Idc lipid algorithm

Diabetes and Dyslipidemia Master DecisionPath
Master DecisionPath:

Primary Lipid Targets
At Presentation
LDL <100 mg/dL (<70 mg/dL with evidence of CVD); TRI <150 mg/dL; HDL >40 mg/dL men, >50 mg/dL women
Secondary Lipid Targets
Non-HDL <130 mg/dL (<100 mg/dL with evidence of CVD)
1. Fasting lipid
Apo B <90 mg/dL (<80 mg/dL with evidence of CVD)
profile (May
consider using
Medical Nutrition and
Emotional Health
Activity Therapy
2. ALT
3. CK

Initiate and Titrate Statin Therapy
Titrate to max tolerated dose and add medication
if not at target within three months
Triglycerides >200 mg/dL
LDL Above Target
and HDL below <35 mg/dL
Add Niacin
Titrate dose*
Consider Adding Fibrate or
Omega-3 Fatty acids
Add Bile Acid Sequestrant
or Ezetimibe
Titrate dose*
Titrate dose*
*Titrate dose;
Add Niacin
add medication
Add Ezetimibe or Bile Acid
if not at target
Titrate dose*
within three
months, or stop
if not tolerated

Titrate dose*
Check for adherence to regimen; consider referral to Lipid Specialist
(Please see other side for clinical considerations, and a key to abbreviations) 2010 International Diabetes Center at Park Nicollet. All rights reserved and protected.
Diabetes and Dyslipidemia Master DecisionPath
Abbreviations and Clinical Considerations

Non-HDL: Non-high-density lipoprotein
Clinical Considerations for Statin Therapy

Titrate statin dose to lower LDL 30–40% regardless of baseline LDL Statin therapy should be considered in all patients with type 2 diabetes and evidence of CVD, and those >40 years of age with additional CV risk factor(s) Determine ALT and CK level at baseline; do not initiate statin or consider discontinuing therapy if >3 times upper limit of normal; consider alternate statin (pravastatin or low dose rosuvastatin) or reduced dose for statin associated myalgia Statin and fibrate combination therapy (especially with gemfibrozil) increases risk of myopathy and rhabdomyolysis Other Clinical Considerations
Non-HDL = total cholesterol – HDL; reflects cholesterol in all athrogenic lipoproteins.
High ApoB associated with CVD; represents a large number of small, dense oxidized LDL particles.
Reinforce importance of glycemic control if persistently elevated triglyceride level; reinforce need for moderating carbohydrate and alcohol intake; consider 2 gm/day plant stanols/sterols for elevated triglycerides.
Flushing is a concern with niacin therapy; frequency diminishes with repeated, consistent dosing; consider taking aspirin 30–60 minutes prior to dose and/or use of extended release niacin; beneficial because raises HDL, lowers triglycerides and LDL.
Bile acid sequestrant contraindicated when triglycerides >500 mg/dL; colesevelam recommended because of better tolerability and impact on lipid panel (may have modest beneficial effect on lowering blood glucose). Ezetimibe well tolerated; modest benefit on lowering LDL when added to statin; no additional reduction in cartoid intimamedia thickness when added to statin.
Fibrate lowers triglycerides and raises HDL; trend towards CV protection when triglycerides >204 mg/dL and HDL <35 mg/dL; suggested benefit in men and possible harm in women; consider baseline CK when starting fibrate with statin.
Omega-3 fatty acids lower triglycerides; limited outcome data on CV protection; prescription grade omega-3 fatty acids available.
2010 International Diabetes Center at Park Nicollet. All rights reserved and protected.


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