X. Reschedule Lipids Evaluation at Appropriate Time and Follow Up to Maintain Goals

objective

Measure the efficacy of prescribed therapy for hyperlipidemia after allowing sufficient time to reach a new steady state.

background

Nadir values of LDL-C and TGs may not be achieved until after three to six months of TLC.  Pharmacotherapy likewise, may not result in lower lipid values until after at least 6-12 weeks of treatment.  Remeasurement of serum lipids after at least 6-12 weeks of drug therapy, or after at least three months of dietary therapy, allows for the documentation of efficacy, the identification of unfavorable effects of treatment, and the dose titration of medication.  The frequency of lipid evaluation is based on the interval used in randomized controlled studies to assess response to therapy.

recommendations

1. Lipid profiles should be reevaluated after at least 6-12 weeks of drug therapy or change in dose or after at least three to six months of dietary therapy to document efficacy, identify adverse effects, and to titrate medication dose.  [I]
2. Follow-up visits should [I] include:
• Patient history
• Physical exam
• Laboratory tests
• Documentation of adverse events
3. Once the goal is achieved, therapy for dyslipidemia should be continued to maintain the goal. Treatment of dyslipidemia is a lifelong process; however, adjustments may be necessary if the patient develops medical conditions that affect the severity of comorbidity or life expectancy.

discussion

Follow-up visits should include:

• Patient history, including compliance with nonpharmacologic measures such as diet, compliance with medication, need for changes in drug therapy regimen, presence of symptoms suggesting adverse drug reactions, adherence to exercise program if prescribed, and reevaluation of the modifiable cardiovascular risk factors.
• Physical exam, including weight and blood pressure, symptoms and severity of co-morbid health conditions.
• Laboratory tests, including periodic fasting lipid profile, and creatine kinase (CK) if symptoms of myopathy are present.  For patients on gemfibrozil, statins, niacin, or zetia check transaminases (AST, ALT); laboratory tests are indicated at 6-12 week intervals initially, and at least every 6 to 12 months for patients on a stable maintenance regimen.  For patients on niacin, check uric acid and fasting blood sugar.  For patients on zetia who are taking wafarin check INR and recheck 2 to 3 months after initial treatments.
• Adverse events to be considered include: hyperglycemia, hyperuricemia (for patients on niacin), significant (>3 times the upper limit of normal) elevations of transaminases (with niacin, statins, or gemfibrozil) and myalgias (with gemfibrozil or statins).  Side effects include: GI symptoms (for patients on BAS) and rash and GI symptoms (for patients on niacin).