encounter. Older patients often present with multiple medical and social concerns that must be dealt with in a respectful and caring fashion. Careful attention to detail and sensitivity to the patient’s concerns is essential to create the positive provider-patient relationship that will result in the best possible outcome for each individual patient. Goal setting is of key importance in that relationship. Patients need to understand the overall goals of the treatment process, and the more specific indicators along the way that identify success in the process. For example, the patient first needs to understand that our objective is to reduce the risk of heart attack or stroke. In order to accomplish that objective, a collaborative relationship is established using lipid, blood pressure and blood glucose levels as surrogate markers that the patient is on track. When these surrogate goals are met, positive reinforcement serves to promote sustained behaviors that result in the best long-term outcomes. When these goals are not met, the patient needs to know that the health care team is not there to judge them, but to help them to identify obstacles that can be jointly addressed to enhance their long-term success. At what point should more aggressive statin or drug therapies be considered? What potential risks are there for drug and statin usage in older adults? Drug therapy has been shown to provide similar relative risk reduction for older and for younger patients who have been determined to be at risk for heart attack and stroke. Drug dosing strategies must take into account the patient’s chronologic age, especially those who are aged 80 years and older. When drug therapy is indicated, we generally recommend similar dosing strategies in the 65–79-year-old age group as we do in those under 65 years of age. In those who are aged 80 years and older who require statins for optimal prevention, we generally advise that providers consider starting treatment with moderate intensity statins based upon a provider-patient discussion of the risks and benefits of such therapy, consideration of drug-drug interactions, polypharmacy, concomitant medical conditions including frailty, cost considerations and patient preference. Potential side effects of statin therapy include muscle pain or muscle weakness, a slightly increased risk for the development of type 2 diabetes, and very rarely, cognitive dysfunction. When muscle issues arise, the provider first must ascertain that the symptoms are related to the medication, and not to another medical issue. If the symptoms are felt to be due to the medication, reduction of the dose or switching to a different statin may sometimes eliminate the symptoms. If this approach does not work, non-statin medications may be substituted. With regard to diabetes, the benefit of statin therapy generally far outweighs the risk of developing diabetes. Furthermore, if the patient develops diabetes, the treatment of choice for protection against heart attack and stroke is a statin. Finally, there are rare patients who develop cognitive dysfunction at variable periods of time after being started on a statin. The provider must first determine whether other medical issues are more likely causes. If the temporal relationship between the administration of the statin and the onset of the patient’s symptoms suggest that the statin may be causative, a period of omission of the medication and observation, followed by a re-challenge is generally warranted, to determine whether the symptoms are statin-related. How quickly can one expect to see the results of implementing some of these methods for lowering and stabilizing cholesterol levels? What possible side effects or lifestyle changes might one expect to accompany these changes? Favorable changes in blood lipids may be seen within several weeks after initiating lifestyle therapy, but for low or some moderate risk patients, an observation period of up to six months may be necessary to demonstrate the full expected lipid benefits of medical nutrition and exercise therapy. Beneficial effects of drug therapy are generally evident within several weeks and monitoring for response is usually done after 6–8 weeks of therapy. Once the patient achieves the desired goal, follow-up lipid monitoring every 4–12 months is recommended to assess adherence to therapy and achievement of lipid goals. Lifestyle change therapy is generally accompanied by weight reduction in those who are overweight or obese, by an improved energy level and sense of well-being, and by an improved ability to engage in the patient’s activities of daily living. Many individuals note an improvement in bowel function, likely related to an increased intake of dietary fiber. In addition to improvement in the lipid profile, therapeutic lifestyle changes may result in blood pressure reduction in hypertensive patients and in improved glycemic control in those with impaired fasting glucose or with type 2 diabetes. Are there any data to suggest that facilities might benefit from implementing nutritional changes on a larger scale, or is it best to apply changes in diet specific to the individuals? There are easy-to-implement general dietary changes that can be readily employed both by individual patients and by institutions caring for older patients. The NLA Expert Panel subcommittee on lifestyle therapy has identified several alternate dietary patterns that have been shown to have favorable effects on cardiovascular risk; this information was included in Part 2 of the NLA Recommendations. Whenever possible, we advocate counseling by a registered dietitian-nutritionist to facilitate these changes most effectively. We also advocate that older patients engage in at least 150 minutes per week of moderate cardiorespiratory exercise, such as walking to support cardiovascular health. Other forms of exercise including resistance training and flexibility exercises are also recommended to improve quality of life. These recommendations apply equally to those elder patients who are free-living and those who reside in assisted-living facilities. References 1. High Cholesterol Facts. https://www.cdc.gov/cholesterol/facts.htm. Published March 17, 2015. Accessed September 10, 2015. 2. Carroll MD, Kit BK, Lacher DA, Yoon SS. Total and high-density lipoprotein cholesterol in adults: National Health and Nutrition Examination Survey, 2011-2012. NCHS Data Brief. 2013(123):1-8. 3. Navar-Boggan AM, Peterson ED, D’Agostino RB Sr., Neely B, Sniderman AD, Pencina MJ. Hyperlipidemia in early adulthood increases long-term risk of coronary heart disease. Circulation. 2015;131(5):451-458. 4. Mozaffarian D, Benjamin EJ, Go AS. Heart disease and stroke statistics--2015 update: a report from the American Heart Association. Circulation. 2015;131(4):e29-322. 5. Nasseh K, Frazee GS, Visaria J, Viahiotis A, Tian Y. Cost of medication nonadherence associated with diabetes, hypertension, and dyslipidemia. Am J Pharm Benefits.[epub] 2012;4(2):e41-e47. 6. Jukema JW, Cannon CP, de Craen AJ, Westendorp RG, Trompet S. The controversies of statin therapy: weighing the evidence. J Am Coll Cardiol. 2012; 60(10):857-881. 7. Sattar N, Preiss D, Murray HM, et al. Statins and risk of incident diabetes: a collaborative meta-analysis of randomised statin trials. Lancet. 2010;375(9716):735-742.