【病例学习第30期】hypercholesterolemia(高脂血症)

From Pharmacy Times(www.pharmacytimes.com)
Thanks to the author Craig I. Coleman, PharmD(Dr. Coleman is an assistant professor of pharmacy practice and director of the pharmacoeconomics and outcomes studies group at the University of Connecticut School of Pharmacy.)

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hypercholesterolemia
AG is a 59-year-old white man with no medical history who comes in for his yearly physical at an ambulatory care clinic. He has no known drug allergies and is taking no medication. He has no family history for premature coronary artery disease and does not consume tobacco products. During the physical assessment, his blood pressure is measured at 130/82 mm Hg. The lipid panel comes back with the following: total cholesterol, 285 mg/dL; low-density lipoprotein (LDL) cholesterol, 155 mg/dL; high-density lipoprotein (HDL) cholesterol, 37 mg/dL; and triglycerides, 116 mg/dL. Due to AG's hypercholesterolemia, his physician refers him to a pharmacy-managed lipid clinic. Which of the following is the correct LDL cholesterol goal for AG, and what should the pharmacist recommend to AG to treat his hypercholesterolemia?

ANSWER
AG is older than 44 years of age and has low HDL cholesterol (2 risk factors) and does not have proven coronary disease or a coronary artery disease risk equivalent (eg, diabetes mellitus). This makes his goal LDL <130 mg/dL, according to the National Cholesterol Education Program (NCEP) guidelines (www.nhlbi.nih.gov/guidelines/cholesterol/atp3_rpt.htm). The pharmacist should first recommend more exercise and weight management, including following a diet consisting of <7% of calories as saturated fat, cholesterol <200 mg/day, and increased amounts of soluble fiber (5-10 g/day) and plant stanols/sterols (2 g/day). In addition, drug therapy is likely warranted, although a 3-month trial of lifestyle modification without drug therapy also is reasonable. If and when drug therapy is initiated, even though AG has a low HDL, his elevated LDL should be the first problem addressed. Based upon NCEP guidelines, a moderate dose of a statin (eg, atorvastatin 20 mg) would be a reasonable first drug to start in AG.


高脂血症
AG是一位59岁没有既往病史的白种人，他来日间诊所例行每年一次的体格检查。他没有药物过敏史，目前没有服用任何药物，没有早期冠状动脉疾病家族史，也没有吸烟的不良嗜好。在体检中，他的血压为130/82mmHg，脂质报告回报如下：总胆固醇，285mg/dl；低密度脂蛋白（LDL），155mg/dl；高密度脂蛋白（HDL），37mg/dl；甘油三酯，116mg/dl。因为AG的高脂血症，他的医师建议他去药品经营脂质诊所进行咨询。对于AG来说，哪些是要达到纠正低密度脂蛋白的目标，同时药师应该建议AG如何对待他的高脂血症。
回答
AG年龄已经超过44岁同时伴有较低的高密度脂蛋白（2个危险因素），没有被证明患有心脏病或与冠状动脉血管病相当的疾病（例如，糖尿病）。按照国民胆固醇教育项目（NCEP）指导准则，以上情况使得他的低密度脂蛋白理想值应少于130mg/dl。药师首先应该建议他多锻炼和进行体重控制，包括食用含有少于7%卡路里饱和脂肪的日常饮食，每日摄取少于200mg的胆固醇，并且增加可溶纤维（5-10克/天）和植物固醇或甾醇（2克/天）的数量。此外，尽管在没有服药的情况下，3个月的生活方式改变的做法是合理的，但是药物治疗是很有必要的。如果开始药物治疗，即使是AG具有低的高密度脂蛋白，但是他较高的低密度脂蛋白也是首先要解决的问题。按照NCEP指导准则，AG应该首先服用中等剂量的抑制素（比如，阿活他汀20mg）。

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