EXECUTIVE SUMMARY OF THE THIRD REPORT OF THE NATIONAL CHOLESTEROL EDUCATION PROGRAM (NCEP) EXPERT PANEL ON DETECTION, EVALUATION AND TREATMENT OF HIGH BLOOD CHOLESTEROL IN ADULTS [Expert Panel.JAMA2001; 285:2486]: The Panel of 13 members and five consultants provide the recommendations for “Adult Treatment Panel III,” which emphasizes LDL cholesterol and defines risk in three categories. At highest risk are those with established coronary heart disease or other forms of atherosclerotic disease, diabetes, or risk factors that confer a 10-year risk for coronary heart disease that is >20%. The latter category is based on a supplementary risk assessment score based on age, cholesterol, HDL, and systolic blood pressure, utilizing data from the Framingham Study. The second category consists of many of the risk factors that were identified in NCEP II including smoking, hypertension, HDL <40, age, and heredity factors that confer risk. Two or more of these factors define the second category which is further defined by the risk scoring system noted above. The third risk group includes persons with 0–1 risk factors. Each of these categories has a defined LDL goal and recommendations for drug therapy based on LDL as summarized in Table 1 below:TABLE 1: LDL goal based on riskIn terms of intervention, two strategies are defined. The first concerns therapeutic life-style changes (TLC) consisting of diet, exercise, and weight reduction. With regard to diet, the emphasis is on reduced saturated fat (<7% of total calories), cholesterol <200 mg/day, increased fiber (20–30 g/day), and LDL-lowering plant stanols/sterols (2 g/day). With regard to drugs, Table 2 below summarizes recommendations for four classes of agents that lower blood lipids:TABLE 2: Drug therapyIn terms of sequence, the lifestyle changes are initiated with diet and physical activity. Evaluation is completed at 6 weeks to determine effect on LDL, and subsequent action includes intensifying these efforts, referral to a dietitian, or the use of drug therapy if the LDL goals have not been achieved. With regard to drugs, LDL-lowering agents include statins, bile acid, sequestrants, or nicotinic acid. When initiated, these should be evaluated for effect on LDL in 6 weeks. If the goals for LDL are not achieved, drug therapy should be intensified with a higher dose of statin; there should be addition of bile acid sequestrants or nicotinic acid to statins, and there should be reevaluation in 6 weeks. Failure to achieve the LDL goal at that point should lead to referral to a lipid specialist. Assuming goals are achieved, the lipid profile should be measured at 4–6-month intervals. Triglycerides are reviewed separately: normal values are <150 mg/dL, high levels are 200–499 mg/dL, and very high levels are >500 mg/dL. Very high levels merit immediate intervention to prevent pancreatitis and reduce CHD risk. This intervention takes precedent over lowering LDL cholesterol. The two major interventions are TLC (very low-fat diet of <15% calories), weight reduction and physical activity, and drug therapy with a fibrate or nicotinic acid. Comment. These guidelines are summarized here because of their relevance to HIV care in the context of lipodystrophy. The current recommendation is for patients with HIV infection to observe these guidelines because it appears that the blood lipid changes noted in the Framingham Study apply here to HIV-infected persons with lipodystrophy as well. The ACTG Expert Panel dealing with this issue has endorsed the prior edition of the NCEP guidelines and presumably endorses this edition as well. With regard to statins, they recommend atorvastatin and pravastatin because these two have the least impact on the P450 metabolic pathway. Fibric acids (genfibersozil and fenofibrate) are other options. Perhaps one of the most important issues that is raised with these newer guidelines is the emphasis/concern for triglyceride levels >500 mg/dL. Both the LDL levels and the triglyceride levels discussed will be found in many HAART recipients, resulting in the obvious increased complexities in HIV care.
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&NA; (2001) studied this question.