What is the recommended treatment for hyperlipidemia?

From the Guidelines

The primary treatment for hyperlipidemia should involve lifestyle modifications and statin therapy, with the goal of reducing LDL-C levels and minimizing cardiovascular risk. According to the most recent guidelines 1, patients with hyperlipidemia should receive adequate counseling and support regarding diet, physical activity, and other beneficial lifestyle modifications. Pharmacological treatment of hypercholesterolaemia should be performed primarily by statins, with statins having profound anti-inflammatory effects, such as atorvastatin or rosuvastatin, being particularly beneficial.

Key aspects of treatment include:

• Lifestyle modifications, such as a heart-healthy diet and regular physical activity, as the first-line approach
• Statin therapy as the primary medication class for lowering LDL-C levels
• Consideration of other lipid-lowering therapies, such as ezetimibe, PCSK9 inhibitors, bile acid sequestrants, or fibrates, for patients who cannot tolerate statins or require additional lipid lowering
• Treatment intensity dependent on cardiovascular risk factors, with higher-risk patients requiring more aggressive therapy

The 2020 European Society of Cardiology position paper 1 emphasizes the importance of statin therapy in managing hyperlipidemia, while the 2020 update from the American College of Cardiology/American Heart Association 1 provides guidance on the use of additional lipid-lowering therapies, such as ezetimibe and PCSK9 inhibitors, in patients with severe hypercholesterolemia. Additionally, the 2020 European Heart Journal paper 1 highlights the potential benefits of novel lipid therapies, including PCSK9 inhibitors, in managing lipid abnormalities.

Regular monitoring of lipid levels and liver function is essential to assess treatment effectiveness and detect potential side effects. By prioritizing lifestyle modifications and statin therapy, and considering additional lipid-lowering therapies as needed, healthcare providers can help minimize cardiovascular risk and improve outcomes for patients with hyperlipidemia.

From the FDA Drug Label

The initial treatment for dyslipidemia is dietary therapy specific for the type of lipoprotein abnormality. Patients should be placed on an appropriate lipid-lowering diet before receiving fenofibrate tablets and should continue this diet during treatment with fenofibrate tablets. Excess body weight and excess alcoholic intake may be important factors in hypertriglyceridemia and should be addressed prior to any drug therapy. Physical exercise can be an important ancillary measure Diseases contributory to hyperlipidemia, such as hypothyroidism or diabetes mellitus should be looked for and adequately treated.

The recommended treatment for hyperlipidemia is:

• Dietary therapy: The initial treatment is dietary therapy specific for the type of lipoprotein abnormality.
• Lifestyle modifications: Addressing excess body weight and excess alcoholic intake, and incorporating physical exercise as an ancillary measure.
• Treatment of underlying diseases: Looking for and adequately treating diseases contributory to hyperlipidemia, such as hypothyroidism or diabetes mellitus.
• Fenofibrate tablets: Can be used as adjunctive therapy to diet to reduce elevated low-density lipoprotein cholesterol (LDL-C), total cholesterol (Total-C), Triglycerides and apolipoprotein B (Apo B), and to increase high-density lipoprotein cholesterol (HDL-C) in adult patients with primary hypercholesterolemia or mixed dyslipidemia 2.

From the Research

Treatment Options for Hyperlipidemia

The recommended treatment for hyperlipidemia involves a combination of lifestyle changes and pharmacological interventions.

• Lifestyle changes are considered the first-line therapy for hyperlipidemia, including increased exercise, healthy nutrition, smoking cessation, and alcohol abstinence 3.
• Statins are the mainstay treatment for hyperlipidemia, however, adjunct therapies such as niacin, bile acid sequestrants, fibric acids, and ezetimibe may be necessary for patients who require additional treatment 4.
• For patients with familial hypercholesterolemia (FH), treatment options may include lomitapide, mipomersen, proprotein convertase subtilisin/kexin type 9 inhibitors, or low-density lipoprotein cholesterol apheresis, in addition to high-dose statins or other agents 4.
• PCSK9 inhibitors, such as Evolocumab and Alirocumab, are novel medications that target and inactivate proprotein convertase subtilsin-kexin type 9 (PCSK9), a hepatic protease that promotes the destruction of LDL receptors, and can lower LDL-C levels by 50%-60% above that achieved by statin therapy alone 5.

Pharmacological Treatment

Pharmacological treatment options for hyperlipidemia include:

• Statins, which remain the first-line drug treatment 6
• Ezetimibe, bile acid sequestrants, fibrates, and fish oil as further treatment options 6
• Oral antihyperglycemic agents, such as metformin and thiazolidinediones, for patients with diabetic dyslipidemia 7
• Weight reduction drugs, such as orlistat and sibutramine, for patients with diabetic dyslipidemia 7
• Lipid-lowering drugs, such as HMG-CoA reductase inhibitors, fibric acid derivatives, nicotinic acid, and bile acid sequestrants, for patients with diabetic dyslipidemia 7

Special Considerations

Special considerations for treating hyperlipidemia include:

• Patients with statin-related myopathies, who may require gene analysis to predict which statin can be administered at which dose with the least risk of side effects 6
• Patients with renal insufficiency, who may benefit from the combination of simvastatin plus ezetimibe to reduce cardiovascular events 6
• Young patients with hyperlipidemia, for whom primary prevention remains problematic 6
• Patients with diabetic dyslipidemia, who require lifestyle modifications and pharmacological treatment to reduce the risk of cardiovascular disease 7