What is the management of hyperlipidemia?

Management of Hyperlipidemia

Statin therapy is the cornerstone of hyperlipidemia management, with treatment goals based on cardiovascular risk stratification and targeting LDL-C levels below specific thresholds (< 1.8 mmol/L or 70 mg/dL for very high-risk patients). 1

Risk Assessment and Treatment Goals

Risk stratification is essential for determining appropriate lipid targets:

• Very high-risk patients (established ASCVD, diabetes with target organ damage, or severe CKD): LDL-C < 1.4 mmol/L (< 55 mg/dL) 1
• High-risk patients (multiple risk factors or single markedly elevated risk factor): LDL-C < 1.8 mmol/L (< 70 mg/dL) 1
• Moderate-risk patients: LDL-C < 2.6 mmol/L (< 100 mg/dL) 2
• Low-risk patients: LDL-C < 3.0 mmol/L (< 115 mg/dL) 2

Therapeutic Approach

First-Line: Lifestyle Modifications

All patients with hyperlipidemia should receive counseling on:

• Diet: Mediterranean or DASH diet pattern with:

  • Reduced saturated fat (<7% of total calories)
  • Limited dietary cholesterol (<200 mg/day)
  • Minimal trans fats (<1% of energy)
  • Increased plant stanols/sterols (can reduce LDL-C by 7-15%) 2

• Physical activity: ≥150 minutes/week of moderate-intensity exercise 2

• Weight management: 5-7% weight loss if overweight 2

• Smoking cessation and limiting alcohol consumption (especially important for hypertriglyceridemia) 2

Pharmacological Therapy

1. Statins

• High-intensity statins (atorvastatin 40-80 mg, rosuvastatin 20-40 mg) are first-line for very high-risk and high-risk patients 1, 2
• Moderate-intensity statins for moderate-risk patients 2
• Monitor LDL-C 4-12 weeks after initiating therapy or dose change 2
• Check liver enzymes at baseline and 8-12 weeks after starting therapy 2
• Monitor for muscle symptoms and check CK if symptoms develop 2

2. Add-on Therapies (if LDL-C goals not achieved with maximally tolerated statin)

Sequential approach:

1. Add ezetimibe (10 mg daily) if LDL-C remains ≥2.6 mmol/L (≥100 mg/dL) despite high-intensity statin 1, 2
2. Add PCSK9 inhibitor (evolocumab or alirocumab) if LDL-C remains ≥2.6 mmol/L (≥100 mg/dL) on statin plus ezetimibe 1, 2
3. Consider bempedoic acid as an additional option for patients not reaching goals 1

3. Management of Hypertriglyceridemia

• For triglycerides 175-499 mg/dL:

  • Address lifestyle factors (obesity, metabolic syndrome)
  • Treat secondary causes (diabetes, liver/kidney disease, hypothyroidism)
  • Consider adding icosapent ethyl for patients with ASCVD or other CV risk factors on statin therapy 1

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

  • Evaluate for secondary causes
  • Consider fibrates (fenofibrate 54-160 mg daily or gemfibrozil 600 mg twice daily) 3
  • Very low-fat diet, avoid simple sugars and alcohol 1
  • Fish oils (omega-3 fatty acids) may be considered 1

Special Populations

Diabetes

• All diabetics >40 years of age should use statins 1
• High-intensity statin targeting LDL-C <70 mg/dL for patients with type 2 diabetes and CVD or CKD 2

Familial Hypercholesterolemia (FH)

• Treat with high-intensity statin, often in combination with ezetimibe 2
• Consider PCSK9 inhibitors for those not reaching goals 1
• Testing from age 5 years, or earlier if homozygous FH is suspected 2

Rheumatoid Arthritis

• Patients with 'high-risk RA' should be reclassified into a higher cardiovascular risk category, requiring lower LDL-C targets 1
• Ultrasonographic detection of carotid plaques can help determine very high cardiovascular risk 1

Monitoring and Follow-up

• Measure lipid levels 4-6 weeks after initiating or changing therapy 2
• Monitor annually once at goal, with more frequent monitoring (every 3-6 months) for patients not at goal 2
• Consider non-HDL-C or apolipoprotein B measurements for patients with elevated triglycerides (≥200 mg/dL) 2

Common Pitfalls to Avoid

1. Statin-fibrate combination therapy has not been shown to improve ASCVD outcomes and is generally not recommended due to increased risk of myopathy 1

2. Niacin plus statin is not recommended due to lack of efficacy on major ASCVD outcomes and increased side effects 1

3. Underestimating cardiovascular risk in patients with inflammatory conditions like rheumatoid arthritis 1

4. Poor adherence to therapy - consider simplified dosing regimens and comprehensive education programs to improve compliance 1

5. Inadequate monitoring of liver enzymes and muscle symptoms in patients on statin therapy 2