Dyslipidemia: Pharmacological Treatment

 

Primary prevention 

- Make treatment decisions based on 10 year ASCVD clinical risk calculation (http://tools.acc.org/ASCVD-Risk-Estimator-Plus)

-  In all patients of Diabetes aged 40 to 75 years, start a moderate dose statin regardless of estimated 10 year risk.

- In age 40-75 years without diabetes, if LDL-C ≥ 70 mg/dl at ASCVD risk >7.5%, start moderate intensity statin therapy.

- In age 20-75 years with LDL-C ≥ 190 mg/dl, offer maximally tolerated statin therapy

- Add Ezetimibe to maximally tolerated statin therapy in adults who have diabetes and a 10-year risk of ≥ 20% to reduce LDL-C levels by ≥ 50%

-Add PCSK9 inhibitor in 40 to 75 years of age with baseline LDL-C level  ≥ 220 mg per dL and who achieve an on-treatment LDL-C level of ≥ 130 mg per dL while receiving maximally tolerated statin and ezetimibe therapy/

 

Secondary Prevention

- For secondary prevention, use at least a moderate-dose statin as the mainstay of treatment

- Initiate or continue high-intensity statin therapy in patients who are ≤ 75 years who have clinical ASCVD ( ACS, MI, Stroke, TIA, PAD ) with the aim of achieving a ≥ 50% reduction in LDL-C levels

- Add Ezetimibe for patients with clinical ASCVD who taking maximally tolerated statin therapy, who are judged to be at very high risk, and LDL-C level of ≥ 70 mg/dL

 

Repeat lipid measurement 4 to 12 weeks after statin initiation or dose adjustment, repeated every 3 to 12 months as needed 

Note:

Moderate Intensity Statin: Atorvastatin 10 to 20 mg, Rosuvastatin 5 to 10 mg, Simvastatin 20 to 40 mg

High Intensity Statin: Atorvastatin 40 to 80 mg, Rosuvastatin 20 to 40 mg

Ezetimibe dose: 10 mg once daily

Hypertriglyceridimia

- For primary prevention, pharmacologic management of fasting serum triglyceride levels less than 500 mg/dL is not indicated

- ASCVD < 5% and TG < 150 mg/dl- Lifestyle modification and routine surveillance

- ASCVD 5%-7.4% and TG 150-499 mg/dl- Intensify Lifestyle modification and discuss statin use

- ASCVD 7.5%-19.9% and TG 150-499 mg/dl- Intensify Lifestyle modification and consider statin use

-ASCVD >20% and TG 150-499 mg/dl- Intensify Lifestyle modification and add statin- Consider Icosapent if TG still within 150 and 499

- TG > 500 mg/dl- Initiate Fibrate, Omega 3 FA or Niacin to bring TG < 500 

Note: Lifestyle modifications- Reduce excessive alcohol use, tobacco cessation, implementing nutritional changes (limit refined carbohydrates and added sugar, increasing foods lower on the glycemic index and foods containing omega-3 fatty acids), and do high- or moderate-intensity aerobic and resistance exercises

 

References:

1. Arnold M et al, Am Fam Physician. 2021 Apr 15;103(8):455-458 

2. 2018 AHA guideline on Management of Blood Cholesterol