What are the guidelines for managing hyperlipidemia?

Guidelines for Managing Hyperlipidemia

The management of hyperlipidemia should begin with comprehensive cardiovascular risk assessment followed by lifestyle modifications for all patients, with statins as first-line pharmacological therapy for those requiring medication based on risk stratification. 1

Risk Assessment

• 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
• Screen men aged 20-35 years and women aged 20-45 years with risk factors including diabetes, family history of premature cardiovascular disease, familial hyperlipidemia, or multiple coronary heart disease risk factors 2
• For adults without risk factors, screening can begin at age 40 for men and age 50 for women or post-menopause 2
• Consider more frequent screening for individuals with lipid levels close to treatment thresholds and less frequent for those with consistently normal levels 2

Lifestyle Modifications

• Implement lifestyle modifications in all patients as first-line therapy and as synergistic means for improving lipid control 1, 3
• Recommend a diet low in saturated fat (7-10% of calories) and high in fruits and vegetables 2, 4
• Consider plant-based diet and limiting red meat consumption 1
• Encourage consumption of foods rich in omega-3 polyunsaturated fats (fish, nuts, flaxseed oil) 1
• Consider foods enriched with phytosterols (1-2 g/day) for individuals with elevated total and LDL cholesterol 1
• Promote regular physical activity, which can increase HDL-C when combined with diet and weight loss by 10-13% 4
• Advise smoking cessation and moderate alcohol consumption 4

Pharmacological Therapy

Statins

• Start with statins as first-line pharmacological therapy for persistent hyperlipidemia 1
• Align statin dosage intensity to ASCVD risk 1
• For patients requiring LDL-C reduction >45%, consider starting with atorvastatin 40 mg daily 5
• Monitor lipid levels 4-12 weeks after starting treatment or dose adjustment 1
• Check liver enzymes (ALT) before treatment and 8-12 weeks after starting therapy or dose increase 1
• Monitor creatine kinase (CK) before starting therapy and be alert for myopathy symptoms 1
• Be cautious with statin use in patients aged ≥65 years, those with uncontrolled hypothyroidism, renal impairment, or taking certain medications 5

Non-Statin Therapies

• Consider non-statin therapy in patients who cannot tolerate statins or fail to achieve LDL-C goals despite maximally tolerated statin dose 1
• Options include bile acid sequestrants, fibrates, ezetimibe, PCSK9 inhibitors, and nicotinic acid 1, 6
• For severe hypertriglyceridemia (>500 mg/dL), consider fibrates such as gemfibrozil (600 mg twice daily) or fenofibrate (54-160 mg daily) 1

Special Populations

Patients with Renal Impairment

• For patients with severe renal impairment (creatinine clearance 15-29 mL/min), start with simvastatin 5 mg once daily 7
• In the SHARP Study, the combination of simvastatin plus ezetimibe was effective in reducing cardiovascular events in patients with severe renal insufficiency 6

Pediatric Patients

• Consider statins in children aged >8 years with concerning family history or extremely elevated LDL-C or Lp(a) 1
• Start with lifestyle modifications as first-line treatment for hyperlipidemia in children 1
• For children 10 years and older with heterozygous familial hypercholesterolemia (HeFH), the recommended dosage range of simvastatin is 10 mg to 40 mg daily 7

Familial Hypercholesterolemia

• Patients with familial hypercholesterolemia have greater risk of developing CVD at an earlier age and require more aggressive treatment 8
• May require lomitapide, mipomersen, PCSK9 inhibitors, or LDL-C apheresis in addition to high-dose statins 8
• When using lomitapide with simvastatin, reduce simvastatin dosage by 50% 7

Drug Interactions and Dosage Modifications

• Adjust statin dosage when used with certain medications:
  • With lomitapide: Reduce simvastatin by 50%, not exceeding 20 mg daily 7
  • With verapamil, diltiazem, or dronedarone: Do not exceed simvastatin 10 mg daily 7
  • With amiodarone, amlodipine, or ranolazine: Do not exceed simvastatin 20 mg daily 7
• Be cautious with grapefruit juice, which can significantly increase simvastatin exposure 7
• Monitor digoxin levels when used with simvastatin, as it may increase digoxin plasma concentrations 5, 7

Treatment Goals

• Base treatment goals on individual cardiovascular risk assessment 1
• Regularly assess adherence to lifestyle changes and effects of LDL-C lowering medication 1
• For high-risk patients who cannot achieve goals with simvastatin 40 mg daily, consider alternative LDL-C-lowering treatments 7

Monitoring

• Check lipid levels 8 (±4) weeks after starting treatment or adjusting dose 1
• Monitor for common side effects, including myopathy and elevated liver enzymes 1
• Be vigilant for symptoms of immune-mediated necrotizing myopathy (IMNM), a rare but serious autoimmune condition associated with statin use 5