Question

A 48-year-old man is referred for management of elevated cholesterol. He has history of obesity, hypertension, and hyperlipidemia. He had a non–ST-segment elevation myocardial infarction one year ago with drug-eluting stent placement in his right coronary artery. His current medications include aspirin 81 mg daily, lisinopril 20 mg daily, and metoprolol XL 50 mg daily. His physical exam is notable for a body mass index (BMI) of 32 kg/m2 but is otherwise unremarkable. His blood pressure is 135/85 mm Hg.

A recent lipid panel shows the following:
• Total Cholesterol: 226 mg/dL
• Triglycerides: 154 mg/dL
• High-Density Lipoprotein Cholesterol (HDL-C): 39 mg/dL
• Friedewald-Estimated Low-Density Lipoprotein Cholesterol (LDL-C): 156 mg/dL
• He has a normal creatinine and normal liver enzymes.
• His TSH and vitamin D levels are within normal limits.

He was advised to lose weight and referred to a weight loss counselor. He also started rosuvastatin 20 mg daily but developed severe aching in his thighs and calves’ muscles. He discontinued the medication with resolution of his aches. Then, he started atorvastatin 20 mg daily but again developed aching in his thighs. Similar aches occurred on a red yeast rice/CoQ10 combination and intermittent dosing of simvastatin 20 mg weekly and rosuvastatin 5 mg weekly. His creatine kinase levels were never elevated during his episodes of muscle aches. He is not willing to try any more statin therapy.

Questions:
1. What food will be highly recommended to the patient? Explain by citing its implications to the human body.

2. What other antihyperlipidemic drug would you recommend to the patient who refuses to take statin as his medication drug? Why?

Answer 1

Question 1

1. What food highly recommended for the patient? Explain by citing its implications to the human body.

Normal Values:

Total cholesterol: less than 170mg/dl

HDL: LESS THAN 100mg/dl

LDL: more than 45mg/dl

Triglycerides : less than 150mg/dl

Here this patient has elevated lipid profile.

Food recommendation for this patient:

1. High Fibre Diet:

         Soluble fiber lowers cholesterol by binding to it in the small intestine. Once inside the small intestine, the fiber attaches to the cholesterol particles, preventing them from entering your bloodstream and traveling to other parts of the body. Instead, cholesterol will exit the body through the feces.

2. High HDL in diet:

          HDL (high-density lipoprotein), or “good” cholesterol, absorbs cholesterol and carries it back to the liver. The liver then flushes it from the body. High levels of HDL cholesterol can lower your risk for heart disease and stroke.

3. Fruits and Vegetables:

· Oats.

· Barley and other whole grains

· Beans

· Eggplant and okra

· Nuts

· Vegetable oils. ...

· Apples, grapes, strawberries, citrus fruits

· Foods fortified with sterols and stanols

4. Omega 3 Fatty acids:

        Omega-3 fatty acids can lower your cholesterol and triglyceride levels. You can incorporate omega-3s into your diet by eating certain kinds of fish and nuts, or by taking supplements containing these healthy compounds, including fish oil.

5. Limit alcohol

6. Salt restrictions.

             A diet rich in fruits and vegetables can increase important cholesterol-lowering compounds in your diet. These compounds, called plant stanols or sterols, work like soluble fiber.

          Eat fish that are high in omega-3 fatty acids. These acids won't lower your LDL level, but they may help raise your HDL level.

QUESTION 2

2. What other antihyperlipidemic drug would you recommend to the patient who refuses to take statin as his medication drug? Why?

    Answer:

    Ezetimibe. Ezetimibe (Zetia) lowers LDL by about 20%

    Rational:

· There are currently seven HMG-CoA reductase inhibitors (statins) approved for lowering cholesterol levels and they are the first line drugs for treating lipid disorders and can lower LDL-C levels by as much as 60%.

· Statins also are effective in reducing triglyceride levels in patients with hypertriglyceridemia. Statins lower LDL levels by inhibiting HMG-CoA reductase activity leading to decreases in hepatic cholesterol content resulting in an up-regulation of hepatic LDL receptors, which increases the clearance of LDL.

· The major side effects are muscle complications and an increased risk of diabetes. The different statins have varying drug interactions.

· Ezetimibe lowers LDL-C levels by approximately 20% by inhibiting cholesterol absorption by the intestines leading to the decreased delivery of cholesterol to the liver, a decrease in hepatic cholesterol content, and an up-regulation of hepatic LDL receptors.

· Ezetimibe is very useful as add on therapy when statin therapy is not sufficient or in statin intolerant patients. Ezetimibe has few side effects. Bile acid sequestrants lower LDL-C by10-30% by decreasing the absorption of bile acids in the intestine which decreases the bile acid pool consequently stimulating the synthesis of bile acids from cholesterol leading to a decrease in hepatic cholesterol content and an up-regulation of hepatic LDL receptors.

· Bile acid sequestrants can be difficult to use as they decrease the absorption of multiple drugs, may increase triglyceride levels, and cause constipation and other GI side effects.