Dyslipidemia Clinical Practice Guidelines:

Updates from Societies

dr. Laurentius Aswin Pramono, SpPD
Dokter Spesialis Penyakit Dalam -
RS St Carolus Jakarta
CASE REPORT

Perempuan, 56 tahun dengan riwayat hipertensi, diabetes melitus tipe 2, gula

terkontrol, tidak memiliki riwayat angina dan stroke. Kolesterol total 230,
Trigliserida 193, HDL 23, LDL 160. Obat apa dan berapa dosis yang masuk?
Laki-laki, 64 tahun, riwayat merokok, masuk IGD dengan kelemahan kedua
ekstremitas, stroke sebelumnya ada, DM dan hipertensi ada. Kolesterol total 180,
Trigliserida 210, HDL 57, LDL 140. Obat apa dan berapa dosis yang masuk?
 DEFINISI
Dislipidemia = kelainan metabolisme lemak yang ditandai
dengan peningkatan maupun penurunan lemak dalam darah
(gangguan lemak kolesterol dalam darah)
Kelainan yang utama:
Kolesterol total (K-total)
LDL
Trigliserida (TG)
HDL
Molekul lemak diangkut oleh senyawa lipid yaitu apoprotein
(Apo) bergabung menjadi lipoprotein
KLASIFIKASI

D. Primer
• Akibat kelainan genetik
• Sedang karena hiperkolesterolemia poligenik dan dislipidemia
kombinasi familial (turunan keluarga)
• Berat karena hiperkolesterolemia familial, dislipidemia remnant, dan
hipertrigliseridemia primer
D. Sekunder
• Akibat suatu penyakit lain
• Tangani penyakit primernya
 KELOMPOK ORANG YANG BERISIKO
Riwayat Riwayat
Perokok aktif Diabetes Hipertensi keluarga PJK keluarga
dini hyperlipidemia

Aterosklerosis
Penyakit LP > 90 cm
Penyakit ginjal Disfungsi atau
inflamasi laki-laki, > 80
kronis ereksi abdominal
kronis cm wanita aneurisma

MK
Obesitas: Asia Laki-laki > 40 th,
hyperlipidemi
> 25 kg/m2 wanita > 50 th
a
PENGOBATAN

Gaya Hidup
• Aktivitas jasmani 30 menit intensitas sedang 4-6 x/minggu, penguatan
otot 2 hari/minggu
• Nutrisi medis diet rendah kalori buah-buahan dan sayuran (> 5
porsi/hari), biji-bijian (> 6 porsi/hari), ikan, daging tanpa lemak, stanol/sterol
2 g/hari dan serat larut air 20-25 g/hari (untuk ↓ kadar LDL-C)
• Stop merokok merokok mempercepat pembentukan plak coroner, efek
negative pada lipid postprandial
FARMAKOLOGIS UNTUK ↓ RISIKO PENYAKIT KV

ACC/AHA 2013 statin, obat lain hanya

bila ada keterbatasan pemakaian statin
ATP III obat-obatan penurun kolesterol
STATIN
Pencegahan primer
• Pada dewasa yang berisiko
jantung & pembuluh darah
20% (Framingham)
• Tidak ada target K-total dan
LDL untuk pencegahan
primer
• Tidak ada rekomendasi
pemeriksaan ulang
Pencegahan sekunder
• Pada dewasa yang disertai
bukti klinis kelainan jantung
& pembuluh darah
• Perhitungkan aspek ekonomi
karena dosis harian dan
harga obat
• Sindrom koroner akut
statin intensitas tinggi
 THE GUIDELINES: ACC/AHA, NOVEMBER 2013

15
 GUIDELINES IDENTIFY FOUR STATIN BENEFIT GROUPS

Group 1 Group 2

Clinical ASCVD LDL-C ≥190 mg/dL

CHD, stroke, and
(~5 mmol/L)
peripheral arterial disease,
all of presumed
atherosclerotic origin

Group 3 Group 4

Diabetes mellitus ASCVD risk ≥7.5%

+ aged 40–75 years No diabetes

+ LDL-C 70–189 mg/dL + aged 40–75 years
(1.8–4.9 mmol/L) + LDL-C 70–189 mg/dL
(1.8–4.9 mmol/L)

ASCVD, atherosclerotic cardiovascular disease

CHD, coronary heart disease
LDL-C, low-density lipoprotein-cholesterol Stone NJ, et al. J Am Coll Cardiol 2013 Nov 7. Epub ahead of print
 GROUP 4. ASCVD RISK ≥7.5%
LDL-C 70–189 MG/DL, NO DIABETES OR CLINICAL ASCVD

No diabetes, age 40–75 years,

LDL-C 70–189 mg/dL
(1.8–4.9 mmol/L)

Estimate 10-year ASCVD risk

with AHA/ACC risk calculator

ASCVD risk ≥7.5% ASCVD risk 5–<7.5% ASCVD risk <5%

• Initiate moderate-to- • Consider moderate

• Additional factors may
high intensity statin intensity statin
be considered before
• Re-emphasize lifestyle • Re-emphasize lifestyle
initiating statin therapy
habits habits

Stone NJ, et al. J Am Coll Cardiol 2013 Nov 7. Epub ahead of print
17
INTENSITY OF TREATMENT
(Group1) Known ASCVD: high-intensity statin*
(Group2) LDL-C >190 mg/dl: high-intensity statin*
* Unless >75 years old or statin-intolerant, then use moderate-intensity statin
(Group3) Diabetes, age 40-75, LDL-C 70-189 mg/dl: moderate-
intensity statin unless score ≥7.5%, then high-intensity statin
(Group4) Patients aged 40-75, LDL-C 70-189 mg/dl with a
global 10-year risk score of ≥7.5%: moderate to high-intensity
statin

