What is the treatment for lipemia (elevated lipid levels)?

Treatment of Lipemia (Elevated Lipid Levels)

The first-line treatment for lipemia (elevated lipid levels) is therapeutic lifestyle changes, including dietary modifications, physical activity, and weight management, followed by pharmacological therapy when lifestyle modifications are insufficient to reach target lipid levels. 1

Therapeutic Lifestyle Changes

Dietary Modifications

• Limit calories from saturated fat to <7% of total calories 1
• Reduce dietary cholesterol to <200 mg/day 1
• Avoid trans-fatty acids 1
• Consider adding plant stanols/sterols (up to 2 g/day) and/or increased viscous (soluble) fiber (10-25 g/day) for additional LDL-C lowering 1
• For elevated triglycerides, focus on decreasing simple sugar intake and increasing dietary n-3 fatty acids 1
• Advocate consumption of fruits, vegetables, whole grains, low-fat dairy products, fish, legumes, poultry, and lean meats 1
• Strict dietary modification alone can reduce LDL cholesterol by 20-30% 2

Physical Activity

• Aim for at least 30 minutes of moderate-intensity physical activity on most (preferably all) days of the week 1
• Include resistance training with 8-10 different exercises, 1-2 sets per exercise, and 10-15 repetitions at moderate intensity 2 days/week 1
• Incorporate flexibility training and increased daily lifestyle activities 1

Weight Management

• Address excess body weight, which is an important factor in hypertriglyceridemia 3
• Weight reduction is key to reducing postprandial lipemia, particularly in patients with atherogenic dyslipidemia 2

Pharmacological Therapy

First-Line Pharmacological Therapy

• Statins (HMG-CoA reductase inhibitors) are the first-line pharmacological therapy for LDL-C reduction 1
• Statins have been shown to significantly reduce coronary and cerebrovascular events in patients with hyperlipidemia 1
• In primary prevention trials, cholesterol-lowering drug treatment decreased the risk of coronary heart disease events by approximately 30% 4

Alternative and Adjunctive Therapies

• For patients who cannot tolerate statins, consider bile acid-binding resins or fenofibrate 1
• For combined hyperlipidemia, improved glycemic control plus high-dose statin is the first choice 1
• For severe hypertriglyceridemia (≥1,000 mg/dL), fibric acid derivatives (gemfibrozil, fenofibrate) are recommended with severe dietary fat restriction (<10% of calories) 1
• Fenofibrate is indicated as adjunctive therapy to diet for treatment of adult patients with severe hypertriglyceridemia 3
• Niacin is particularly useful for patients with combined hyperlipidemia and low HDL cholesterol levels 5

Treatment Goals

• LDL cholesterol goal varies based on risk factors: <100 mg/dL if 0 risk factors are present; <130 mg/dL if 1 risk factor is present; <160 mg/dL if 2 risk factors are present 1
• Optimal lipid goals include LDL cholesterol <100 mg/dL, HDL cholesterol >35 mg/dL, and triglycerides <150 mg/dL 1
• For patients with diabetes, LDL-C goal is <100 mg/dL 1
• Annual lipid testing is recommended for monitoring progress, with less frequent testing (every 2 years) possible if lipid values are at low risk levels 1

Special Considerations

Diabetes and Hyperlipidemia

• Treatment of LDL cholesterol is considered the first priority for pharmacological therapy of dyslipidemia in diabetes 1
• Improved glycemic control is the first priority for triglyceride lowering in diabetic patients 1
• In patients with both elevated LDL cholesterol and triglycerides, the level of non-HDL cholesterol or apolipoprotein B might guide decisions about initiation of drug therapy 4

Severe Hypertriglyceridemia

• Patients with triglycerides >4 mmol/L (350 mg/dL) or random levels >8 mmol/L (700 mg/dL) might benefit from therapy aimed primarily at preventing pancreatitis 4
• Markedly elevated levels of serum triglycerides (e.g., >2,000 mg/dL) may increase the risk of developing pancreatitis 3
• Improving glycemic control in diabetic patients showing fasting chylomicronemia will usually obviate the need for pharmacologic intervention 3

Combination Therapy

• Consider combination therapy for patients not reaching goals on monotherapy 1
• Options include statin plus resin, statin plus niacin, or statin plus fibrate 1
• Caution: The combination of statins with nicotinic acid or fibrates (especially gemfibrozil) may increase risk of myositis 1

Common Pitfalls and Caveats

• Rule out secondary causes of hyperlipidemia (liver function test, thyroid-stimulating hormone level, urinalysis) before initiating drug therapy 1
• Monitor for statin-related adverse effects, including myopathy and rhabdomyolysis, particularly in patients over 65 years, those with hypothyroidism or renal impairment, and those on combination therapy 1
• Poor dietary choices can overwhelm the effects of medication and negatively impact arterial health, thus promoting atherosclerosis 2
• Fenofibrate is contraindicated in patients with severe renal impairment, active liver disease, preexisting gallbladder disease, and nursing mothers 3
• When using combination therapy with statins and fibrates, the risk of myositis is higher with gemfibrozil than with fenofibrate 1