What are the guidelines for managing dyslipidemia in the Philippines?

Philippines Dyslipidemia Management Guidelines

The Philippines follows European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines for dyslipidemia management, focusing on comprehensive risk assessment, lifestyle modifications, and appropriate pharmacological interventions to reduce morbidity and mortality from cardiovascular disease. 1

Risk Assessment and Lipid Testing

• Before starting lipid-lowering treatment, at least two lipid measurements should be made with an interval of 1-12 weeks, except in acute coronary syndrome (ACS) and very high-risk patients 2
• After starting treatment, lipids should be tested at 8 (±4) weeks and after any treatment adjustment until target levels are reached 2
• Once target lipid levels are achieved, annual testing is recommended unless adherence issues or other specific reasons warrant more frequent monitoring 3

Treatment Goals Based on Risk Categories

• For VERY HIGH CV risk patients: LDL-C goal <1.8 mmol/L (70 mg/dL), or reduction of at least 50% if baseline LDL-C is between 1.8-3.5 mmol/L 3
• For HIGH CV risk patients: LDL-C goal <2.6 mmol/L (100 mg/dL), or reduction of at least 50% if baseline LDL-C is between 2.6-5.2 mmol/L 3
• For patients with type 2 diabetes and CVD or CKD: LDL-C goal <1.8 mmol/L with secondary goals for non-HDL-C of <2.6 mmol/L 3

Pharmacological Management

• Statins are the first-line therapy for dyslipidemia management due to their effectiveness in reducing cardiovascular morbidity and mortality 4
• For patients not reaching goals with maximally tolerated statin doses, consider adding ezetimibe, bile acid absorption inhibitors, or fibrates (not gemfibrozil) 3
• For very high-risk patients not reaching goals with available options, consider PCSK9 monoclonal antibody therapy 3
• When selecting a statin, consider:
  • The degree of LDL-C reduction required to reach target
  • Patient's clinical conditions
  • Concomitant treatments
  • Drug tolerability 2

Monitoring Liver and Muscle Enzymes

• Liver enzymes (ALT) should be measured:
  • Before treatment
  • Once 8-12 weeks after starting treatment or dose increase
  • Routine monitoring thereafter is not recommended 2
• If ALT rises to <3x ULN: continue therapy and recheck liver enzymes in 4-6 weeks 2
• Creatine kinase (CK) should be measured before starting therapy; if baseline CK is >4x ULN, do not start drug therapy and recheck 2

Management of Statin-Associated Muscle Symptoms

• If CK >10x ULN: stop treatment, check renal function, monitor CK every 2 weeks 2
• If CK <10x ULN without symptoms: continue lipid-lowering therapy while monitoring CK 2
• If CK <10x ULN with symptoms: stop statin, monitor normalization of CK, then re-challenge with a lower statin dose 2
• For patients with persistent statin-attributed muscle symptoms:
  • Consider 2-4 weeks washout of statin if CK <4x ULN
  • Consider 6 weeks washout if CK ≥4x ULN until normalization of CK, creatinine and symptoms
  • Try a different statin at low dose or alternate-day dosing regimen 2

Lifestyle Modifications

• 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 2
• Diet recommendations to lower total cholesterol and LDL-C:
  • Reduce intake of saturated fats and trans fats
  • Increase consumption of fiber-rich foods
  • Consider foods enriched with phytosterols (1-2 g/day) for individuals with elevated cholesterol who don't require medication 2
• Regular physical activity and weight management are essential components of dyslipidemia management 5
• Consume a diet rich in fruits and vegetables for antioxidant benefits 2
• Include at least 2-3 portions of fish per week and other sources of n-3 PUFAs 2
• Limit salt intake to <5 g/day, especially for patients with hypertension or metabolic syndrome 2

Adherence Strategies

• "Agree" on rather than "dictate" a drug regimen tailored to the patient's lifestyle and needs 3
• Provide clear written instructions to back up verbal guidance 3
• Simplify dosing regimens and consider fixed-dose combination pills where available 3
• Regularly review medications to minimize polypharmacy 3
• Encourage self-monitoring and use reminders 3
• Provide information on common side effects and management strategies 3
• Involve family members or caregivers in the patient's treatment 3

Special Considerations

• For patients with heterozygous familial hypercholesterolemia (HeFH), intense-dose statin therapy is often needed, frequently in combination with ezetimibe 3
• In pediatric patients (10 years and older) with HeFH, the recommended starting dosage of simvastatin is 10 mg once daily (range 10-40 mg) 6 or atorvastatin 10 mg once daily (range 10-20 mg) 7
• For patients with acute coronary syndrome, initiate or continue high-dose statins early after admission regardless of initial LDL-C levels 3