What are the current guidelines for managing dyslipidemia?

Dyslipidemia Management Guidelines 2025

Risk-Based LDL-C Treatment Targets

For very high-risk patients (established CVD, diabetes with target organ damage, familial hypercholesterolemia, or CKD stage 3-5), target LDL-C <1.8 mmol/L (70 mg/dL) or achieve at least 50% reduction from baseline if starting between 1.8-3.5 mmol/L. 1

Risk Stratification and Goals

• Very High Risk (prior MI, stroke, PAD, ACS, diabetes with CVD/CKD): LDL-C <1.8 mmol/L (<70 mg/dL); non-HDL-C <2.6 mmol/L (<100 mg/dL); apoB <80 mg/dL 2, 1

• High Risk (diabetes >40 years with risk factors, marked single risk factor elevation, moderate CKD): LDL-C <2.6 mmol/L (<100 mg/dL) or ≥50% reduction if baseline 2.6-5.2 mmol/L 1

• Moderate Risk (type 2 diabetes without additional risk factors): LDL-C <2.6 mmol/L (<100 mg/dL); non-HDL-C <3.4 mmol/L (<130 mg/dL); apoB <100 mg/dL 2

Initial Assessment and Screening

Screen all men ≥40 years and women ≥50 years (or post-menopausal) with at least two lipid measurements 1-12 weeks apart before initiating therapy, except in ACS or very high-risk patients where immediate treatment is warranted. 2, 1

Who to Screen Immediately

• All patients with established atherosclerotic disease in any vascular bed 2
• Type 2 diabetes patients regardless of age 2
• Family history of premature CVD 2
• Central obesity (waist ≥94 cm men, ≥80 cm women) or BMI ≥25 kg/m² 2
• CKD with GFR <60 mL/min/1.73 m² 2
• Autoimmune conditions (rheumatoid arthritis, SLE, psoriasis) 2
• Clinical signs: xanthomas, xanthelasmas, premature arcus cornealis 2

Baseline Lipid Panel

• Total cholesterol, triglycerides, HDL-C, calculated LDL-C (Friedewald formula if TG <4.5 mmol/L or <400 mg/dL) 2
• Non-HDL-C and TC/HDL-C ratio 2
• Consider apoB and apoB/apoA1 ratio as alternative risk markers 2
• Require 12-hour fasting only for triglyceride assessment 2

First-Line Pharmacological Treatment

Initiate high-intensity statin therapy as first-line treatment for all patients requiring lipid-lowering medication, with atorvastatin 40-80 mg or rosuvastatin 20-40 mg being the preferred agents for achieving aggressive LDL-C reduction. 2, 1, 3, 4

Statin Dosing Strategy

• Starting dose: 10-20 mg daily for most patients; 40 mg for those requiring >45% LDL-C reduction 3
• Dosage range: 10-80 mg daily depending on LDL-C goal and tolerance 3
• ACS patients: Initiate or continue high-dose statin immediately upon admission regardless of baseline LDL-C 2, 1
• Familial hypercholesterolemia: Intense-dose statin, often combined with ezetimibe from initiation 2, 1

When Statins Alone Are Insufficient

If LDL-C goals are not achieved with maximally tolerated statin doses, add ezetimibe 10 mg daily as the preferred second agent. 1

• Consider bile acid sequestrants as alternative add-on therapy 2
• Fibrates (not gemfibrozil) may be added for persistent hypertriglyceridemia 2
• PCSK9 monoclonal antibodies for very high-risk patients not reaching goals with statin plus ezetimibe 1

Monitoring Protocol

Lipid Testing Schedule

• After treatment initiation: Test at 8 (±4) weeks 2, 1
• After dose adjustment: Test at 8 (±4) weeks until target achieved 2, 1
• Once at goal: Annual testing unless adherence concerns or clinical changes 2, 1

Liver Enzyme Monitoring

Measure ALT before treatment and once at 8-12 weeks after starting or dose increase; routine monitoring thereafter is not recommended. 2, 1

• If ALT <3× ULN: Continue therapy, recheck in 4-6 weeks 2, 1
• If ALT ≥3× ULN: Discontinue or reduce dose, investigate other causes 2
• Contraindication: Acute liver failure or decompensated cirrhosis 3, 4

Creatine Kinase Monitoring

Measure CK before starting therapy; do not initiate if baseline CK >4× ULN. 2, 1

• CK >10× ULN: Stop treatment immediately, check renal function, monitor CK every 2 weeks 2, 1
• CK 4-10× ULN without symptoms: Continue therapy while monitoring CK 2, 1
• CK 4-10× ULN with symptoms: Stop statin, monitor normalization, re-challenge with lower dose 2, 1
• CK <4× ULN: Continue treatment, consider transient elevation from exercise 2, 1

