Consultant Pharmacists Impact on the Treatment of HypercholesterolemiaWhat is Cholesterol, and Why is it of Concern?

Guidelines for Treating Hypercholesterolemia

Management of Hypercholesterolemia

Management of Hypercholesterolemia By Different Health Care Workers.

Practical Management of Hypercholesterolemia

Community Pharmacists and the Management of Hypercholesterolemia

Economic Impact of Pharmacists' Treatment of Hypercholesterolemia

This paper will look at the impact of consultant pharmacists on the treatment of hypercholesterolemia by physicians. Pharmacists have now assumed responsibilities outside the dispensing counter and have been active in monitoring and treating (under protocol) patients with high cholesterol levels (as well as other disease states).

A review of the treatment of hypercholesterolemia by physicians by a group of consultant pharmacists who call on physicians offices, and check physicians progress by reference to the achievement of NCEP cholesterol guidelines, has shown that physicians are doing an overall poor job of getting their patients to national cholesterol treatment standards (NCEP guidelines).

This paper is therefore essentially a review of the problem, through an analysis of the fact that many patients are not achieving control of cholesterol despite treatment by their physicians. Some of the suspected reasons behind this will be discussed, through a review of related literature with summary of findings of research already conducted on this topic.

Firstly, cholesterol and the problems it presents to health will be discussed, and a short review of the various treatment options that are available will be presented, in order to show that hypercholesterolemia is - fundamentally - treatable, but that the management of this treatment is failing.

The thesis will then move on to discussing a review of research on the topic of why and how patients tend not to respond well to treatment of hypercholesterolemia by physicians, in terms of the lifestyle changes necessary to reduce cholesterol levels, and the various psychological and cultural barriers to cholesterol reduction.

The paper then moves on to a short review of the most relevant research on this topic, and then looks at the role pharmacists have played in helping physicians to reduce cholesterol levels in individuals, through a review of the relevant literature and a review of two short case studies, of the ImPACT program in the United States, and the SCRIP program in Canada.

Chapter 1: What is Cholesterol, and Why is it a Concern?

Cholesterol is a soft waxy substance that is a natural component of the fats in the bloodstream and in all the cells of the body, and while cholesterol is an essential part of a healthy body, high levels of cholesterol in the blood (known as hypercholesterolemia) increase a person's risk for cardiovascular disease, which can lead to stroke or heart attack (Anderson et al., 2001). When there is too much cholesterol circulating in the blood, it can create sticky deposits (plaques) along the artery walls, and plaque can eventually obstruct or even block the flow of blood to the brain, heart, and other organs (Anderson et al., 2001). A recent report indicates that more and more Americans have high cholesterol -- the condition is most common among those living in Western cultures (Anderson et al., 2001). While heredity may be a factor for some people, increasingly sedentary lifestyles combined with diets high in saturated fats appear to be the main culprits (Anderson et al., 2001).

The normal range for total blood cholesterol is between 140 and 200 mg per decilitre (mg/dL) of blood (Anderson et al., 2001). Levels between 200 and 240 mg/dL indicate moderate risk, and levels surpassing 240 mg/dL indicate high risk (Anderson et al., 2001). While total cholesterol level is important, it does not tell the whole story, as there are two main types of cholesterol: low density lipoproteins (LDL) and high density lipoproteins (HDL): HDL is generally considered to be "good" cholesterol, while LDL is considered "bad" (Anderson et al., 2001). Triglycerides are a third type of fatty material found in the blood, and while their role in heart disease is not entirely clear, it appears that as triglyceride levels rise, levels of "good" cholesterol fall (Anderson et al., 2001). The complex interaction of these three types of lipids is thrown out of balance when a person has hypercholesterolemia (Anderson et al., 2001). High cholesterol is characterized by a combination of elevated levels of LDL cholesterol, normal or low levels of HDL cholesterol, and normal or elevated levels of triglycerides (Anderson et al., 2001).

Signs and...

