What is the management of dyslipidemia?

From the Guidelines

Managing dyslipidemia requires a multifaceted approach that includes therapeutic lifestyle changes and, when necessary, pharmacological therapy, with the primary goal of reducing LDL-C levels to below 190 mg/dL in individuals with no other risk factors for cardiovascular disease, or below 160 mg/dL in those with additional risk factors, as recommended by the American Heart Association guidelines 1.

Therapeutic Lifestyle Changes

Therapeutic lifestyle changes are the foundation of dyslipidemia management. These changes include:

• Dietary modifications, such as reducing saturated fat intake to 7% of calories and cholesterol to 200 mg per day, in conjunction with a trained dietitian 1.
• Increasing soluble fiber intake, with the amount based on the individual's age plus 5 to 10 grams up to a maximum of 25 grams per day for those aged 15 and above 1.
• Emphasizing weight management through appropriate energy intake and expenditure, particularly for individuals who are overweight or obese, as this can help reduce LDL-C levels and improve overall cardiovascular health 1.
• Encouraging increased physical activity, aiming for a level that contributes to overall health and wellbeing, such as 150 minutes of moderate exercise weekly.

Pharmacological Therapy

Pharmacological therapy is considered for individuals with persistently elevated LDL-C levels despite therapeutic lifestyle changes. The decision to initiate pharmacological therapy is based on the individual's LDL-C level and the presence of other risk factors for cardiovascular disease.

• For individuals with LDL-C levels of 190 mg/dL or higher with no other risk factors, or 160 mg/dL or higher with other risk factors present, pharmacological therapy may be initiated 1.
• First-line pharmacological agents include bile acid–binding resins or statins, which are effective in lowering LDL-C levels and reducing the risk of cardiovascular events 1.

Monitoring and Follow-Up

Regular monitoring of lipid levels is essential to assess the effectiveness of therapeutic lifestyle changes and pharmacological therapy.

• Lipid levels should be checked 4-12 weeks after initiating therapy and then annually, or as clinically indicated 1.
• Liver function tests should be performed before starting statins and as clinically indicated thereafter, due to the potential for statins to cause liver enzyme elevations 1.

Special Considerations

Certain populations, such as children and adolescents, require special consideration when managing dyslipidemia.

• For pediatric patients, pharmacological intervention should be accomplished in collaboration with a physician experienced in the treatment of disorders of cholesterol in pediatric patients 1.
• Elevated fasting triglycerides and reduced HDL-C are often seen in the context of overweight and insulin resistance, and therapeutic lifestyle changes should include weight management and decreased intake of simple sugars 1.

From the FDA Drug Label

The initial treatment for dyslipidemia is dietary therapy specific for the type of lipoprotein abnormality. Excess body weight and excess alcoholic intake may be important factors in hypertriglyceridemia and should be addressed prior to any drug therapy. Physical exercise can be an important ancillary measure Diseases contributory to hyperlipidemia, such as hypothyroidism or diabetes mellitus should be looked for and adequately treated.

The management of dyslipidemia involves:

• Dietary therapy specific to the type of lipoprotein abnormality
• Addressing excess body weight and alcoholic intake
• Physical exercise as an ancillary measure
• Treating underlying diseases that may be contributing to hyperlipidemia, such as hypothyroidism or diabetes mellitus 2

From the Research

Management of Dyslipidemia

The management of dyslipidemia involves a combination of lifestyle modifications and pharmacotherapy.

• Lifestyle modification should be emphasized in all patients to reduce cardiovascular risk and can be initiated before pharmacotherapy in primary prevention of cardiovascular disease 3.
• The treatment of lipid disorders begins with lifestyle therapy to improve nutrition, physical activity, weight, and other factors that affect lipids 4.

Pharmacotherapy

Pharmacotherapy is initiated based on a patient's risk for atherosclerotic cardiovascular disease (ASCVD).

• Patients at extreme ASCVD risk should be treated with high-intensity statin therapy to achieve a goal low-density lipoprotein cholesterol (LDL-C) of <55 mg/dL, and those at very high ASCVD risk should be treated to achieve LDL-C <70 mg/dL 4.
• Treatment for moderate and high ASCVD risk patients may begin with a moderate-intensity statin to achieve an LDL-C <100 mg/dL, while the LDL-C goal is <130 mg/dL for those at low risk 4.
• Other LDL-C-lowering agents such as proprotein convertase subtilisin/kexin type 9 inhibitors, ezetimibe, colesevelam, or bempedoic acid may be added as needed to achieve treatment goals 4, 5, 6.
• For patients with high triglyceride levels, statin therapy may be combined with a fibrate, prescription-grade omega-3 fatty acid, and/or niacin to reduce triglycerides 4.

Alternative Therapies

For patients who are intolerant of statins, alternative therapies such as ezetimibe, proprotein convertase subtilisin/kexin type 9 inhibitors, and bempedoic acid may be used 6.

• These therapies have been shown to lower LDL-C levels, regress atherosclerosis, and lower the risk of major adverse cardiovascular events (MACE) 6.
• Functional foods and natural health products such as soy protein, green tea, plant sterols, probiotic yogurt, marine-derived omega-3 fatty acids, and red yeast rice may also have a beneficial effect on lipid levels, although the evidence is not as strong as for pharmacotherapy 3.