..

2559

2016 RCPT Clinical Practice Guideline on Pharmacologic Therapy of Dyslipidemia

for Atherosclerotic Cardiovascular Disease Prevention


..

.. (2016 RCPT Clinical Practice Guideline on Pharmacologic Therapy of Dyslipidemia for Atherosclerotic
Cardiovascular Disease Prevention)
( )



Triglycerides Cholesterol










-

-

..

.. 2559

10

10
Thai CV risk score


12 .. 2559

1.

2.
3.
4.
5.

6.


7.
8.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27. .
28. .
29. .
30. 2
31. 2
32. 2
33. 6
34. 6
35. 7
36. 7
37. 7
38. 7


(Definition)
(Objective)


(Atherosclerosis)
10

statin

1 statin LDL-C
2
3


lipoprotein metabolism
(atherosclerosis)
(Primary prevention)
Clinical Atherosclerotic Cardiovascular Disease (Clinical ASCVD)

(Secondary prevention) Clinical ASCVD

recurrent events

Clinical Atherosclerotic CardioVascular Disease (Clinical ASCVD) acute coronary

syndrome (ACS), myocardial infarction, stable coronary artery disease, stable/unstable angina, coronary or other arterial
revascularization, ischemic stroke, transient ischemic attack (TIA), peripheral artery disease (PAD), atherosclerotic aortic
diseases

Subclinical ASCVD ACSVD atherosclerosis

atherosclerotic plaque coronary
calcium score

1.
(atherosclerosis)

2.
(atherosclerosis)
3.















(Strength of Recommendation)
++
(cost effective)
+ ( )

+/-


- ( )

- -

(Quality of Evidence)
1 systemic review randomized controlled clinical trials
well-designed randomized controlled clinical trials
2 systemic review controlled clinical trial

( cohort study, case-control study)
3 descriptive studies controlled clinical trial

4 (consensus)



Life Styles Biochemical characteristics Personal characteristics

- - -
- - -
- - -
- -
-
-
-
-
-
-


- -
- -
- - (
- )
-
-
-
-
-
- *
- *

10
Framingham risk score, SCORE, QRISK, ASCVD risk score


EGAT heart study

Thai CV Risk Score
application
10-year Thai CV Risk Score
10 10


lipoprotein metabolism

1.

nephrotic syndrome, hypothyroidism

2.



3.





4.



5.








6.

7.



8.

8.1 myopathy, rhabdomyolysis statin
[ ++ 3]
8.2 [ ++
3]
8.3 [ + 4] ()
8.4 statin LDL-C < 40 ./.
statin [ +/- 4]
8.5
[ - 4]


3-6 familial hypercholesterolemia

1.1 21 LDL-C >190 ./. LDL-C < 130 /.

LDL-C 50 moderate intensity statin
moderate intensity statin (simvastatin 40 ./ atorvastatin 20 ./) 6
LDL-C high intensity statin [ ++ 1]
1.2 LDL-C familial hypercholesterolemia LDL-C
< 100 /. LDL-C 50 high intensity statin
[ ++ 1] LDL-C 6
non-statin ezetimibe cholestyramine [ ++ 1]
1.3 35 LDL-C < 190 ./.
(Thai CV Risk Score)
10 > 10 low moderate intensity statin
LDL-C < 130 /. LDL-C 30 [ +
4]
1.4 Thai CV Risk Score 10 subclinical atherosclerosis, coronary calcium score > 300
Agatston units, ankle-brachial index < 0.9,
( psoriasis, rheumatoid arthritis, HIV infection) low
moderate intensity statin LDL-C < 190 ./. LDL-C < 130
./. 30 [ + 4]

2.1 40 moderate intensity statin

LDL-C < 100 /. LDL-C 30
LDL-C 190 ./. statin LDL-C
 50 LDL-C statin statin
non-statin ezetimibe cholestyramine [ ++ 1]

2.2 40 2

3 6 LDL-C
>100 ./. statin LDL-C < 100 ./. [ +
4]

2.3 40 LDL-C
3 6
LDL-C > 100 ./. statin LDL-C
< 100 ./. [ +/- 4]

2.4 statin non-HDL-C ( < 130 ./. , < 100

./. ) intensity statin non-HDL-C
fibrates [ + 3]

3.1 50 estimated glomerular filtration rate (eGFR) < 60 .//1.73 ..

