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Management of Hyperlipidemia

Introduction

Hyperlipidemia is a risk factor for accelerated vascular disease. It is a major modifiable risk factor for coronary artery disease, cerebrovascular disease, and peripheral vascular disease. The most aggressive treatment of elevated lipids should be reserved for those patients at highest risk for vascular disease:

  • Patients with a documented history of coronary artery disease, cerebrovascular disease, or peripheral vascular disease.
  • Patients with a history of diabetes or hypertension.
  • Patients with two or more risk factors for vascular disease.
  • Patients with an LDL-C level above 160 mg/dL.
  • Patients with elevated triglycerides, low levels of HDL cholesterol, and those who smoke.

Screening recommendations for the general population are:

  • Every 5 years for males age 35-65
  • Every 5 years for females age 45-65.

Screening for adults under age 35 and over age 65 should generally be limited to those with risk factors for vascular disease which include:

  • Family history of premature vascular disease (<50 male, <60 female)
  • Smoking
  • Hypertension
  • Diabetes
  • Documented vascular disease

Elevated cholesterol levels are generally classified as:

  • Desirable: TC<200 mg/dL, HDL>35 mg/dL, LDL<130
  • Borderline: TC 200-239, HDL>35 mg/dL, LDL 131-160, and fewer than 2 risk factors and without vascular disease
  • High: presence of vascular disease and LDL>160 or TC>240 mg/dL or HDL <35 mg/dL, or 2 or more risk factors.
  • An additional factor to consider is the total cholesterol/HDL ratio. The goal is to keep the ratio below 5:1; the optimum ratio is 3.5:1.

Treatment

The treatment of hyperlipidemia is based on the "stepped care" model. This involves classifying the severity of the patient's lipid elevations and risk factors, then beginning treatment with diet and progressing to more aggressive treatment in a step-wise fashion. Patients who have made no attempt to change their diet and who are not at high risk for vascular disease should generally begin with the Step 1 diet and advance to the Step 2 diet only if their lipid levels do not reach goal. Patients classified as high risk should proceed directly to Step 2 diet.

  • Step 1: Provide information on dietary modification, physical activity, and risk factor reduction. Diet should generally consist of =<30% fat, <8-10% saturated fat, <300 mg/d cholesterol.
  • Step 2: Provide information on dietary modification, physical activity, and risk factor reduction. Diet should generally consist of =<30% fat, <7% saturated fat, <200 mg/d cholesterol.

Patients who fail maximal diet therapy may be candidates for drug therapy.

 

Risk Category

Goal LDL

 

Without CHD and with fewer than two risk factors

< 160 mg/dL

 

Without CHD and with two or more risk factors

< 130 mg/dL

 

With CHD

100 mg/dL

 

Medication Selection

  • The drugs of first choice for elevated LDL cholesterol are the bile acid sequestrants (cholestyramine, colestipol) and nicotinic acid (niacin). These medications are effective and have no serious side effects. They can have troublesome side effects requiring member education to improve compliance. Niacin is preferred in the presence of elevated triglycerides (exceeding 250 mg/dL). Bile acid sequestrants should not be used as a single agent in the presence of elevated triglycerides.
  • HMG CoA reductase inhibitors (lovastatin, pravastatin, fluvastatin, and simvastatin) are very effective for lowering LDL levels in patients who do not tolerate or respond to the first line agents of choice.
  • Fibrates (Gemfibrazil and clofibrate) have moderate effects on LDL levels but are more effective in lowering elevated triglycerides.
  • Combination therapy may be used on high risk patients who fail to respond to diet and single agent medication regimens. Combining a bile acid sequestrant with either nicotinic acid or an HMG CoA reductase inhibitor can markedly lower LDL levels.

Monitoring Guidelines

  • Once a patient has been diagnosed with hyperlipidemia, measure LDL/lipid profiles on a regular basis, at least annually.
  • After initiation of drug therapy, measure LDL levels at 4 to 6 weeks and repeat again in 3 months.Monitor for cholesterol response and side effects of therapy.
  • If response is adequate, i.e., the goals above are met, continue to monitor every 4 to 6 months.
  • If inadequate response, use a combination of 2 drugs or switch to a different agent. Combination therapy is most useful for those with severe hypercholesterolemia and combined hyperlipidemia.

 

References

Second Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. NIH Publication number 93-3095. September 1993.
Schwartz, JS, The Cost-Effectiveness of Cholesterol Lowering Therapy: A Guide for the Perplexed. JCOM. 1996;3(6):48-51.
Grundy, et. al., When to Start Cholesterol-Lowering Therapy in Patients with Coronary Artery Disease. Circulation. 1997;95:1693-1685. American College of Physicians. Guidelines for Using Serum Cholesterol, HDL Cholesterol, and Triglyceride Levels as Screening Tests for Preventing Coronary Heart Disease in Adults. Annals of Internal Medicine. 1996;124(5):515-517.
Garber, et al, Cholesterol Screening in Asymptomatic Adults Revisited. Annals of Internal Medicine. 1996;124(5):518-531.