DISLIPIDEMIA

OLEH : APT. DINI PERMATA SARI, S.FARM, M.SI

Defenisi
Dislipidemia/Hiperlipidemia adalah suatu kondisi kelebihan
lemak dalam sirkulasi darah.
Dapat disebut juga dengan hiperlipoproteinemia karena
substansi lemak yang mengalir di peredaran darah terikat oleh
protein karena lemak merupakan partikel yang tidak larut air.
Secara umum, hiperlipidemia dapat dibedakan menjadi 2 sub
kategori yaitu
I. hiperkolesterolemia dan
II. hipertrigliseridemia
The story of lipids
• Chylomicrons transport fats from the intestinal mucosa to the liver
• In the liver, the chylomicrons release triglycerides and some cholesterol
and become low-density lipoproteins (LDL).
• LDL then carries fat and cholesterol to the body’s cells.
• High-density lipoproteins (HDL) carry fat and cholesterol back to the liver
for excretion.
The story of lipids (cont.)
• When oxidized LDL cholesterol gets high, atheroma formation in the
walls of arteries occurs, which causes atherosclerosis.
• HDL cholesterol is able to go and remove cholesterol from the
atheroma.
• Atherogenic cholesterol → LDL, VLDL, IDL
Atherosclerosis
Klasifikasi
Klasifikasi hiperlipidemia berdasarkan etiologinya dibedakan menjadi
tiga yaitu,
i. dislipidemia primer yang disebabkan karena kelainan genetik
spesifik
ii. dislipidemia sekunder yaitu, dislipidemia yang terjadi karena
penyakit lain yang menyebabkan kelainan metabolism lemak dan
lipoprotein
iii. hiperlipidemia idiopatik, yaitu hiperlipidemia yang belum dapat
diketahui secara pasti penyebabnya.
Dislipidemia Sekunder
Dislipidemia sekunder atau dislipidemia didapat memiliki bentuk yang
mirip dengan dislipidemia primer.
Dislipidemia sekunder dapat meingkatkan resiko aterosklerosis dini,
pancreatitis, atau berbagai komplikasi lainnya.
Penyebab tersering dari dislipidemia sekunder ini adalah diabetes
mellitus, penggunaan obat diuretik, beta bloker, dan esterogen jangka
panjang
Tanda dan Gejala
Tanda dan Gejala Hiperlipidemia biasanya tidak terdeteksi dini sehingga
baru ditemukan ketika evaluasi atau pemeriksaan penyakit
aterosklerosis atau penyakit kardiovaskuler.
Tanda dan gejalanya yaitu xantoma, xanthelasma, nyeri dada, nyeri
perut, hepatosplenomegali, kadar kolesterol atau trigliserida tinggi,
serangan jantung, obesitas, intoleransi glukosa, lesi menyerupai jerawat
pada sekujur tubuh, plak ateromatosus pada pembuluh darah arteri,
arkus senilis, dan xantomata
Kolesterol
Goals for Lipids
• LDL • HDL
• < 100 →Optimal • < 40 → Low
• 100-129 → Near optimal • ≥ 60 → High
• 130-159 → Borderline • Serum Triglycerides
• 160-189→ High • < 150 → normal
• ≥ 190 → Very High • 150-199 → Borderline
• Total Cholesterol • 200-499 → High
• < 200 → Desirable • ≥ 500 → Very High
• 200-239 → Borderline
• ≥240 → High
Determining Cholesterol Goal
(LDL!)
