What is the management of hyperlipidemia?

Management of Hyperlipidemia

The management of hyperlipidemia should be guided by cardiovascular risk assessment with statins as first-line pharmacotherapy, targeting specific LDL-C goals based on risk stratification. 1

Risk Assessment and Stratification

• Assess overall cardiovascular risk profile using:

  • Major risk factors count
  • 10-year ASCVD risk calculation (Framingham risk score)
  • Risk categories: high, moderate, or low risk 1

• Target LDL-C goals based on risk category:

  • High-risk patients: <100 mg/dL (option of <70 mg/dL for very high-risk)
  • Moderately high-risk patients: <130 mg/dL (option of <100 mg/dL)
  • Lower-risk patients: <160 mg/dL 1

Therapeutic Lifestyle Changes

• Dietary modifications:

  • Reduce saturated fat to <7% of total calories
  • Limit dietary cholesterol to <200 mg/day
  • Increase plant sterols/stanols (2 g/day)
  • Increase soluble fiber (10-25 g/day)
  • Consider Mediterranean diet pattern 1

• Physical activity:

  • 150-300 minutes of moderate-intensity exercise weekly
  • Include both aerobic exercise and resistance training
  • Exercise at least 5 days/week 1

• Weight management:

  • Target BMI of 18.5-24.9 kg/m²
  • Aim for 5-10% weight reduction in overweight/obese individuals 1

• Limit alcohol consumption as it can raise triglycerides 1

Pharmacotherapy

Statin Therapy

• First-line therapy for LDL-C reduction based on risk assessment:

  • Low-risk patients: Consider statin if LDL-C ≥160 mg/dL after lifestyle changes
  • Moderate-risk patients: Initiate statin if LDL-C ≥130 mg/dL after lifestyle changes
  • High-risk patients: Start statin along with lifestyle changes if LDL-C ≥100 mg/dL 1

• Statin intensity selection:

  • High-intensity statins (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) for high-risk patients
  • Moderate-intensity statins for moderate-risk patients targeting LDL-C reduction of 30-40% 1

• Early initiation of statin therapy, even in young individuals with low absolute but high relative cardiovascular risk, provides greatest long-term benefits 2

Add-on Therapies

• Ezetimibe:

  • Consider adding if LDL-C remains >100 mg/dL despite maximum tolerated statin dose
  • Reduces cardiovascular morbidity by inhibiting intestinal lipid absorption
  • Has anti-inflammatory effects similar to statins 2, 1, 3

• PCSK9 inhibitors (alirocumab, evolocumab):

  • Consider for very high-risk patients with LDL-C ≥70 mg/dL despite maximally tolerated statin and ezetimibe
  • Substantially reduce cardiovascular disease morbidity
  • Authorized for primary hyperlipidemia and secondary CVD prevention 2, 1

• Fibrates:

  • Used primarily for hypertriglyceridemia
  • Reduce serum triglycerides, LDL-C, and very low-density lipoprotein levels
  • Use with caution due to small risk of autoimmune adverse effects
  • Statin plus fibrate combination therapy has not been shown to improve ASCVD outcomes and is generally not recommended 2

Management of Hypertriglyceridemia

• For moderate hypertriglyceridemia (175-499 mg/dL):

  • Address lifestyle factors (obesity, metabolic syndrome)
  • Treat secondary factors (diabetes, liver/kidney disease, hypothyroidism)
  • Review medications that raise triglycerides 2

• For severe hypertriglyceridemia (≥500 mg/dL):

  • Evaluate for secondary causes
  • Consider fibrates or fish oil to reduce pancreatitis risk 2

• Consider icosapent ethyl for patients with established ASCVD or other cardiovascular risk factors on a statin with controlled LDL-C but elevated triglycerides (135-499 mg/dL) 2

Monitoring and Follow-up

• Check lipid panel 4-12 weeks after initiating therapy 1
• Monitor liver enzymes at baseline, 8-12 weeks after starting treatment, and after dose increases 1
• If ALT <3x ULN, continue therapy and recheck liver enzymes in 4-6 weeks 1
• If ALT ≥3x ULN, consider dose reduction or alternative therapy 1, 3
• Assess for muscle symptoms at follow-up visits 1

Special Considerations

• Consider secondary causes of hypercholesterolemia (hypothyroidism, nephrotic syndrome, cholestasis, medications) 1
• Evaluate for familial hypercholesterolemia if there's a family history of premature cardiovascular disease 1
• All diabetics >40 years of age should use statins; consider in younger diabetics with pronounced cardiovascular risk 2
• Ultrasonographic detection of carotid plaques can help determine very high cardiovascular risk 2

The management of hyperlipidemia requires a systematic approach based on cardiovascular risk assessment, with appropriate lifestyle modifications and pharmacotherapy tailored to achieve specific LDL-C goals, ultimately reducing morbidity and mortality from cardiovascular disease.