Hyperlipoproteinemia medical therapy

# Overview
Hyperlipidemia requires early detection, careful evaluation and aggressive treatment with combination of therapeutic lifestyle changes and lipid-lowering drug therapies to reduce the risk of cardiovascular and cerebrovascular complications.

# Medical Therapy for Adults

## NCEP ATP III Recommendations for Medical Therapy of Hyperlipidemia in Adults

## Original Recommendations of the National Cholesterol Education Program (NCEP) ATP III for Medical Therapy of Hyperlipidemia in Adults (DO NOT EDIT)
- Obtain  complete lipid profile after 9 to 12-hour fast.

### Detect Presence of Coronary Heart Disease (CHD) Risk Equivalent
- Previous personal history of clinical CHD
- Clinical carotid artery disease
- Abdominal aortic aneurysm
- Peripheral arterial disease
- Diabetes

### Determine Presence of Major Risk Factors
(Other than LDL)
- Hypertension (BP140/90 mmHg or on antihypertensive medication)
- Cigarette smoking
- Low HDL-cholesterol (<40 mg/dL)
HDL-cholesterol 60 mg/dL counts as a "negative" risk factor and removes one risk factor from the total count.
- HDL-cholesterol 60 mg/dL counts as a "negative" risk factor and removes one risk factor from the total count.
- Age (men 45 years; women 55 years)
- Family history of premature CHD in first degree relative (CHD in men <55 years; CHD in women <65 years)
If 2+ major risk factors (other than LDL) are present without CHD or CHD risk equivalent, assess 10-year (short-term) CHD risk using Framingham Risk Score. The Framingham Risk Score is based on data obtained from the Framingham Heart Study. There are two Framingham Risk Scores, one for men and one for women. Three levels of 10-year risk:

### Determine Risk Category, LDL Goal of Therapy, Level for Therapeutic Lifestyle Changes (TLC), and Level for Drug Therapy

### Therapeutic Lifestyle Changes (TLC)
Therapeutic lifestyle changes (TLC) should be initiated, if LDL level is above goal.
- TLC diet - consists of saturated fat <7% of calories, cholesterol <200 mg/day, increased viscous (soluble) fiber (10-25 g/day), and plant sterols (2g/day) to enhance LDL lowering.
- Weight management
- Increased physical activity

### Drug Therapy
Drug therapy should be initiated, if LDL exceeds levels shown in above table. Initiate drug simultaneously with TLC for CHD and CHD equivalents, whereas add drug to TLC after 3 months for other risk categories.
(LDL=LDL cholesterol, HDL=HDL cholesterol, TG=Triglycerides)

### Treatment of Elevated Triglycerides
- In case of hyperlipidemia with elevated triglycerides (150 mg/dL), primary aim of therapy is to reach LDL goal, intensify weight management and increase physical activity.
- If triglycerides are 200 mg/dL after LDL goal is reached, set secondary goal for non-HDL cholesterol (total - HDL) 30 mg/dL higher than the LDL goal for respective categories.
- If triglycerides are 200-499 mg/dL after LDL goal is reached, consider adding drug if needed to reach non-HDL goal:
Intensify therapy with LDL-lowering drug
Add niacin or fibrate to further lower triglycerides
- Intensify therapy with LDL-lowering drug
- Add niacin or fibrate to further lower triglycerides
- If triglycerides are 500 mg/dL, first lower triglycerides to prevent pancreatitis:
Very low-fat diet (<15% of calories from fat)
Intensified weight management and increased physical activity
Add niacin or fibrate
When triglycerides reach <500 mg/dL, turn to LDL-lowering drug
- Very low-fat diet (<15% of calories from fat)
- Intensified weight management and increased physical activity
- Add niacin or fibrate
- When triglycerides reach <500 mg/dL, turn to LDL-lowering drug

### Treatment of Low HDL Cholesterol (<40 mg/dL)
First reach LDL goal, intensify weight management, and increase physical activity; then if triglycerides are 200-499 mg/dL, achieve non-HDL goal and if triglycerides are <200 mg/dL (isolated low HDL) in CHD or CHD equivalent, add niacin or fibrate.

### Treatment of the Metabolic Syndrome
- Identification of the metabolic syndrome (any 3 of the following):
Abdominal obesity - waist circumference of >102 cm (>40 in) in men and >88 cm (>35 in) in women
Serum triglyceride level 150 mg/dL
HDL cholesterol level of <40 mg/dL in men and <50 mg/dL in women
Blood pressure 130/85 mmHg
Fasting glucose 110 mg/dL.
- Abdominal obesity - waist circumference of >102 cm (>40 in) in men and >88 cm (>35 in) in women
- Serum triglyceride level 150 mg/dL
- HDL cholesterol level of <40 mg/dL in men and <50 mg/dL in women
- Blood pressure 130/85 mmHg
- Fasting glucose 110 mg/dL.
- Treat underlying causes:
Intensify weight management
Increase physical activity.
- Intensify weight management
- Increase physical activity.
- Treat lipid and non-lipid risk factors, if they persist despite TLC:
Treat hypertension
Use aspirin for CHD patients to reduce thromboembolic risk
Treat elevated triglycerides and/or low HDL as shown above.
- Treat hypertension
- Use aspirin for CHD patients to reduce thromboembolic risk
- Treat elevated triglycerides and/or low HDL as shown above.

## Other Lipid Lowering Agents

### Omega-3 Fatty Acids
( - Increase,  - Decrease)

### Ezetimibe
Ezetimibe is a new class of lipid lowering agents. It inhibits intestinal absorption of cholesterol. It has been approved as a monotherapy or in combination with statins to treat hypercholesterolemia. It has also been approved in combination with fenofibrate to treat mixed hyperlipidemia.

# Medical Therapy in Children and Adolescents
Click on the respective microchapter to read more about it:
- Drug Therapy
- Statins
- Adjuvant Therapies

# A Trial Based Approach to Statin Guidelines
Shown below is a table suggesting an approach to the use of statin according to different trials.