Mixed hyperlipidemia

A 47-year-old male is seen in the medicine clinic with recently diagnosed mixed hyperlipidemia. An anti hyp er lip idem ic is administered that favorably affects levels of VLDL, low-density lipoprotein (LDL), and high-density lipoprotein (IIDL) and inhibits cholesterol synthesis. This drug is ... 

The principal use of niacin is for mixed hyperlipidemia or as a second-line agent in combination therapy for hypercholesterolemia. It is a first-line agent or alternative for the treatment of hypertriglyceridemia and diabetic dyslipidemia. 

Ari pi prazole, olanzapine, quetiapine, risperidone, and ziprasidone are effective as monotherapy or as add-on therapy to lithium or valproate for acute mania. Prophylactic use of antipsychotics can be needed for some patients with recurrent mania or mixed states, but the risks versus benefits must be weighed in view of long-term side effects (e.g., obesity, type 2 diabetes, hyperlipidemia, hyperprolactinemia, cardiac disease, and tardive dyskinesia). 

Primary hypercholesterolemia or mixed hyperlipidemia Initial dose 130 mg/day Initial dose 200 mg/day Initial dose 145 mg/day Initial dose 160 mg/day... 

It is indicated as an adjunct to diet to reduce elevated total cholesterol, LDL-cholesterol and TG levels in patients with primary hypercholesterolemia, diabetic dyslipidaemia or mixed hyperlipidemia, hypertriglyceridemia, dysbetalipo-proteinemia and familial hypercholesterolemia. 

In combination with a resin or reductase inhibitor, niacin normalizes LDL in most patients with heterozygous familial hypercholesterolemia and other forms of hypercholesterolemia. These combinations are also indicated in some cases of nephrosis. In severe mixed lipemia that is incompletely responsive to diet, niacin often produces marked reduction of triglycerides, an effect enhanced by marine omega-3 fatty acids. It is useful in patients with combined hyperlipidemia and in those with dysbetalipoproteinemia. It is clearly the most effective agent for increasing HDL and the only agent that may reduce Lp(a). 

Monogenic dyslipoproteinemias can generally be grouped into five categories (1) hypertriglyceridemia with an increase in chylomicrons and the clinical sign of pancreatitis, (2) mixed hyperlipidemia with an increase in chylomicron and VLDL remnants and an increased risk of premature atherosclerosis, (3) hypercholesterolemia with an increase in LDL and an increased risk for premature atherosclerosis, (4) hypoalphalipoproteinemia with low HLD and an increased risk for premature atherosclerosis, and (5) hypolipoproteinemia with a decrease in VLDL and LDL, which may lead to neurological disease. 

Mixed hyperlipidemia is one of the most common lipid disorders, but only a minor fraction of the affected patients has a monogenic inherited disease. Most patients with mixed hyperlipidemia have a familial combined hyperlipidemia, a multifactorial disease for which the causative factors are not known. Patients have elevated remnant lipoproteins with elevated triglycerides > 3.0 mmol/1 and total cholesterol > 5.0 mmol/1. Two rare monogenic disorders lead to such a lipoprotein pattern,... 

In 80 patients with primary mixed hyperlipidemia, gemfibrozil used together with lovastatin resulted in 3% discontinuation because of myositis, but none attributable to rhabdomyolysis or myoglobinuria (72). 

Giral P, Bruckert E, Jacob N, Chapman MJ, Foglietti MJ, Turpin G. Homocysteine and lipid lowering agents. A comparison between atorvastatin and fenofibrate in patients with mixed hyperlipidemia. Atherosclerosis 2001 154(2) 421-7. 

Although it is not exactly clear how much these agents can reduce the risk of a major cardiac event (e.g., infarction, stroke), these drugs will probably remain the first choice for people with certain hyper-lipidemias (e.g., increased triglycerides). These drugs are likewise advocated for mixed hyperlipidemias that are common in metabolic disorders such as type 2 diabetes mellitus (see Chapter 32).32,141 Certain fibrates can be used with other drugs, such as statins, to provide more comprehensive pharmacologic control of certain lipid disorders.30,147... 

Some patients will be seen for multiple reasons therefore, the pharmacist may need to record more than one ICD-9-CM code to fully describe the patient visit. For example, if a client with coronary artery disease (CAD) is referred to a pharmacist, it may not be uncommon that the physician requests education on lowering cholesterol through both diet and medications and education on weight loss and smoking cessation. All three conditions (CAD, obesity, and tobacco use) can be coded to represent the health conditions discussed. Example ICD-9 codes for these conditions include 414.01 (native-vessel disease), 272.2 (mixed hyperlipidemia), and 305.1 (tobacco-use disorder) (Buck and Lockyear, 2007). The specific ICD-9 code used on the claim form should be the same code used by the physician to decrease the risk of claim rejection owing to mismatched codes. Therefore, the ICD-9 code should be requested on the referral form from the physician (Snella et ah, 2004). 

Mixed hyperlipidemia (28.3, 28.4) Remnants (high) Premature atherosclerosis... 

Fenofibrate + a statin Raised triglycerides (TG), decreased HDL-C levels and a predominance of small LDL are characteristics of the metabolic syndrome. In patients with mixed hyperlipidemia and metabolic syndrome, high-dose rosuvastatin (40 mg/d, n = 30) was more effective in decreasing LDL-C and non-HDL-C levels... 

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