What is the primary treatment for hyperlipidemia?

From the Guidelines

The primary treatment for hyperlipidemia is statin therapy, with the goal of reducing LDL-Cholesterol (LDL-C) to specific targets based on cardiovascular risk. According to the 2016 ESC/EAS guidelines for the management of dyslipidaemias 1, LDL-C should be used as the primary lipid analysis for screening, risk estimation, diagnosis, and management. The guidelines recommend that a statin is the usual first-line treatment to reach the LDL-C goal and should be used up to the highest recommended dose or highest tolerable dose to reach the goal.

For patients at very high CV risk, an LDL-C goal of < 1.8 mmol/L (70 mg/dL), or a reduction of at least 50% if the baseline LDL-C is between 1.8 and 3.5 mmol/L (70 and 135 mg/dL) is recommended 1. In patients at high CV risk, an LDL-C goal of < 2.6 mmol/L (100 mg/dL), or a reduction of at least 50% if the baseline LDL-C is between 2.6 and 5.1 mmol/L (100 and 200 mg/dL) is recommended 1.

Key considerations in hyperlipidemia treatment include:

• Identifying high- and very high-risk individuals based on documented CVD, diabetes mellitus, moderate to severe renal disease, very high levels of individual risk factors, familial hypercholesterolaemia, or a high SCORE risk 1
• Using LDL-C as the primary target for treatment 1
• Considering statin therapy as the first-line treatment for reaching LDL-C goals 1
• Measuring Lipoprotein(a) in patients at high risk of cardiovascular disease and targeting levels below 50 1

Treatment with statins is recommended for older adults with established CVD in the same way as for younger patients 1. High-dose statins should be given early after admission in all acute coronary syndrome patients without contraindication or a history of intolerance, regardless of initial LDL-C values 1.

From the FDA Drug Label

Ezetimibe reduces total-C, LDL-C, Apo B, and non-HDL-C in patients with hyperlipidemia. The primary treatment for hyperlipidemia includes ezetimibe, which can be used as monotherapy or in combination with statins.

• Monotherapy: Ezetimibe significantly lowers total-C, LDL-C, Apo B, and non-HDL-C compared to placebo.
• Combination with statins: Ezetimibe added to on-going statin therapy significantly lowers total-C, LDL-C, Apo B, and non-HDL-C compared with a statin administered alone 2

From the Research

Hyperlipidemia Treatment

The primary treatment for hyperlipidemia involves a combination of lifestyle modifications and pharmacological interventions.

• Lifestyle modifications, such as diet and physical exercise, play a crucial role in managing hyperlipidemia, although they may have a limited impact on lowering low-density lipoprotein (LDL) cholesterol levels 3.
• Statins are widely recommended as the first-line pharmacological treatment for hyperlipidemia, as they have been shown to effectively reduce LDL cholesterol levels and the risk of atherosclerotic cardiovascular disease (ASCVD) 4, 5.

Pharmacological Treatment Options

In addition to statins, other pharmacological treatment options are available for managing hyperlipidemia, including:

• Ezetimibe, a cholesterol absorption inhibitor, which can be used in combination with statins to further reduce LDL cholesterol levels 3, 4, 5.
• Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, which have been shown to significantly decrease serum LDL cholesterol levels and ASCVD risk when added to maximally tolerated statin therapy 3, 4.
• Fibrates, such as fenofibrate, which can be used to reduce triglyceride levels, although they may have a limited impact on LDL cholesterol levels 5, 6.
• Bile acid sequestrants, which can be used to reduce LDL cholesterol levels, although they may have a limited impact on triglyceride levels 5.

Treatment Goals

The treatment goals for hyperlipidemia vary depending on the individual patient's risk factors and lipid profile.

• For patients with a very high risk of ASCVD, an LDL cholesterol level of < 55 mg/dl (< 1.4 mmol/l) and at least a 50% reduction from baseline should be aimed for 3.
• For patients with elevated triglyceride levels, lifestyle modifications and pharmacological treatments, such as fibrates and omega-3 fatty acids, may be used to reduce triglyceride levels 3.