Managing Statin-Associated Muscle Symptoms

For symptomatic patients with CK <4× ULN, perform 2-4 week statin washout; if symptoms improve, re-challenge with a different statin at usual or starting dose. 2, 1

Algorithmic Approach to Muscle Symptoms

1. Symptoms persist after washout: Consider non-statin causes; if statin-related, try low-dose potent statin or alternate-day/weekly dosing 2, 1

2. Symptoms improve after washout: Re-challenge with second statin at standard dose 2, 1

3. Symptoms recur with second statin: Try low-dose third potent statin or alternate-day dosing regimen 2, 1

4. Goal: Achieve LDL-C target with maximally tolerated statin dose, then add ezetimibe or other agents 2, 1

Immune-Mediated Necrotizing Myopathy (IMNM)

• Rare autoimmune myopathy characterized by proximal weakness, elevated CK persisting after statin discontinuation, positive anti-HMG-CoA reductase antibody 4
• Action: Discontinue statin immediately if IMNM suspected; may require immunosuppressive therapy 4

Special Population Considerations

Type 1 Diabetes

For all type 1 diabetes patients with microalbuminuria or renal disease, achieve at least 50% LDL-C reduction with statins regardless of baseline LDL-C. 2

Type 2 Diabetes

• With CVD/CKD or >40 years with risk factors: LDL-C <1.8 mmol/L (<70 mg/dL) 2, 1
• Without additional risk factors: LDL-C <2.6 mmol/L (<100 mg/dL) 2

Chronic Kidney Disease

• Stage 3-5 CKD (non-dialysis): Consider high or very high CV risk; use statins or statin/ezetimibe combination 2, 1
• Dialysis-dependent without atherosclerotic CVD: Do not initiate statins 2

Familial Hypercholesterolemia

Suspect FH in patients with CHD before age 55 (men) or 60 (women), relatives with premature CVD, tendon xanthomas, or LDL-C >5 mmol/L (190 mg/dL) in adults or >4 mmol/L (150 mg/dL) in children. 2

• Children: Screen from age 5 years, earlier if homozygous FH suspected 2
• Treatment: Intense-dose statin plus ezetimibe; consider PCSK9 inhibitors if goals not met 2, 1
• Family screening: Perform cascade screening when index case diagnosed 2

Peripheral Arterial Disease and Stroke Prevention

• PAD (including carotid disease): Very high-risk condition requiring statin therapy 2
• Primary stroke prevention: Statin therapy for high/very high CV risk patients 2
• Secondary stroke prevention: Intensive statin therapy for non-cardioembolic ischemic stroke or TIA 2

Conditions Where Statins Are NOT Recommended

• Heart failure without other indications: Statins not recommended but not harmful 2
• Aortic stenosis without CAD: Cholesterol-lowering not recommended 2
• Autoimmune diseases: Universal lipid-lowering not recommended 2

Lifestyle Interventions

Implement comprehensive lifestyle modifications as the foundation of all dyslipidemia management, including smoking cessation, regular aerobic exercise, healthy diet low in saturated fat (7-10% calories) with adequate unsaturated fat (15-20% calories), and weight normalization. 2, 5, 6

Evidence-Based Lifestyle Effects

• Combined healthy diet, weight loss, and physical activity can increase HDL-C by 10-13% 6
• Saturated fat reduction and unsaturated fat adequacy directly lower LDL-C 6
• Regular physical activity improves all lipid parameters 5, 6
• Smoking cessation and moderate alcohol consumption benefit HDL-C 6

Multidisciplinary Approach

Deliver care through a comprehensive patient- and family-centered approach in one healthcare setting, drawing on expertise from smoking cessation, dietetics, physical activity, and health psychology disciplines. 2, 1

Adherence Optimization Strategies

• Agree on (not dictate) drug regimen tailored to patient's lifestyle 1
• Provide clear written instructions backing verbal guidance 1
• Simplify dosing with once-daily regimens and fixed-dose combinations where available 1
• Regularly review medications to minimize polypharmacy 1
• Encourage self-monitoring and use of reminders 1
• Educate on common side effects and management strategies 1
• Involve family members or caregivers in treatment plan 1

Critical Pitfalls to Avoid

• Do not delay statin initiation in ACS patients waiting for lipid results—start high-dose immediately 2, 1
• Do not routinely monitor ALT after initial 8-12 week check unless clinically indicated 2, 1
• Do not automatically discontinue statins for CK elevation <10× ULN without symptoms 2, 1
• Do not start statins in dialysis patients without established atherosclerotic CVD 2
• Do not overlook familial hypercholesterolemia in young patients with markedly elevated LDL-C or family history 2
• Do not use gemfibrozil with statins due to increased myopathy risk 2