How to manage hypercholesterolemia with a total cholesterol level of 7.5 mmol/L?

From the Guidelines

To manage a total cholesterol level of 7.5 mmol/L, implementing both lifestyle changes and medication therapy, with statins as the first-line treatment, is crucial to reduce the risk of cardiovascular disease and stroke. According to the 2019 American College of Cardiology/American Heart Association guideline on the management of blood cholesterol 1, a heart-healthy lifestyle should be emphasized across the life course, including a diet low in saturated fats and trans fats, regular physical activity, weight loss if overweight, limited alcohol consumption, and smoking cessation.

For medication, statins such as atorvastatin (20-40mg daily) or rosuvastatin (10-20mg daily) are recommended as the primary treatment to lower LDL-C levels by at least 50% 1. The 2016 ESC/EAS guidelines for the management of dyslipidaemias also recommend using LDL-C as the primary target for treatment and suggest that a statin should be used up to the highest recommended dose or highest tolerable dose to reach the LDL-C goal 1.

In patients with severe primary hypercholesterolemia, such as those with an LDL-C level ≥190 mg/dL, high-intensity statin therapy should be initiated without calculating 10-year ASCVD risk 1. If the LDL-C level remains ≥100 mg/dL on statin therapy, adding ezetimibe is reasonable, and if the LDL-C level remains ≥100 mg/dL on statin plus ezetimibe, a PCSK9 inhibitor may be considered, although long-term safety and economic value are uncertain 1.

Regular follow-up blood tests every 3-6 months are essential to monitor progress and adjust treatment as needed. The combination of lifestyle changes and medication can significantly reduce cholesterol levels and cardiovascular risk within 3-6 months. It is also important to note that the management of total cholesterol levels should be individualized based on the patient's risk factors, medical history, and response to treatment.

From the FDA Drug Label

The effects of simvastatin on total-C and LDL-C were assessed in controlled clinical studies in adult patients with heterozygous familial and non-familial forms of hyperlipidemia and in mixed hyperlipidemia. simvastatin significantly decreased total-C, LDL-C, and TG, and increased HDL-C

TREATMENT N TOTAL-C LDL-C HDL-C TG* Lower Dose Comparative Study† (Mean % Change at Week 6) Simvastatin 5 mg at night. 109 -19% -26% +10 -12% Simvastatin 10 mg at night 110 -23% -30% +12 -15%

To manage a total cholesterol of 7.5, simvastatin can be considered as a treatment option.

• The dosage of simvastatin can be started at 5-10 mg at night, with a mean percent change from baseline of -19% to -23% in total-C at week 6.
• The goal is to decrease total-C and LDL-C levels, and increase HDL-C levels.
• It is essential to monitor the patient's response to treatment and adjust the dosage as needed, with a maximal to near maximal response generally achieved within 4-6 weeks and maintained during chronic therapy 2.

From the Research

Managing Total Cholesterol of 7.5

To manage a total cholesterol level of 7.5, several approaches can be considered based on existing research:

• Statins as the Mainstay Treatment: Statins are widely recommended for managing hyperlipidemia, including high total cholesterol levels 3. They work by inhibiting the enzyme HMG-CoA reductase, which plays a central role in the production of cholesterol in the liver.
• Adjunct Therapies: For patients who do not respond adequately to statins or cannot tolerate them, adjunct therapies such as niacin, bile acid sequestrants, fibric acids, and ezetimibe can be considered 3.
• Specific Statin Options: Certain statins like atorvastatin have been shown to be effective in reducing total cholesterol and LDL-cholesterol levels in patients with hypercholesterolemia 4, 5. Atorvastatin's efficacy in achieving cholesterol goals and improving plasma lipids has been compared favorably to other statins like simvastatin and pravastatin 6.
• Dose-Related Efficacy: The dose of atorvastatin can impact its efficacy, with higher doses leading to greater reductions in LDL-cholesterol 5. However, the choice of dose should be individualized based on the patient's response and tolerance.
• Guidelines and Recommendations: Current management guidelines for hyperlipidemia emphasize the importance of controlling modifiable risk factors, including elevated lipids, to prevent cardiovascular events 7. These guidelines often recommend statin therapy as a first-line treatment but also acknowledge the need for alternative treatments for patients who cannot tolerate statins.

Considerations for Treatment

When managing a total cholesterol level of 7.5, it's essential to:

• Assess Cardiovascular Risk: Evaluate the patient's overall cardiovascular risk to determine the intensity of statin therapy required 3.
• Monitor Lipid Levels: Regularly monitor lipid levels to assess the effectiveness of treatment and adjust the therapeutic plan as needed.
• Consider Combination Therapy: For patients with very high cholesterol levels or those at high risk of cardiovascular events, combination therapy with statins and other lipid-lowering agents may be necessary 3, 6.
• Address Potential Side Effects: Be aware of the potential side effects of statins and other lipid-lowering therapies, and monitor patients for signs of adverse effects 4, 5.