Lipid (cholesterol) Management

Lipid lowering medications GOAL = reduce risk of cardiovascular event (ASCVD)

 STATINS ARE FIRST LINE medication (lifestyle modification should always be the foundation)

When to use Statin (use moderate to high intensity for primary and secondary prevention of ASCVD)

  1. 21 years or greater w/ knownASCVD (arteriosclerotic cardiovascular disease)
  2. 21 + w/ LDL 190+
  3. 40-75 w/o ASCVD but w/DM and LDL 70 to 189
  4. 40-75 w/o ASCVD and no DM but w/ 10yr risk >7.5%
    1. use ASVD Suite app to calculate
    2. if statin fails use -> higher dose
    3. if fail use ezetimibe
    4. if fail use bile acid sequestrants

 

Examples of commonly used statin with dose (moderate, high intensity)

  1. Atorvastatin (Lipitor) – 10 to 20mg, 40 to 80mg
  2. Rosuvastatin (Crestor) – 5 to 10mg, 20 to 40 mg
  3. Pravastatin (Pravachol) – 40mg
  4. Lovastatin (Altoprev) – 40mg
1. Secondary prevention
  • no guidelines for specific LDL or HDL targets
  • All pt <75 with ASCVD should be on high intensity statin therapy
    • if cannot tolerate try moderate intensity
    • >75 based on clinical judgement and if they have tolerated well in the past
2. Primary prevention (>=21 w/ LDL >=190)
  • eval for secondary causes
  • treat with high intensity statin therapy  try to achieve 50% reduction
    • add second drug (updated info – ezetimibe ) if not reduction not achieved
2a. W/ Diabetes 70 to 189 LDL
  • moderate intensity statin for age 40-75
  • high intensity if 10-year ASCVD risk >=7.5% 40 -75
2b. W/O Diabetes 70 to 189
  • estimate 10 year risk to guide therapy
    • >7.5% 10 yr risk = treat
    • 5 ot 7.5 can treat w/ moderate intensity

 

Nonstatin
3 new studies since 2013 guidelines.
  1. Niacin provides no additional benefits, may cause harm
  2. ezetimibe = modest benefit when added to statin
    1. this should be first medication considered when adding to statin therapy or is statin not tolerated
  3. PCSK9 = on short term data available
    1. should only be used for highest risk pt
      1. those with ACS (acute coronary syndrome) who cannot tolerate statins
      2. familial hypercholesterolemia -> refer to lipid specialist
  4. Bile acid sequestrants = 2nd line if ezetimibe not tolerated
    1. triglyceride less than 300
  5. Alirocumab/evolocumab -> only if statin and ezetimibe not tolerated for high risk
In groups: familial, DM, high risk for CVD
General measures
  1. After starting statin – check q3 to 12 months
  2. if statin intolerant – stop statin or lower dose, re-challenge with different long actin statin at 1 to 3 times weekly intervals
    1. statin intolerance = muscle pain the improves when statin is stopped and another is tried
    2. try alternate day dosing
  3. high intensity = reduction of 50%+
  4. mod intensity = 30 to 50% reduction
  5. nonstatins added to high risk groups who have not achieved 50% reduction with statin
    1. existing ASCVD
    2. LDL 190+
  6. predisposition to statin side effects
    1. renal/hepatic impairment or ALT increase 3x normal after starting
    2. prior history of intolerance
    3. >75 years
  7. unexplained muscle symptoms -> order a Ck (r/o rhabdo)
Sources: Medscape, ACP, uptodate