2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce

Atherosclerotic Cardiovascular Risk in Adults
INTENSITY OF STATIN THERAPY
High Moderate Low
LDL-C ≥50% LDL-C 30 to <50% LDL-C <30%
Atorva 40-80 mg Atorva 10-20 mg Simva 10 mg
Rosuva 20-40 mg Rosuva 5-10 mg Prava 10-20 mg
Simva 20-40 mg Lova 20 mg
Pravas 40 mg Fluva 20-40 mg
Lova 40 mg Pitava 1 mg
Fluva XL 80 mg
Fluva 40 mg bid
Pitava 2-4 mg

Statins in bold were evaluated in randomized controlled trials;

those in italics were not

2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce

Atherosclerotic Cardiovascular Risk in Adults, p 34
 GUIDELINE COMPARISON: ACC/AHA VS NCEP ATP III
ACC/AHA1 NCEP ATP III2,3
Secondary ≤75 years: high-intensity statin* LDL-C <100 mg/dL;
prevention >75 years: moderate-intensity <70 mg/dL optional
statin† (↓ LDL-C by at least 30−40% recommended)
LDL-C ≥190 mg/dL High-intensity statin* Consider drugs to ↓ LDL-C
(~5 mmol/L) (as soon as lifestyle options not effective)
Diabetes 10-year ASCVD risk: LDL-C <100 mg/dL ;
40−75 years ≥7.5%: high-intensity statin* <70 mg/dL optional
<7.5%: moderate-intensity statin† (intensity that ↓ LDL-C by ≥30−40%)
Primary prevention 10-year ASCVD risk ≥7.5%: LDL-C <100 to <160 mg/dL according to 10-year
40−75 years moderate†- to high*-intensity statin CHD riskǂ
First-line drug Highest tolerated statin Statin “usual” (LDL-C primary target)

Combination with If target not reached with highest Consider adding fibrate or niacin to
non-statin tolerated statin ↓ triglycerides or ↑ HDL-C

Non-statin drugs If statin not tolerated Alternative initial drugs: bile acid sequestrant or
niacin

*Expected to reduce LDL-C by ≥50%

†Expected to reduce LDL-C by 30 to <50% 1. Stone NJ, et al.J Am Coll Cardiol 2013 Nov 7. Epub ahead of print;
ǂLDL-C <70 mg/dL (<≈1.8 mmol/L) optional for patients at highest risk 2. NCEP Adult Treatment Panel III. Circulation 2002;106:3143−3421;
20 NCEP ATP III, National Cholesterol Education Program Adult Treatment Panel III 3. Grundy S et al. Circulation 2004;110:227−239
 NICE LIPID GUIDELINES 2014: STATIN INTENSITY CATEGORIES
ARE BASED ON LDL-CHOLESTEROL REDUCTION

Statin LDL-cholesterol reduction

Dose (mg/day) 5 10 20 40 80
Fluvastatin – – 21%1 27%1 33%2
Pravastatin – 20%1 24%1 29%1 –
Simvastatin – 27%1 32%2 37%2 42%3§
Atorvastatin – 37%2 43%3 49%3 55%3
Rosuvastatin 38%2 43%3 48%3 53%3 –

1 20–30% reduction in LDL-C: low-intensity statin

2 31–40% reduction in LDL-C: medium-intensity statin
3 >40% reduction in LDL-C: high-intensity statin (atorva 20, 40 or 80 mg)

§ Advice from UK Medicines and Healthcare products Regulatory Agency (MHRA). There is an increased risk of myopathy associated with high-dose
(80 mg) simvastatin. The 80 mg dose should be considered only in patients with severe hypercholesterolemia and high risk of cardiovascular
complications who have not achieved their treatment goals on lower doses, when the benefits are expected to outweigh the potential risks

The information used to make the table is from Law MR et al BMJ 2003;326:1423

National Institute for Health and Care Excellence

21 Lipid modification July 2014 http://www.nice.org.uk/Guidance/CG181
UK NICE GUIDELINES
UK NICE GUIDELINES
PEMANTAUAN DAN EVALUASI

6 minggu setelah awal terapi (LDL, fungsi hati dan ginjal)

Bila target LDL belum tercapai pantau setiap 6 bulan sampai
tercapai
Bila sudah tercapai pantau dengan interval 6-12 bulan
Pemantauan yang lebih sering pada:
Kendali glukosa buruk
Penggunaan obat lain yang mengganggu
Progresivitas sumbatan pembuluh darah
Penambahan berat badan
Ada perubahan tak terduga dari angka kolesterol pasien
PEMANTAUAN DAN EVALUASI

SGOT dan SGPT diperiksa sebelum dan sesudah 3 bulan setelah pemberian statin
atau asam fibrat
Karena gangguan lipid terjadi kebanyakan pada 3 bulan setelah inisiasi terapi
Kreatinin kinase diperiksa bila pasien mengeluh nyeri otot atau mengalami
kelemahan otot
CASE REPORT

Perempuan, 56 tahun dengan riwayat hipertensi, diabetes melitus tipe 2, gula

terkontrol, tidak memiliki riwayat angina dan stroke. Kolesterol total 230,
Trigliserida 193, HDL 23, LDL 160. Obat apa dan berapa dosis yang masuk?
Laki-laki, 64 tahun, riwayat merokok, masuk IGD dengan kelemahan kedua
ekstremitas, stroke sebelumnya ada, DM dan hipertensi ada. Kolesterol total 180,
Trigliserida 210, HDL 57, LDL 140. Obat apa dan berapa dosis yang masuk?
Departemen Ilmu Penyakit Dalam RS St. Carolus - Jakarta