Dyslipidaemia

E78.0-9/E78.8-9

DESCRIPTION

Non-pharmacological therapy plays a vital role in the management of dyslipidaemia. Many patients with mild or moderate dyslipidaemia will be able to achieve optimum lipid levels with lifestyle modification alone and may not require lifelong lipid modifying therapy.

Accompanying modifiable risk factors for coronary artery disease (CAD) e.g. hypertension, smoking, diabetes, must be sought and treated.

Underlying causes of secondary dyslipidaemia, e.g. excess alcohol intake, hypothyroidism, should be identified and corrected.

The goal of treatment should be explained clearly to the patient and the risks of untreated dyslipidaemia should be emphasised.

GENERAL MEASURES

Lifestyle modification

Dietary strategies are effective.

  • Replace saturated fats with unsaturated fats (mono-and polyunsaturated fats) without increasing calories from fats.
  • Consume a diet high in fruits, vegetables, nuts and whole unrefined grains.

Smoking cessation.

Increase physical activity.

Maintain ideal body weight.

MEDICINE TREATMENT

Indication for medicine therapy

Cardiovascular

The main indication for lipid-modifying medication is to reduce the risk of a cardiovascular event. Medicine therapy should be considered when non-pharmacological means have failed to reduce the lipid levels to within the target range. When lipid-lowering medicines are used, this is always in conjunction with ongoing lifestyle modification.

Patients with any of the following factors are at a relatively high risk for a

cardiovascular event and would benefit from lipid lowering therapy:

  • established atherosclerotic disease
    • confirmed ischaemic heart disease
    • peripheral vascular disease
    • atherothrombotic stroke
  • type 2 diabetics with age >40 years of age
  • type 1 diabetes with microalbuminuria
  • diabetes with chronic kidney disease (eGFR <60 mL/minute).

LoEI [24]

Patients without established vascular disease, with a risk of MI ≥20% in 10 years: lifestyle modification and start statin treatment - see: Ischaemic heart disease and atherosclerosis, prevention.

Non-cardiovascular

The most serious non-cardiovascular complication of dyslipidaemia is the development of acute pancreatitis. This is seen in patients with severe hypertriglyceridaemia (fasting triglycerides >10 mmol/L). Ideally such patients should be discussed with a lipid specialist.

Fibrates are the medicines of choice for severe hypertriglyceridaemia not due to secondary causes.

Choice of medication

Depends on the type of lipid disturbance:

  • predominant hypercholesterolaemia: statin
  • mixed hyperlipidaemia: statin or fibrate
  • predominant hypertriglyceridaemia: fibrate

HMGCoA reductase inhibitors (statins), according to table below:

INDICATION HMGCOA REDUCTASE INHIBITOR (STATIN) DOSE
A: Primary prevention  - no existing CVD
» Type 2 diabetes with age >40 years.
»  Diabetes for >10 years.
»  Diabetes with chronic kidney disease.
»  ≥20% 10-year risk of cardiovascular event. 		HMGCoA
reductase inhibitors (statins), e.g.:
·  Simvastatin,
oral, 10 mg at night.
»  Patients on protease inhibitors.
(Risks as above, after switching to atazanavir – see section below). 		·  Atorvastatin, oral, 10 mg at night.
B: Secondary prevention – existing CVD
»    Ischaemic heart disease.
»    Atherothrombotic stroke.
»    Peripheral vascular disease. 		HMGCoA
reductase inhibitors (statins), e.g.:
·  Simvastatin,
oral, 40 mg at night
LoE:I [25]
»    Patients on protease inhibitors. ·  Atorvastatin, oral, 10 mg at night.
LoE:I [26]
»    Patients on amlodipine (and not on protease inhibitor). ·  Simvastatin, oral, 10–20 mg at night.
LoE:III [27]
»     If patient complains of muscle pain. Reduce dose:
·  HMGCoA reductase inhibitors (statins), e.g.:
·  Simvastatin,
oral, 10 mg at night.
OR
Consult specialist for further management.
LoE:III [28]

LoEI [25]

LoEI [26]

LoEIII [27]

LoEIII [28]

Note: Lipid-lowering medicines must always be used in conjunction with ongoing lifestyle modification.

For patients with moderate to severe fasting hypertriglyceridaemia and for patients on antiretroviral therapy i.e. triglycerides >10 mmol/L:

  • Fibrates, e.g.:
  • Bezafibrate, slow release, oral, 400 mg daily.

Aspirin therapy:

Use in adult patients with diabetes who have a history of cardiovascular disease i.e.

  • ischaemic heart disease
  • peripheral vascular disease
  • previous thrombotic stroke

Aspirin, oral, 150 mg daily.

LoEI [29]

Dyslipidaemia in HIV-infected patients: See: Management of selected antiretroviral adverse drug reactions.

REFERRAL