What are the guidelines for managing dyslipidemia?

Dyslipidemia Management Guidelines

The management of dyslipidemia requires a structured approach focusing on risk assessment, lipid testing, lifestyle modifications, and pharmacological interventions to reduce cardiovascular morbidity and mortality.

Risk Assessment and Lipid Testing

• Total risk estimation using a system such as SCORE is recommended for asymptomatic adults >40 years of age without evidence of CVD, diabetes, CKD, or familial hypercholesterolemia 1
• Before starting lipid-lowering drug treatment, at least two lipid measurements should be made with an interval of 1-12 weeks, except in conditions requiring immediate treatment such as acute coronary syndrome (ACS) and very high-risk patients 1
• After starting lipid-lowering treatment, lipids should be tested at 8 (±4) weeks and again after any treatment adjustment until target levels are reached 1
• Once target lipid levels are achieved, annual testing is recommended unless adherence issues or other specific reasons warrant more frequent monitoring 1

Treatment Goals Based on Risk Categories

• 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 baseline LDL-C is between 1.8 and 3.5 mmol/L (70 and 135 mg/dL) is recommended 1
• For 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 baseline LDL-C is between 2.6 and 5.2 mmol/L (100 and 200 mg/dL) is recommended 1
• In patients with type 2 diabetes and CVD or CKD, the recommended LDL-C goal is <1.8 mmol/L (<70 mg/dL) with secondary goals for non-HDL-C of <2.6 mmol/L (<100 mg/dL) and apoB of <80 mg/dL 1

Pharmacological Management

• Statins are the first-line medical treatment for dyslipidemia due to their effectiveness and favorable adverse effect profile 2
• For patients with heterozygous familial hypercholesterolemia (FH), intense-dose statin therapy, often in combination with ezetimibe, is recommended 1
• If LDL-C goals are not achieved with maximally tolerated statin doses, consider adding ezetimibe, bile acid absorption inhibitors, or fibrates (not gemfibrozil) 1
• For very high-risk patients not reaching goals with available options, PCSK9 monoclonal antibody therapy may be considered 1

Monitoring Liver and Muscle Enzymes

• Liver enzymes (ALT) should be measured before treatment and once 8-12 weeks after starting treatment or after dose increase 1
• Routine control of ALT thereafter is not recommended during lipid-lowering treatment 1
• If ALT rises to <3x ULN, continue therapy and recheck liver enzymes in 4-6 weeks 1
• Creatine kinase (CK) should be measured before starting therapy; if baseline CK is >4x ULN, do not start drug therapy and recheck 1
• Be vigilant for myopathy and CK elevation in high-risk patients (elderly, those on interfering medications, multiple medications, liver/renal disease, athletes) 1

Management of Statin-Associated Muscle Symptoms

• If CK >10x ULN: stop treatment, check renal function, and monitor CK every 2 weeks 1
• If CK <10x ULN without symptoms: continue lipid-lowering therapy while monitoring CK 1
• If CK <10x ULN with symptoms: stop statin, monitor normalization of CK, then re-challenge with a lower statin dose 1
• For patients with persistent statin-attributed muscle symptoms, consider using a low-dose alternative statin or an alternate-day dosing regimen 1

Special Populations

• In children with FH, testing is recommended from age 5 years, or earlier if homozygous FH is suspected 1
• For patients with type 1 diabetes and microalbuminuria/renal disease, LDL-C lowering (at least 50%) with statins is recommended regardless of baseline LDL-C 1
• In patients with acute coronary syndrome, high-dose statins should be initiated or continued early after admission regardless of initial LDL-C levels 1

Lifestyle Modifications

• All persons with dyslipidemia should focus on lifestyle interventions, including regular aerobic exercise, a healthy diet, maintenance of healthy weight, and smoking cessation 2
• A comprehensive patient- and family-centered approach in one healthcare setting is recommended rather than addressing single risk factors with multiple interventions in different locations 1
• Drawing on expertise from different disciplines (smoking cessation, dietetics, physical activity, exercise, health psychology) is essential for effective management 1

Adherence Strategies

• "Agree" on rather than "dictate" a drug regimen tailored to the patient's lifestyle and needs 1
• Provide clear written instructions to back up verbal guidance 1
• Simplify dosing regimens and consider fixed-dose combination pills where available 1
• Regularly review medications to minimize polypharmacy 1
• Encourage self-monitoring and use reminders 1
• Provide information on common side effects and management strategies 1
• Involve family members or caregivers in the patient's treatment 1