( 3-5) LDL-C > 100 ./.
LDL-C < 100 ./. LDL-C 30
low moderate intensity statin statin/ezetimibe combination [ +
1]

3.2 > 30 ./ 30 ./ eGFR > 60 .//1.73 ..

( 1-2)

3.3 statin LDL-C

[ + 2] ()
3.4 high intensity statin (
3b-5) () statin
statin

3.5
statin
statin/ezetimibe [ - 2]

3.6 statin
statin [ +
4]

4.1 acute vascular events acute coronary syndrome clinical ASCVD acute vascular
events 12 high intensity statin LDL-C < 70 ./.
LDL-C 50 75
3b-5 moderate
intensity statin LDL-C < 70 ./. LDL-C
50 3 non-statin ezetimibe cholestyramine
[ ++ 1]

4.2 clinical ASCVD vascular events 12 stable coronary artery

disease moderate high intensity statin LDL-C < 70 ./. LDL-C
50 , ASCVD events
statin, LDL-C > 190 ./., ASCVD
LDL-C < 100 ./. LDL-C
50 [ ++ 2]

4.3 LDL-C > 100 /.

high intensity statin [ ++ 2]
 LDL-C < 100 ./. moderate high intensity statin [ +
3]

4.4
statin statin statin
[ + 3]

4.5 statin [ -
3]
 statin
Fibrate
1. fibrate triglycerides > 500 ./.
eGFR < 60 .//1.73 .. triglycerides > 1,000 ./. [ +
2]

2.
triglycerides > 200 ./. HDL-C < 35 .. fibrate statin
[ + 3]

3. gemfibrozil statin

4 fibrate (eGFR) ()

Ezetimibe

1 ezetimibe LDL-C statin

statin

2 ezetimibe statin

2.1 high intensity statin 6 LDL-C

2.2 statin statin LDL-C

2.3 LDL-C statin 4-5

3 statin ezetimibe (AST, ALT) 3

Cholestyramine
Cholestyramine LDL-C
statin statin
LDL-C
4 . 1 . cholestyramine

Niacin (Nicotinic acid)

Extended-release niacin triglycerides 10-30 LDL-C 15-18
niacin HDL-C 25 niacin cardiovascular events
statin triglycerides triglycerides

(Fish oil , Omega-3 Fatty acid)

1 Omega-3 fatty acid [eicosapentaenoic acid (EPA)/docosahexaenoic acid (DHA)] LDL-C LDL-C
2 Omega-3 fatty acid (EPA/DHA) triglycerides 20-50
3 omega-3 fatty acid (EPA/DHA) statin
1 / [ +/-
2]
4 omega-3 fatty acid (EPA/DHA) 2 triglycerides
triglycerides > 500 ./. fibrate [ + 2]

1 (fasting lipid panel)
1 4-12
adherence LDL-C statin
3-12

2 (AST, ALT) statin 4-12

3 LDL-C
[ ++ 4]

4 (AST, ALT) 3
statin

5
(CK) statin statin
2-4 statin
statin

6 CK > 10 rhabdomyolysis
statin statin statin
CK

1
2
3 non-HDL-C

( 50 .) 10-12 .
1
2
3 triglycerides > 400 ./.
 1 statin LDL-C

1 statin LDL-C

High intensity statin Moderate intensity statin Low intensity statin

LDL-C LDL-C LDL-C
50 30- 50 30
Atorvastatin 40-80 . Simvastatin 20-40 . Simvastatin 10 .
Rosuvastatin 20 . Atorvastatin 10-20 . Pravastatin 10-20 .
Rosuvastatin 5-10 . Fluvastatin 20-40 .
Pravastatin 40 . Pitavastatin 1 .
Fluvastatin 80 .
Pitavastatin 2-4 .

