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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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