In its advanced state, however, high cholesterol may result in any of the following: fat deposits in the tendons and skin (called xanthomas); enlarged liver and spleen (which the healthcare provider may feel on exam); severe abdominal pain as a result of pancreatitis (this happens if triglycerides deposit in the pancreas, which may occur when triglyceride levels are 800 mg/dL or higher); chest pain and even a heart attack (this may occur when enough cholesterol has built up in blood vessel walls to block the flow of blood in the heart) (Anderson et al., 2001).
Causes Of Hypercholesterolemia (Anderson et al., 2001)

In some cases, abnormally high cholesterol may be related to an inherited disorder, and certain genetic causes of abnormal cholesterol and triglycerides, known as hereditary hyperlipidemias, are often very difficult to treat (Anderson et al., 2001). High cholesterol or triglycerides can also be associated with other diseases a person may have, such as diabetes (Anderson et al., 2001). In most cases, however, elevated cholesterol levels are associated with an overly fatty diet coupled with an inactive lifestyle (Anderson et al., 2001). It is also more common in those who are obese, a condition that has now reached epidemic proportions in the United States, affecting as much as half of the adult population (Anderson et al., 2001).

Causes of high total and LDL cholesterol levels include: Hereditary hyperlipidemia (Types IIa or IIb); Diets high in saturated fats and cholesterol; Liver diseas; Underactive thyroid; Poorly controlled diabetes; Overactive pituitary gland (a gland in the brain that helps control hormones in the body); A kidney disorder called nephrotic syndrome characterized by elevated cholesterol, loss of protein in the urine leading to low levels of protein in the blood, and excessive fluid retention causing swelling; Anorexia nervosa Medications such as progestogens, cyclosporins, and thiazide diuretics (Anderson et al., 2001).

Causes of low HDL cholesterol include: Malnutrition; Obesity; Cigarette smoking; Certain medications such as beta blockers and anabolic steroids; Low levels of physical activity; Polycystic ovarian syndrome (a hormonal disorder caused by multiple cysts in the ovaries accompanied by irregular or no menstruation, acne, obesity, and excessive facial hair) (Anderson et al., 2001).

Causes of high triglyceride levels include: Hereditary hyperlipidemia (Types I, IIb, III, IV, or V); Diets high in calories, especially from sugar and refined carbohydrates; Obesity; Poorly controlled diabetes; Insulin resistance (decreased effectiveness of insulin, a hormone that lowers blood sugar levels); Alcohol use; Kidney failure; Stress; Pregnancy; Polycystic ovarian syndrome; Hepatitis; Lupus; Multiple myeloma (a rare disease that occurs more frequently in men than in women and is associated with anemia, bleeding, recurrent infections, and weakness); Lymphoma (tumor of the lymphoid tissue); Certain medications such as estrogens (available in either oral contraceptives or as part of hormone replacement therapy for menopausal women), corticosteroids, a class of cholesterol-lowering medications known as bile acid binding resins (including cholestyramine, colestipol, colesevelam), and isotretinoin (used to treat acne) (Anderson et al., 2001).

Risk Factors (Anderson et al., 2001)

There are certain factors that put a person at increased risk of having high cholesterol; while some factors cannot be altered by changes in lifestyle, many can be changed (Anderson et al., 2001). The most important risk factors for high cholesterol are: Obesity; Diets high in saturated fat and trans fatty acids (found frequently in processed foods, such as those that have been hydrogenated or fried); Low fiber in the diet; Physical inactivity; Stress; Smoking cigarettes; Living in an industrialized country; Underactive thyroid Diabetes; Polycystic ovary syndrome (Anderson et al., 2001).

Diagnosis (Anderson et al., 2001)

Since most people have few if any symptoms of hypercholesterolemia (another term for high cholesterol), blood screening is very important (Anderson et al., 2001). An initial blood test is done to check a "random" measurement of total and HDL cholesterols, meaning that the test is performed at any time during the day, regardless of what has been eaten (Anderson et al., 2001). Those with abnormal levels (total cholesterol more than 200 mg/dL or HDL less than 40 mg/dL), will go on to have a test called fasting lipid profile (in which the person being tested refrains from eating for 8 to 12 hours, usually overnight, prior to the test) (Anderson et al., 2001). The fasting…