Hyperlipidemia Treatments
The goal of
hyperlipidemia treatment is to
prevent atherosclerosis and other cardiovascular diseases, and, in the case of hypertriglyceridemia, to
prevent pancreatitis.
Prevention and treatment of hyperlipidemia comprises
lifestyle modifications that promote cardiovascular health, including a low-fat diet, increased physical activity, weight loss, and avoidance of cigarette smoking.
When those measures are not enough, medications can be prescribed.
Hyperlipidemia Medications
Statins
HMG-CoA reductase inhibitors: upregulate hepatic LDL receptors, which lowers serum levels of LDL.
Statins can
reduce LDL levels by 20-60%, and reduce triglyceride levels as well.
Adverse effects include
myalgia and myositis; some statins are associated with increased risk of
diabetes.
Statins are contraindicated in liver disease, and can interact with several drugs, including warfarin.
Statins are a
mainstay treatment of hyperlipidemia and have been shown to reduce the risk of cardiovascular disease and reduce the progression and mortality from atherosclerotic cardiovascular disease (ASCVD).
Cholesterol absorption inhibitors
These drugs, which include
ezetimibe, are the most commonly used non-statin drugs.
They block the intestinal absorption of cholesterol and
upregulate hepatic LDL receptors.
Cholesterol absorption inhibitors reduce LDL and Apolipoprotein B; these drugs are often used in combination with statins to produce additional reductions in LDL.
They are generally well-tolerated, though
diarrhea is common, and can be used when statins are contraindicated or in conjunction with statins.
PCSK9 inhibitors
Proprotein convertease subtilsin-kexin type 9 inhibitors
Block PCSK9 from binding with LDL receptors, which allows more LDL binding and, therefore, clearance.
These drugs
reduce LDL levels 50-70%.
They are administered via injection, which can lead to
inflammation at the injection site.
The need for self-injection and refrigeration can be prohibitive for some individuals.
Fibric acid derivatives
Also called fibrates.
Reduce synthesis of triglycerides and VLDL.
These drugs can
reduce triglycerides by 20-35%, and can
increase HDL levels by up to 20%.
Recall that HDL are the "good" lipoproteins with anti-atherogenic properties.
Common side effects include gastrointestinal upset and cholelithiasis (formation of gallstones); when taken in conjunction with statins, they may exacerbate myopathy.
Fibrates may
increase serum creatinine levels, but this is not necessarily indicative of renal dysfunction.
Niacin
Nicotinic acid reduces hepatic synthesis of LDL and VLDL.
Can
reduce LDL by 10-25%;
triglycerides by 20-30%, and may
increase HDL by 10-40%.
Side effects include
flushing and abdominal issues; more rarely, patients experience hepatotoxicity or atrial fibrillation.
Increased uric acid levels may cause
gout.
Bile acid sequestrants
Bind bile acids and prevent their reabsorption in the intestine; ultimately, this induces LDL receptor upregulation.
These drugs can
reduce LDL by 15-25%.
Possible side effects include
increased serum triglycerides, as well as
constipation and bloating; they also impair intestinal absorption of other drugs, vitamins, and folic acid.
Unfortunately, gastrointestinal issues may reduce drug adherence.
ASCVD risk and the use of statins
ASCVD is an umbrella term that includes:
- Coronary heart disease (for example, heart attack, coronary artery stenosis)
- Cerebrovascular disease (for example, transient ischemic attack, ischemic stroke)
- Peripheral artery disease
- Aortic atherosclerotic disease.
Factors that enhance a patient's risk of ASCVD include a family history of ASCVD, metabolic and inflammatory disorders, preeclampsia, inclusion in certain populations, and, abnormal biomarkers.
Guidelines for Statin use
Primary prevention comprises heart-healthy lifestyles, though clinicians and their patients should be aware of and consider the patient's risks of ASCVD.
ASCVD risk profiles guide the use of statins: http://tools.acc.org/ASCVD-Risk-Estimator-Plus/
Patients
with ASCVD can be given high-intensity statins with the goal of a 50% or greater reduction in LDL.
– If LDL remains elevated,
non-statins, such as cholesterol absorption inhibitors, can be added.
Patients with
hypercholesterolemia can also use high-intensity statins, with the additional of non-statins if LDL isn't reduced by at least 50%.
Patients with
diabetes and LDL levels greater than 70 mg/dL can prescribed moderate or high-intensity statins, depending on their ASCVD risk.
Patients with 10-year ASCVD risk scores between 7.5% and 19.9% are classified as "intermediate risk"; these patients can be prescribed moderate-intensity statins.
Be aware that other factors, including age, are also included in the guidelines.
– See more: https://www-ahajournals-org.proxy.medlib.uits.iu.edu/doi/pdf/10.1161/CIR.0000000000000625