• Look at JNC 7 Risk Factors
• Cigarette smoking
• Hypertension (BP ≥140/90 or on anti-hypertensives)
• Low HDL cholesterol (< 40 mg/dL)
• Family History of premature coronary heart disease (CHD)
(CHD in first-degree male relative <55 or CHD in first-degree
female relative < 65)
• Age (men ≥ 45, women ≥ 55)
Determining Goal LDL
• CHD and CHD Risk Equivalents:
• Peripheral Vascular Disease
• Cerebral Vascular Accident
• Diabetes Mellitus
LDL Goals
• 0-1 Risk Factors:
• LDL goal is 160
• If LDL ≥ 160: Initiate TLC (therapeutic lifestyle changes)
• If LDL ≥ 190: Initiate pharmaceutical treatment
• 2 + Risk Factors
• LDL goal is 130
• If LDL ≥ 130: Initiate TLC
• If LDL ≥ 160: Initiate pharmaceutical treatment
• CHD or CHD Risk Equivalent
• LDL goal is 100 (or 70)
• If LDL ≥ 100: Initiate TLC and pharmaceutical treatment
Pendekatan terapi obat:
• Obat penurun kadar kolesterol LDL, atau
• Ditambahkan obat fibrat atau nicotinic acid. Golongan fibrat terdiri
dari
• Gemfibrozil 2x600 mg atau 1x900 mg
• Fenofibrat 1x200 mg
Tatalaksana Farmakologis (Predominan)
• Golongan statin:
• Simvastatin 5-40mg
• Lovastatin 10-80 mg
• Pravastatin 10-40 mg
• Fluvastatin 20-80 mg
• Atorvastatin 10-80 mg
• Rosuvastatin 10-40 mg
• Pitavastatin 1-4 mg
• Golongan bile acid sequestrant
• Kolestiramin 4-16 mg
• Golongan nicotinic acid
• Nicotinic acid (immediate release) 2x100 mg s.d. 1,5-3 g
Tatalaksana Farmakologis (Predominan)
• Terapi hiperkolesterolemia untuk pencegahan primer, dimulai dengan
statin atau bile acid sequestrant atau nicotinic acid. Pemantauan
profil lipid dilakukan setiap 6 minggu.
• Bila target sudah tercapai, pemantauan setiap 4-6 bulan. Bila setelah
6 minggu terapi, target belum tercapai: intensifkan atau naikkan dosis
statin atau kombinasi dengan yang lain.
• Bila setelah 6 minggu berikutnya terapi farmakologis diintensifkan.
Pasien dengan PJK, kejadian koroner mayor atau dirawat untuk
prosedur koroner, diberi terapi obat saat pulang dari RS jika kolesterol
LDL > 100 mg/dL.
Penatalaksanaan Pasien dengan
Hipertrigliseridemia
• Penatalaksanaan pasien dengan hipertigliseridemia hampir sama
dengan pasien dengan hiperkolesterolemia dalam pendekatan non-
farmakologis. Perbedaan yang jelas ada pada pendekatan
farmakologis pasien dengan hipertrigliseridemia.
Case # 1
• A 55-year-old woman without symptoms of CAD seeks assessment and
advice for routine health maintenance. Her blood pressure is 135/85
mm Hg. She does not smoke or have diabetes and has been
postmenopausal for 3 years. Her BMI is 24. Lipoprotein analysis shows a
total cholesterol level of 240 mg/dL, an HDL level of 55 mg/dL, a
triglyceride level of 85 mg/dL and a LDL level is 180 mg/dL. The patient
has no family history of premature CAD.
Case # 1 (cont.)
• What is the goal LDL in this woman?
• What would you do if exercise/diet change do not improve
cholesterol after 3 months?
• How would your management change if she complained of
claudication with walking?
Case # 2
• A 40- year-old man without significant past medical history comes in for
a routine annual exam. He has no complaints but is worried because his
father had a “heart attack” at the age of 45. He is a current smoker and
has a 23-pack year history of tobacco use. A fasting lipid panel reveals a
LDL 170 mg/dL and an HDL of 35 mg/dL. Serum Triglycerides were 140
mg/dL. Serum chemistries including liver panel are all normal.
Case # 2 (cont.)
• What is this patient’s goal LDL?
• Would you start medication, and if so, what?
Case # 3
• A 65 year-old woman with medical history of Type II diabetes, obesity,
and hypertension comes to your office for the first time. She has been
told her cholesterol was elevated in the past and states that she has
been following a “low cholesterol diet” for the past 6 months after
seeing a dietician. She had a normal exercise stress test last year prior to
knee replacement surgery and has never had symptoms of CHD. A
fasting lipid profile was performed and revealed a LDL 130, HDL 30 and a
total triglyceride of 300. Her Hgba1c is 6.5%.
Case # 3 (cont.)
• What is this patient’s goal LDL?
• What medication would you consider starting in this patient?
• What labs would you want to monitor in this patient?
The answer for case 1 to 3 is hand written to folio