What are the treatment options for Dyslipidemia (high cholesterol) prescriptions?

From the Guidelines

For dyslipidemia management, statins are the first-line therapy, with the goal of lowering LDL cholesterol to <1.4 mmol/L (<55 mg/dL) and reducing it by at least 50% if the baseline LDL-C level is 1.8-3.5 mmol/L (70-135 mg/dL), as recommended by the most recent guidelines 1. The treatment options for dyslipidemia (high cholesterol) prescriptions include:

• Statins, such as atorvastatin (10-80 mg daily) and rosuvastatin (5-40 mg daily), which are the most potent options and should be started with moderate-intensity therapy (atorvastatin 10-20 mg or rosuvastatin 5-10 mg) for most patients, reserving high-intensity therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) for those with established cardiovascular disease or very high LDL levels.
• Ezetimibe 10 mg daily, which reduces cholesterol absorption, can be added if statins are not tolerated or insufficient.
• PCSK9 inhibitors like evolocumab or alirocumab may be added for patients with familial hypercholesterolemia or those at very high risk who don't reach targets.
• Fibrates (fenofibrate 145 mg daily) can be considered for patients with high triglycerides.
• Omega-3 fatty acids (2-4 g daily) may also help reduce triglycerides. Treatment should be monitored with lipid panels at 4-12 weeks after initiation or dose changes, then annually, as recommended by recent guidelines 1. It's worth noting that the most recent guidelines prioritize the use of statins as the first-line therapy, and the addition of ezetimibe or PCSK9 inhibitors as needed, with the goal of reducing LDL cholesterol levels and cardiovascular risk, as supported by studies 1.

From the FDA Drug Label

The initial treatment for dyslipidemia is dietary therapy specific for the type of lipoprotein abnormality. Fenofibrate tablets are indicated 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.

The treatment options for Dyslipidemia (high cholesterol) prescriptions include:

• Dietary therapy: specific for the type of lipoprotein abnormality
• Fenofibrate tablets: as adjunctive therapy to diet to reduce elevated LDL-C, Total-C, Triglycerides, and Apo B, and to increase HDL-C in adult patients with primary hypercholesterolemia or mixed dyslipidemia
• Lifestyle modifications: such as weight loss, exercise, and reduction of excess alcoholic intake
• Management of contributory diseases: such as hypothyroidism or diabetes mellitus
• Discontinuation of etiologic agents: such as estrogen therapy, thiazide diuretics, and beta-blockers, which may be associated with massive rises in plasma triglycerides 2 2

From the Research

Treatment Options for Dyslipidemia

The primary treatment target for dyslipidemia is the risk-adapted adjustment of low-density lipoprotein (LDL) cholesterol, with statins being the first-line pharmacological treatment due to their efficacy in reducing cardiovascular morbidity and mortality 3, 4.

• Statins have been shown to reduce relative risk of cardiovascular disease by 24-37%, regardless of age, sex, prior history of coronary heart disease (CHD), or other co-morbid conditions 3.
• Other treatment options include ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibition, which have been shown to significantly reduce cardiovascular events in high-risk patients 4.
• Combination therapy, such as statin and niacin or statin and fibrate, can be effective in achieving goals in patients with mixed dyslipidemia or elevated LDL despite statin therapy 5, 6.
• Life style changes can also improve the plasma lipid profile, particularly in the setting of hypertriglyceridemia 4.

Pharmacological Management

Pharmacological management of dyslipidemia involves the use of various medications, including:

• Statins, which are the first-line treatment for most patients to lower LDL 3, 4, 5, 6.
• Ezetimibe, a cholesterol-absorption inhibitor 5.
• Fibrates, which are effective in lowering triglycerides and increasing high-density lipoprotein cholesterol (HDL) 5, 6.
• Niacin, which is effective in combination with statins in lowering LDL, triglycerides, and total cholesterol levels and increasing HDL 5, 6.
• Bile acid sequestrants, which are moderately effective in isolated hypercholesterolemia 6.
• PCSK9 inhibition, which has been shown to significantly reduce cardiovascular events in high-risk patients 4.

Special Considerations

Special consideration should be given to patients with certain conditions, such as:

• High or very high cardiovascular risk patients, who may require more intensive treatment 7.
• Patients with hypertriglyceridemia, who may require treatment with fibrates or niacin 6.
• Patients with HIV infection, who may require special consideration due to poly-pharmacy 7.
• Patients with familial hypercholesterolaemia, who may require more intensive treatment 7.