What are the current guidelines for managing dyslipidemia?

Dyslipidemia Management Guidelines 2025

Risk-Based LDL-C Treatment Targets

The cornerstone of dyslipidemia management is achieving specific LDL-C targets based on cardiovascular risk stratification, with statins as first-line therapy and escalation to combination therapy when targets are not met. 1

Very High-Risk Patients

• Target LDL-C <1.8 mmol/L (70 mg/dL) or ≥50% reduction if baseline is 1.8-3.5 mmol/L 1
• Secondary targets: non-HDL-C <2.6 mmol/L (100 mg/dL) and apoB <80 mg/dL 1
• Very high-risk includes: established CVD, acute coronary syndrome, peripheral arterial disease, prior stroke/TIA, diabetes with target organ damage, or stage 3-5 chronic kidney disease 2, 1

High-Risk Patients

• Target LDL-C <2.6 mmol/L (100 mg/dL) or ≥50% reduction if baseline is 2.6-5.2 mmol/L 1
• Secondary targets: non-HDL-C <3.4 mmol/L (130 mg/dL) and apoB <100 mg/dL 1

Risk Assessment

• Use total risk estimation systems like SCORE for asymptomatic adults >40 years without established CVD, diabetes, CKD, or familial hypercholesterolemia 1
• LDL-C is the primary lipid parameter for screening, risk estimation, diagnosis, and management 1

Pharmacological Treatment Algorithm

First-Line Therapy: Statins

• Statins are the first-line therapy for LDL-C reduction in most patient populations 1
• High-intensity statins for established CVD and very high-risk patients 1
• For acute coronary syndrome: initiate or continue high-dose statins early after admission regardless of initial LDL-C values 2, 1

Second-Line: Add Ezetimibe

• Add ezetimibe when LDL-C goals are not achieved with maximally tolerated statin therapy 1
• Particularly effective in combination with statins for non-dialysis-dependent CKD patients 2, 1

Third-Line: PCSK9 Inhibitors

• Consider PCSK9 inhibitors for very high-risk patients who cannot achieve target LDL-C despite maximum tolerated statin and ezetimibe therapy 1

Special Population Management

Diabetes Mellitus

Type 1 Diabetes:

• LDL-C lowering ≥50% with statins regardless of baseline LDL-C in presence of microalbuminuria or renal disease 2, 1

Type 2 Diabetes with CVD/CKD or >40 years with additional risk factors:

• Target LDL-C <1.8 mmol/L (70 mg/dL) 2, 1
• Non-HDL-C <2.6 mmol/L (100 mg/dL) and apoB <80 mg/dL 2, 1

Type 2 Diabetes without additional risk factors:

• Target LDL-C <2.6 mmol/L (100 mg/dL) 2, 1
• Non-HDL-C <3.4 mmol/L (130 mg/dL) and apoB <100 mg/dL 2, 1

Chronic Kidney Disease

Stage 3-5 CKD (non-dialysis):

• Consider all patients at high or very high CV risk 2, 1
• Use statins or statin/ezetimibe combination 2, 1

Dialysis-dependent CKD:

• Do not initiate statins in patients without atherosclerotic CVD 2, 1

Cerebrovascular Disease

• Intensive statin therapy for patients with history of non-cardioembolic ischemic stroke or TIA for secondary prevention 2, 1
• Statin therapy to reach established treatment goals for primary prevention in high or very high CV risk patients 2

Peripheral Arterial Disease

• PAD is a very high-risk condition requiring lipid-lowering therapy (primarily statins) 2, 1

Conditions Where Statins Are NOT Recommended

Heart Failure:

• Cholesterol-lowering therapy with statins is not recommended in heart failure patients without other indications (though not harmful) 2, 1

Aortic Stenosis:

• Cholesterol-lowering treatment is not recommended in aortic valvular stenosis without CAD in absence of other indications 2, 1

Autoimmune Diseases:

• Universal use of lipid-lowering drugs is not recommended 2

Monitoring Protocol

Lipid Testing Schedule

• 8 (±4) weeks after starting treatment 2
• 8 (±4) weeks after adjustment of treatment until within target range 2
• Annually once target achieved (unless adherence problems or specific reasons for more frequent reviews) 2

Liver Enzyme Monitoring (ALT)

• Before treatment initiation 2
• Once 8-12 weeks after starting drug or dose increase 2
• Routine control thereafter is not recommended 2
• If ALT <3x ULN: continue therapy and recheck in 4-6 weeks 2

Creatine Kinase (CK) Monitoring

• Pre-treatment: before starting therapy 2
• If baseline CK is 4x ULN, do not start drug therapy; recheck 2
• Be alert for myopathy in high-risk patients: elderly, concomitant interfering therapy, multiple medications, liver/renal disease, or athletes 2

If CK becomes elevated:

• CK >10x ULN: stop treatment immediately, check renal function, monitor CK every 2 weeks 2
• CK <10x ULN without symptoms: continue therapy while monitoring CK 2
• CK <10x ULN with symptoms: stop statin, monitor normalization, re-challenge with lower dose 2

Statin Intolerance Management

For symptomatic patients with CK <4x ULN:

• 2-4 weeks washout of statin 2
• If symptoms persist: statin re-challenge 2
• If symptoms improve: try second statin at usual or starting dose 2
• If symptoms recur: low-dose third potent statin or alternate day/once-twice weekly dosing 2

Aim to achieve LDL-C goal with maximally tolerated statin dose, then add:

• Ezetimibe 2
• Bile acid absorption inhibitor 2
• Fibrate (not gemfibrozil) 2
• Consider PCSK9 monoclonal antibody therapy 2

Implementation Strategies

• Simplify dosing regimens and consider fixed-dose combinations when available 1
• Regular medication reviews to minimize polypharmacy 1
• Provide clear written instructions to support verbal advice 1
• Involve family members or caregivers in the treatment plan 1
• Multidisciplinary exercise-based cardiac rehabilitation for CAD patients 1
• Cognitive behavioral interventions to achieve healthy lifestyle 1