Use this as a guide to start conversations with your dyslipidemia patients during comprehensive medication reviews (CMRs), medication synchronization appointments, or during any patient interaction. Tackle one or two topics at a time, but don’t overwhelm your patients or yourself by doing too much too fast. Start with these ideas and build on the topics below. Statin therapy for patients with cardiovascular disease or diabetes are Star Ratings quality measures.
1. Assess adherence. Emphasize importance. (Date discussed:__________)
Review prescription refill history to help assess adherence. Have patients explain how they take their medications and make sure your records match. Assess adherence by asking open ended questions, such as: It can be hard to take all your meds regularly. How many doses did you miss in the past week? What challenges keep you from consistently taking your medicines (e.g., cost, forgetfulness)? 2. Ensure patient is on appropriate statin therapy. (Date discussed: ____________)
Discuss patient’s cardiovascular risk. Visit https://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate/. Use patient specifics and the online calculator to estimate patient’s 10-year risk of heart disease or stroke. See our chart, 2018 ACC/AHA Cholesterol Guidelines, to assess appropriateness of statin therapy, including dose. If therapy isn’t appropriate, contact provider with rationale and recommend a change. Recommend moderate- to high-intensity statins for all diabetes patients age 40 to 75 years. Consider high-intensity statins for patients with cardiovascular disease or high risk. Recommend starting with target statin doses, as titrating up doesn’t improve tolerability. 3. Discuss benefits and side effects associated with statin therapy. (Date discussed:__________)
Often there are no symptoms due to high cholesterol. Remind patients of statin benefits to encourage adherence: reduced peripheral artery disease (PAD), heart attacks (MIs), and strokes. Educate and reassure patient about less common side effects. Encourage patients to contact their provider if they notice: liver problems(e.g., dark urine, yellowing of eyes or skin, abdominal pain), memory problems (e.g., confusion, forgetfulness, clouded thinking), or diabetes (e.g., excessive hunger or thirst, unexplained weight loss). 4. Discuss muscle pain associated with statins. (Date discussed:___________)
Ensure appropriate statin-dose and screen for drug interactions to reduce the risk of muscle pain. See our chart, Clinically Significant Statin Drug Interactions, for meds to watch for. See our chart, Statin Muscle Symptoms: Managing Statin Intolerance, for information on symptoms and tips to treat and reduce the risk of occurrence. Ask patients about potential causes: grapefruit intake, exercise, symptoms of hypothyroidism, etc. If muscle pain is intolerable, recommend (to prescriber) holding the statin for two to four weeks. Work with the prescriber to reduce recurrence: re-initiate at a lower dose, switch statins, or extend the dosing interval to every other day or even twice a week. Discourage coenzyme Q10 use, as data doesn’t support a benefit for statin-associated muscle pain. If patients insist, recommend 100 to 200 mg daily. 5. Discuss healthy lifestyle (e.g., diet, physical activity, etc). (Date discussed:_______________)
Encourage aerobic activity (e.g., brisk walking) >40 minutes, three or four times per week. Encourage at least five servings of fiber per day (e.g., fresh fruits and vegetables, cooked dry beans). Recommend psyllium 5.1 g twice daily for patients that don’t like fruits and vegetables. Recommend limited intake of sugary foods and drinks. Recommend “good fats,” mono and polyunsaturated fats, (e.g., salmon, walnuts, sunflower seeds, avocado) and discourage “bad fats,” saturated and trans fats, (fatty meats, baked goods, fried foods). Encourage weight loss if appropriate, and a healthy body mass index (BMI) of 18.5 to 24.9.