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Clinical Care
Part III
APPENDIX
Appendix 13
Appendix 13 a
| Some Common Causes of Secondary
Dyslipidemia other than diabetes |
| Increased LDL cholesterol level |
Increased triglyceride level |
Decreased HDL cholesterol level |
Hypothyroidism Nephrotic syndrome Obstructive liver disease
Drugs
Anabolic steroids Progestins Beta-adrenergic blockers (without intrinsic
sympathomimetic action) Thiazides |
Alcoholism Hypothyroidism Obesity Renal insufficiency
Drugs
Beta-adrenergic blockers (without intrinsic sympathomimetic action)
Bile acidbinding resins Estrogens Ticlopidine |
Cigarette smoking Hypertriglyceridemia Menopause Obesity Uremia
Drugs
Anabolic steroids Beta-adrenergic blockers (without intrinsic sympathomimetic
action) Progestins |
Appendix 13 b
| List of some common drugs and other
factors which may increase the risk of statin associated myopathy |
| Advanced age (especially more than 80 years) in patients (women
more than men) |
| Small body frame and frailty |
| Multisystem disease (e.g., chronic renal insufficiency, especially
due to diabetes) |
| Perioperative periods |
| Multiple medications |
| Fibrates (especially gemfibrozil, but other fibrates
too) |
| Nicotinic acid (rarely) |
| Macrolides (azithromycin, clarithromycin, erythromycin) |
| Azole antifungals (itraconazole, ketoconazole) |
| Calcium antagonists (mibefradil, diltiazem, verapamil) |
| Protease inhibitors (amprenavir, indinavir, nelfinavir, ritonavir,
saquinavir) |
| Cyclosporine, tacrolimus |
| Warfarin |
| PDE-5 inhibitors |
| Nefazodone (antidepressant) |
| Verapamil |
| Amiodarone |
| Large quantities of grapefruit juice (usually
more than 1 quart per day) |
| Alcohol abuse (independently predisposes to myopathy) |
NOTE: This does not represent a complete list.
Appendix 13c
| Changes in Serum Lipid Values with
Different Classes of lipid lowering drugs |
| Drug class |
Total cholesterol levels |
LDL levels |
HDL levels |
Triglycerides |
| Bile acid binding resins |
 20% |
10%
to 20% |
 3%
to 5% |
Neutral or |
| Nicotinic acid |
25% |
10%
to 25% |
15%
to 35% |
20%
to 50% |
| Fibric acid analogs |
15% |
5%
to 15% |
14%
to 20% |
20%
to 50% |
| HMG-CoA reductase inhibitors |
15%
to 30% |
20%
to 60% |
5%
to 15% |
10%
to 40% |
| Ezetimibe |
|
15-20% |
2-4% |
3-5% |
Appendix 14
| Some points about the suggested
drug therapy approach to achievement of blood pressure goal: |
All patients must be prescribed lifestyle changes and this should be
continued even if drug therapy is started.
If BP <15/10 mm Hg above goal (130/80 mm Hg), then ACE inhibitors (ACEi's)
or Angiotensin Receptor Blockers (ARBs) alone may be used to initiate
therapy. The doses can be gradually increased, as needed to the highest
dose range to achieve the blood pressure goal;
If this does not allow for optimal control, add a small dose of a thiazide
diuretic.
If the patient has a blood pressure of >15/10 mm Hg above the goal
(<130/80 mm Hg), begin therapy with a combination of an ACEi or ARB
and a thiazide diuretic, increasing the dosage of the former, as needed,
to the high-dose range to achieve the blood pressure goal.
In both the above cases, if blood pressure is still not controlled, add
a calcium channel blocker (CCB); a nondihydropyridine CCB is recommended
for those with proteinuria of >300 mg/day. Non-dihydropyridine CCBs,
verapamil, diltiazem have been shown to reduce both CV mortality, proteinuria
and diabetic nephropathy progression independent of an ACE inhibitor.
Beta blockers may be substituted for calcium channel blockers if the patient
has angina, heart failure, or arrhythmia necessitating their use. The
newer highly selective beta blockers with proven efficacy to reduce CV
events and the lowest side effect profile are preferred.
The use of a beta blocker with a nondihydropyridine CCB should be avoided
in the elderly and those with conduction abnormalities. Otherwise, such
combinations are safe and particularly effective for lowering blood pressure.
If the blood pressure is still not at the optimal level, add a long acting
alpha blocker at bedtime
Most patients will require multi-drug therapy to achieve and maintain
their BP at the optimal levels.
Appendix 15
Appendix 15a
| Metabolic and Cardiovascular Risk
Factors Associated With Visceral Obesity |
Raised blood pressure ( systolic and /or diatolic)Increased levels of
insulin resistance / hyperinsulinemiaAtherogenic dyslipidemiaRaised levels
of LDL-C and apo-BEndothelial dysfunctionIncreased prothomboitic and procoagulant
stateRaised pro-inflammatory statusDecrease in levels of antiatherogenic
levels of adiponectin Premature atherosclerosis ( leading to early onset
CHD and stroke) Raised levels of serum uric acidSleep apnoea syndrome
and relatedPolycystic ovary syndromeMicroalbuminuria is an integral component
of the cardiometabolic syndrome, and patients with this syndrome have
a propensity to develop type 2 diabetes.
Appendix 15 b
| Partial list of medications which
have weight gain as a side effect |
These medications should preferably not be used if weight loss is the
aim. Moroever, some of these medications lead to lethargy and drowsiness
and may make increased physical activity difficult. Some of these medications
are given in Table.
| Medications |
| Antidepressants |
Serotonin reuptake inhibitors, tricyclic antidepressants, monamine
oxidase inhibitors, eg., amitryptiline, imipramine, doxepin, desipramine,
trazodone, lithium, etc., |
| Antiepileptics: |
valproate, carabamazepine, gabapentin, lithium |
| Antipsychotics |
Atypical neuroleptic agents: clozapine, olanzapine, risperidone
etc., |
| Steroids and other hormones |
Estrogens, progesterone, hormonal contraceptives, corticosteroids |
| Diabetes medications |
Insulin, sulfonylureas, glitazones |
| Antihypertensive Agents |
a- and ß-adrenergic receptor blockers |
| Serotonin and histamine inhibitors |
|
NOTE: This is not a complete list.
Appendix 16
| Framingham Point Score Tables |
NOTE: This system does not take diabetes into its point consideration
as all people with diabetes are considered to be in the high risk category.
People with diabetes and ASCVD are always considered to be in the high
risk category.
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