What is the management of dyslipidemia based on the Malaysian Clinical Practice Guidelines (CPG)?

Management of Dyslipidemia Based on Malaysian Clinical Practice Guidelines

The management of dyslipidemia in Malaysia follows a risk-stratified approach with statins as first-line therapy for high and very high-risk individuals, while therapeutic lifestyle changes are recommended for all patients regardless of risk level.

Risk Assessment and Classification

1. Risk Assessment Tools:

   • Framingham General CV Risk Score has been validated in the Malaysian population for cardiovascular risk assessment 1
   • Patients with Chronic Kidney Disease (CKD) should be considered to have a CHD risk equivalent when deciding appropriate management 2

2. Risk Categories:

   • Low Risk: Therapeutic lifestyle changes (TLC) alone may be sufficient
   • Intermediate Risk: TLC with consideration for pharmacotherapy
   • High Risk: Drug therapy in conjunction with TLC
   • Very High Risk: Aggressive drug therapy with TLC 3

Therapeutic Lifestyle Changes (TLC)

• Recommended for ALL patients with dyslipidemia:
  • Mediterranean diet
  • Regular physical activity and exercise
  • Weight loss for overweight/obese patients
  • Complete smoking cessation
  • Limit alcohol consumption 2

Pharmacological Management

First-Line Therapy

• Statins are the first-line therapy for dyslipidemia management in high and very high-risk individuals 1, 3
• Statin intensity should be selected based on risk level:
  • High-intensity statins (atorvastatin 40-80mg, rosuvastatin 20-40mg): For very high-risk patients
  • Moderate-intensity statins (atorvastatin 10-20mg, rosuvastatin 5-10mg): For high-risk patients
  • Low-intensity statins: For selected intermediate-risk patients

Second-Line Therapy

For patients not achieving LDL-C targets despite maximally tolerated statin therapy:

• Add ezetimibe (cholesterol absorption inhibitor)
• Consider PCSK9 inhibitors for very high-risk patients or those with familial hypercholesterolemia 1, 3

LDL-C Targets

• Very high-risk patients: LDL-C < 1.8 mmol/L
• High-risk patients: LDL-C < 2.6 mmol/L
• Intermediate-risk patients: LDL-C < 3.0 mmol/L
• Low-risk patients: LDL-C < 4.0 mmol/L 1

Monitoring Protocol

1. Before starting lipid-lowering therapy:

   • At least two lipid measurements with 1-12 weeks interval
   • Exception: Acute coronary syndrome and very high-risk patients 2

2. After starting therapy:

   • Check lipids 8 (±4) weeks after starting treatment
   • Check lipids 8 (±4) weeks after any treatment adjustment
   • Annual monitoring once target levels achieved 2

3. Liver enzyme monitoring:

   • Check ALT before treatment
   • Check ALT 8-12 weeks after starting treatment or dose increase
   • Routine ALT monitoring not recommended thereafter 2

4. Muscle enzyme (CK) monitoring:

   • Check CK before starting therapy
   • Do not start statin if baseline CK > 4x ULN
   • Routine CK monitoring not recommended unless patient develops symptoms
   • Be vigilant in high-risk groups: elderly, patients on multiple medications, liver/kidney disease 2

Management of Statin-Associated Muscle Symptoms

If muscle symptoms develop:

1. If CK < 4x ULN with symptoms:

   • 2-4 week statin washout
   • If symptoms persist: Statin rechallenge
   • If symptoms improve: Try second statin at usual/starting dose

2. If CK ≥ 4x ULN with/without rhabdomyolysis:

   • 6-week statin washout until normalization of CK, creatinine, and symptoms
   • Try low-dose second efficacious statin or alternate-day dosing regimen 2

Special Populations

Chronic Kidney Disease (CKD)

• Patients with CKD should be considered to have a CHD risk equivalent
• Dyslipidemia management should be undertaken with all other measures to reduce ACVD risk
• Assess modifiable risk factors (hypertension, smoking, diabetes control, obesity) at initial presentation and yearly thereafter 2

Familial Hypercholesterolemia

• Requires more aggressive therapy
• Often requires combination therapy (statin + ezetimibe + PCSK9 inhibitor) 3

Statin Intolerance

• Consider lower statin doses or alternate-day dosing
• Switch to a different statin
• Add non-statin therapies (ezetimibe, PCSK9 inhibitors) 3

Common Pitfalls in Dyslipidemia Management

1. Inadequate risk assessment: Despite high awareness (98.1%) of guidelines, there are still gaps in practice 4

2. Undertreatment: Many high-risk individuals do not achieve target LDL-C levels despite statin therapy 1

3. Overemphasis on total cholesterol: Focus should be on LDL-C as the primary target 1

4. Ignoring non-HDL cholesterol: Important secondary target, especially in patients with elevated triglycerides 5

5. Poor monitoring of adverse effects: Failure to follow proper monitoring protocols for liver and muscle enzymes 2, 6

6. Discontinuation due to mild enzyme elevations: For ALT < 3x ULN, continue therapy and recheck in 4-6 weeks 2

The prevalence of dyslipidemia subtypes is high in Malaysia, with elevated total cholesterol at 64.0%, elevated LDL-C at 56.7%, elevated triglycerides at 37.4%, and low HDL-C at 36.2% 5. This highlights the importance of comprehensive dyslipidemia management to reduce the burden of cardiovascular disease in Malaysia.