What are the treatment goals and therapy for dyslipidemia according to the latest guidelines in the Philippines?

Treatment Goals and Management of Dyslipidemia According to Latest Philippine Guidelines

Based on the European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines, which are currently adopted in the Philippines, treatment of dyslipidemia should focus on specific LDL-C targets based on cardiovascular risk stratification, with statins as the primary pharmacological intervention. 1

Risk Assessment and Treatment Goals

• Total risk estimation using systems like SCORE is recommended for asymptomatic adults >40 years without evidence of CVD, diabetes, CKD or familial hypercholesterolemia 2

• LDL-C is the primary lipid parameter for screening, risk estimation, diagnosis and management 2

• Treatment goals are stratified by cardiovascular risk:

  • Very high CV risk patients: LDL-C goal <1.8 mmol/L (70 mg/dL), or ≥50% reduction if baseline is between 1.8-3.5 mmol/L 2
  • High CV risk patients: LDL-C goal <2.6 mmol/L (100 mg/dL), or ≥50% reduction if baseline is between 2.6-5.2 mmol/L 2

• Secondary targets include non-HDL-C and apoB levels:

  • For very high-risk patients: non-HDL-C <2.6 mmol/L (<100 mg/dL) and apoB <80 mg/dL 2
  • For high-risk patients: non-HDL-C <3.4 mmol/L (<130 mg/dL) and apoB <100 mg/dL 2

Pharmacological Management

• Statins are the first-line therapy for LDL-C reduction in most patient populations 2

• High-intensity statins are recommended for:

  • Patients with established cardiovascular disease 2
  • Patients with acute coronary syndrome (ACS) - initiate or continue high-dose statins early after admission regardless of initial LDL-C values 2
  • Familial hypercholesterolemia patients, often in combination with ezetimibe 2

• Ezetimibe should be added when LDL-C goals are not achieved with maximally tolerated statin therapy 2

• PCSK9 inhibitors may be considered for very high-risk patients who cannot achieve target LDL-C levels despite maximum tolerated statin and ezetimibe therapy 2

Special Patient Populations

Diabetes Patients

• Type 1 diabetes with microalbuminuria/renal disease: LDL-C lowering (≥50%) with statins regardless of baseline LDL-C 2
• Type 2 diabetes with CVD/CKD or >40 years with additional risk factors: LDL-C goal <1.8 mmol/L, non-HDL-C <2.6 mmol/L, apoB <80 mg/dL 2
• Type 2 diabetes without additional risk factors: LDL-C goal <2.6 mmol/L, non-HDL-C <3.4 mmol/L, apoB <100 mg/dL 2

Chronic Kidney Disease

• Patients with stage 3-5 CKD are considered at high or very high CV risk 2
• Statin or statin/ezetimibe combination is indicated in non-dialysis-dependent CKD 2
• Statins should not be initiated in dialysis-dependent CKD patients without atherosclerotic CVD 2

Other Specific Conditions

• Peripheral arterial disease (PAD): Considered a very high-risk condition requiring lipid-lowering therapy (primarily statins) 2
• Stroke prevention: Intensive statin therapy for patients with history of non-cardioembolic ischemic stroke or TIA 2
• Heart failure: Statin therapy not recommended in the absence of other indications 2
• Aortic valvular stenosis: Cholesterol-lowering treatment not recommended without CAD 2

Non-Pharmacological Management

• Lifestyle modifications form the cornerstone of dyslipidemia management 3, 4
• Multidisciplinary exercise-based cardiac rehabilitation is recommended for patients with CAD 2
• Cognitive behavioral interventions help achieve a healthy lifestyle 2
• Involvement of multidisciplinary healthcare professionals (cardiologists, general practitioners, nurses, dieticians, physiotherapists, psychologists, pharmacists) improves outcomes 2

Implementation Strategies

• Simplify dosing regimens and consider fixed-dose combinations when available 2
• Regular medication reviews to minimize polypharmacy 2
• Provide clear written instructions to support verbal advice 2
• Involve family members or caregivers in the patient's treatment plan 2

Common Pitfalls and Caveats

• Focusing solely on LDL-C may miss other important lipid abnormalities; consider the complete lipid profile including HDL-C and triglycerides 5
• Statin intolerance should be carefully assessed before discontinuing therapy, as many perceived side effects may not be causally related 6
• In patients with severe hypertriglyceridemia, reducing pancreatitis risk becomes an additional treatment goal beyond cardiovascular risk reduction 3
• The quality of HDL function may be more important than HDL-C concentration alone 5