Healthcare Hyperlipidemia Protocol

Healthcare Hyperlipidemia Protocol

Patient Information

Date of Birth:    Gender:    Phone:

Insurance Information

Medical History & Current Status

Baseline Assessment and Laboratory Data

Height:    Weight:    BMI:    Blood Pressure:

Date of most recent lipid panel:

Total Cholesterol:    LDL:    HDL:    Triglycerides:

Date of most recent liver function tests:    ALT/AST:

Other baseline labs (TSH, CK, glucose/HbA1c):

Indications / Inclusion Criteria

The patient meets one or more of the following (select all that apply):
Primary prevention with elevated LDL or risk factors
Known atherosclerotic cardiovascular disease (secondary prevention)
Diabetes mellitus age 40–75 years
Elevated 10-year ASCVD risk warranting therapy

Exclusion / Contraindications

Do any of the following apply? If yes, do not initiate or continue protocol therapy unless consulted with supervising clinician.

Pregnancy or breastfeeding
Active hepatic disease or unexplained persistent transaminase elevation
Known statin hypersensitivity or prior severe adverse reaction
History of rhabdomyolysis or severe myopathy
Concomitant use of contraindicated interacting medications

Standing Orders — Medication Initiation and Dosing

The following orders authorize licensed clinicians to initiate, titrate, and discontinue lipid-lowering therapy consistent with the protocol below and clinical judgment.

Atorvastatin Dose:    Frequency:

Rosuvastatin Dose:    Frequency:

Ezetimibe (adjunct or alternative) Dose/Instructions:

Monitoring and Follow-Up

Baseline and follow-up laboratory and clinical monitoring shall be performed as follows:

Lipid panel at baseline
Repeat lipid panel 4–12 weeks after initiation or dose change
Annual lipid panel once stable
Liver function tests at baseline; repeat if clinically indicated
CK testing only if patient reports muscle symptoms

Next scheduled lipid panel date:

Adverse Events and Management

The patient has been informed of common and serious adverse effects, including but not limited to myalgias, elevated liver enzymes, myopathy, rhabdomyolysis, and potential glucose metabolism effects. If new unexplained muscle pain, weakness, or dark urine occurs, stop medication and contact clinical staff immediately. For ALT or AST elevations greater than three times the upper limit of normal, hold therapy and notify supervising clinician.

Patient Education and Counseling

The patient has received counseling on the following (select all confirmed):

Lifestyle modification: diet, exercise, weight management
Medication purpose, dosing, and administration
Expected side effects and when to seek care
Pregnancy and breastfeeding precautions

Consent and Authorization

I authorize the licensed clinical staff of this facility to initiate, adjust, and discontinue lipid-lowering therapy in accordance with the Healthcare Hyperlipidemia Protocol. I understand the nature and purpose of the proposed therapy, common and significant risks, alternatives (including no drug therapy), and reasonable expectations for monitoring and follow-up. I understand I may decline or withdraw consent at any time, and withdrawal will not affect my access to other medical care.

Authorization expires on:

HIPAA Acknowledgement

I acknowledge that I have been offered or provided the facility's Notice of Privacy Practices describing how my protected health information may be used and disclosed for treatment, payment, and health care operations. I authorize release of medical information necessary for treatment, coordination of care, or billing related to this protocol.

I acknowledge receipt of the Notice of Privacy Practices and consent to use/disclosure as described above.

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