1 statin

2 simvastatin 80 .

3 simvastatin conazole, erythromycin, clarithromycin, protease inhibitor, gemfibrozil,

cyclosporine, danazol

4 simvastatin > 10 . verapamil, diltiazem

5 simvastatin > 20 . amiodarone, amlodipine, ranolazine

6 high intensity statin > 75

( ) 3b-5
 2

(chronic kidney disease, CKD)

1. 3 (estimated glomerular
filtration rate, eGFR)

1.1 2 3
1.1.1 (albuminuria)
albumin excretion rate (AER) 30 ./24 . albumin-to-creatinine ratio
(ACR) 30 ./
1.1.2 (hematuria)
1.1.3 (electrolyte)
1.2
1.3
1.4
2. eGFR 60 ./ /1.73 .. 3

1. eGFR
2. (systemic diseases)

3. eGFR ( 2)

2
eGFR

(CKD stages) (ml/min/1.73m2)
1 > 90
2 60-89
3a 45-59
3b 30-44
 4 15-29
5 < 15
(1) 1 2
(2) eGFR
eGFR = 59.64 ./ /1.73 .. 60 ./ /1.73 ..
2

4. ( 3)

3
albumin excretion rate Albumin-to-creatinine ratio (ACR)
(AER)
(mg/mmol) (mg/g)
(mg/24h)
A1 < 30 <3 < 30
A2 30-300 3-30 30-300
A3 > 300 >30 > 300

(1) A3 nephrotic syndrome (AER 2,200 ./24 . [ ACR 2,200

./ 220 ./])
(2) (urine albumin strip)

4

1 2 3a 3b 5
(GFR 60) (GFR 45 59) (GFR < 45)
Statin (./)
Atorvastatin 40-80 40-80 20-40 20
Fluvastatin 80 80 80
Pitavastatin 4 4 2
Pravastatin 40 40 20 20
 Rosuvastatin 40 20 10 5
Simvastatin 40 40 20-40 20
Simvastatin/Ezetimibe 40/10 40/10 20/10 20/10
Bile acid sequestrants (/)
Cholestyramine 16 16 16 16
Fibric acid derivatives (./)
Fenofibrate 300 150
Fenofibrate (micronized 200 100
form)
Fenofibrate (micronized 160 80
and micro coated form)
Fenofibrate (nano- 145 72.5
technology form)
Gemfibrozil 1,200 1,200 600 600
Others (./)
Ezetimibe 10 10 10 10
Niacin 2,000 2,000 1000
Omega-3 fatty acids 4,000 4,000 4,000 4,000
(EPA/DHA)
KDOQI Clinical Practice Guideline for Diabetes and CKD: 2012 update. Am J Kidney Dis. 2012; 60: 850-
886. KDIGO Lipid Work Group. KDIGO Clinical Practice Guideline for Lipid Management in Chronic Kidney Disease.
Kidney Int Suppl.2013;3:259305
 3

1
(DM = Diabetes Mellitus, CKD = Chronic Kidney Disease, ASCVD = Atherosclerotic Cardiovascular Diseases)
 2
(DM = Diabetes Mellitus, CKD = Chronic Kidney Disease, ASCVD = Atherosclerotic Cardiovascular Diseases)
 3
(ACS = Acute Coronary Syndrome, TIA = Transient Ischemic Attack)
* Target LDL-C < 70 ./. , ASCVD events statin, LDL-C
> 190 ./., ASCVD
target LDL-C < 100 ./.


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26 KDOQI Clinical Practice Guideline for Diabetes and CKD: 2012 update. Am J Kidney Dis. 2012;60:850-886

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