Treatment of Lipemia (Elevated Lipid Levels)

Therapeutic Lifestyle Changes

The American College of Cardiology recommends limiting calories from saturated fat to <7% of total calories, reducing dietary cholesterol to <200 mg/day, and avoiding trans-fatty acids for patients with elevated lipid levels 1
Consider adding plant stanols/sterols (up to 2 g/day) and/or increased viscous (soluble) fiber (10-25 g/day) for additional LDL-C lowering in patients with elevated lipid levels 1
For elevated triglycerides, focus on decreasing simple sugar intake and increasing dietary n-3 fatty acids, and advocate consumption of fruits, vegetables, whole grains, low-fat dairy products, fish, legumes, poultry, and lean meats 1
Aim for at least 30 minutes of moderate-intensity physical activity on most days of the week, and include resistance training with 8-10 different exercises, 1-2 sets per exercise, and 10-15 repetitions at moderate intensity 2 days/week 1

Statins (HMG-CoA reductase inhibitors) are the first-line pharmacological therapy for LDL-C reduction, and have been shown to significantly reduce coronary and cerebrovascular events in patients with hyperlipidemia 1
In primary prevention trials, cholesterol-lowering drug treatment decreased the risk of coronary heart disease events by approximately 30% 2
For patients who cannot tolerate statins, consider bile acid-binding resins or fenofibrate, and for combined hyperlipidemia, improved glycemic control plus high-dose statin is the first choice 1

The American Heart Association recommends LDL cholesterol goal varies based on risk factors: <100 mg/dL if 0 risk factors are present; <130 mg/dL if 1 risk factor is present; <160 mg/dL if 2 risk factors are present 1
Optimal lipid goals include LDL cholesterol <100 mg/dL, HDL cholesterol >35 mg/dL, and triglycerides <150 mg/dL, and for patients with diabetes, LDL-C goal is <100 mg/dL 1

Treatment of LDL cholesterol is considered the first priority for pharmacological therapy of dyslipidemia in diabetes, and improved glycemic control is the first priority for triglyceride lowering in diabetic patients 1
In patients with both elevated LDL cholesterol and triglycerides, the level of non-HDL cholesterol or apolipoprotein B might guide decisions about initiation of drug therapy 3
Patients with triglycerides >4 mmol/L (350 mg/dL) or random levels >8 mmol/L (700 mg/dL) might benefit from therapy aimed primarily at preventing pancreatitis 3

Consider combination therapy for patients not reaching goals on monotherapy, with options including statin plus resin, statin plus niacin, or statin plus fibrate, but caution that the combination of statins with nicotinic acid or fibrates (especially gemfibrozil) may increase risk of myositis 1

Rule out secondary causes of hyperlipidemia (liver function test, thyroid-stimulating hormone level, urinalysis) before initiating drug therapy, and monitor for statin-related adverse effects, including myopathy and rhabdomyolysis 1
When using combination therapy with statins and fibrates, the risk of myositis is higher with gemfibrozil than with fenofibrate 1