Guidelines for Managing Hyperlipidemia
Statins are the first-line pharmacological therapy for hyperlipidemia, with dosage intensity aligned to atherosclerotic cardiovascular disease (ASCVD) risk and LDL-C goals. 1, 2
Risk Assessment and Treatment Approach
- Evaluate total cardiovascular risk before initiating treatment, considering factors such as age, family history, hypertension, diabetes, and existing cardiovascular disease 1
- Obtain a complete lipid profile (total cholesterol, LDL-C, HDL-C, triglycerides) for risk assessment 1
- Assess ASCVD risk based on LDL-C, Apo B, triglyceride and Lp(a) levels, age group, and ASCVD 'risk enhancers' 1
- Risk enhancers include chronic inflammatory conditions (lupus, rheumatoid arthritis), history of preeclampsia, early menopause, South Asian ancestry, chronic kidney disease, and HIV/AIDS 1
Lifestyle Modifications
- Implement lifestyle modifications in all patients as first-line therapy and as synergistic means for improving lipid control 1, 3
- Restrict dietary sodium to <2.0 g/day (<90 mmol/day) 1
- Normalize weight through caloric restriction and increased physical activity 1, 4
- Stop smoking and limit alcohol consumption 1, 5
- Exercise regularly - combined with diet and weight loss can increase HDL-C by 10-13% 4
- Consider a plant-based diet and avoid red meat 1
- Consume foods rich in omega-3 polyunsaturated fats (fish, nuts, flaxseed oil) 1
- Foods enriched with phytosterols (1-2 g/day) may be considered for individuals with elevated total and LDL cholesterol 1
Pharmacological Therapy
Statins
- Start with statins as first-line therapy for persistent hyperlipidemia 1, 2
- Align statin dosage intensity to ASCVD risk 1, 2
- Monitor lipid levels 4-12 weeks after starting treatment or dose adjustment 1
- Common side effects include myopathy and elevated liver enzymes; monitor accordingly 1, 2
- For patients with nephrotic syndrome or glomerular disease, statins are recommended particularly for those with other cardiovascular risk factors 1
Non-Statin Therapies
Consider initiation of non-statin therapy in those who:
- Cannot tolerate statins 1, 6
- Are at high ASCVD risk and fail to achieve LDL-C or triglyceride goals despite maximally tolerated statin dose 1
Options include:
- Bile acid sequestrants 1
- Fibrates (gemfibrozil 600 mg twice daily or micronized fenofibrate 54-160 mg daily) 1
- Ezetimibe 1
- PCSK9 inhibitors 1
- Nicotinic acid (use with caution in certain populations) 1
- Lipid apheresis (for severe cases) 1
Special Populations
Patients with HIV on Antiretroviral Therapy
- For elevated LDL-C: Pravastatin (20-40 mg daily) or atorvastatin (10 mg daily) are recommended 1
- For severe hypertriglyceridemia (>500 mg/dL): Gemfibrozil (600 mg twice daily) or micronized fenofibrate (54-160 mg daily) 1
- Monitor for drug interactions between statins and antiretroviral medications 1
Pediatric Patients
- Statins can be initiated in children aged >8 years with concerning family history or extremely elevated LDL-C or Lp(a) 1
- Lifestyle modifications are considered first-line treatment for hyperlipidemia in children 1
Patients with Renal Impairment
- Reduced eGFR (<60 mL/min/1.73 m²) and albuminuria (ACR >30 mg/g) are independently associated with elevated ASCVD risk 1
- For severe renal impairment (CLcr 15-29 mL/min), lower starting doses of statins are recommended 6
Monitoring
- Check lipid levels 8 (±4) weeks after starting treatment or adjusting dose 1
- Once target levels are reached, monitor annually (unless adherence issues exist) 1
- Monitor liver enzymes (ALT) before treatment and 8-12 weeks after starting therapy or dose increase 1
- Check creatine kinase (CK) before starting therapy and be alert for myopathy symptoms, especially in high-risk patients 1
- If CK >10x ULN or symptoms present, stop statin and monitor for normalization before rechallenge with lower dose 1
Treatment Goals
- Treatment goals should be based on individual cardiovascular risk assessment 1
- For high-risk patients with both hyperlipidemia and hypertension, goals include total cholesterol ≤200 mg/dL, LDL cholesterol ≤135 mg/dL, and triglycerides ≤200 mg/dL 5
- Adherence to lifestyle changes and effects of LDL-C lowering medication should be assessed regularly 1
Common Pitfalls and Caveats
- Combination fibrate-statin therapy should only be used with great caution due to increased risk of myopathy 1
- Counsel patients to hold ACEi/ARB and diuretics when at risk for volume depletion 1
- Consider temporarily stopping renin-angiotensin system inhibitors during "sick days" 1
- Be aware that fibrates will increase serum creatinine levels due to direct action on the kidney 1
- For patients with hypertriglyceridemic pancreatitis, initial management includes nil by mouth for 24-48h, followed by low-fat diet and appropriate lipid-lowering therapy 1