Management of Hyperlipidemia

Initial Assessment and Goals

The American Heart Association recommends primary goal for LDL-C 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 and 10-year CHD risk is <20%; or <100 mg/dL if patient has diabetes 1
Optimal lipid goals include LDL cholesterol <100 mg/dL, HDL cholesterol >35 mg/dL, and triglycerides <150 mg/dL, as recommended by the American Diabetes Association 3, 2
Annual lipid testing is recommended for monitoring progress, with less frequent testing (every 2 years) possible if lipid values are at low risk levels, according to the American Diabetes Association 2, 4

The American Heart Association recommends limiting calories from saturated fat to <7% of total calories 1, 2
Reducing dietary cholesterol to <200 mg/day is recommended by the American Heart Association 1, 2
Avoiding trans-fatty acids is recommended by the American Diabetes Association 4
Considering adding plant stanols/sterols (up to 2 g/day) and/or increased viscous (soluble) fiber (10-25 g/day) for additional LDL-C lowering is recommended by the American Heart Association 1
For elevated triglycerides, focusing on decreasing simple sugar intake and increasing dietary n-3 fatty acids is recommended by the American Diabetes Association 4
Advocating consumption of fruits, vegetables, whole grains, low-fat dairy products, fish, legumes, poultry, and lean meats is recommended by the American Heart Association 1

Aiming for at least 30 minutes of moderate-intensity physical activity on most (preferably all) days of the week is recommended by the American Heart Association 1
Including resistance training with 8-10 different exercises, 1-2 sets per exercise, and 10-15 repetitions at moderate intensity 2 days/week is recommended by the American Heart Association 1
Incorporating flexibility training and increased daily lifestyle activities is recommended by the American Heart Association 1

Statins (HMG-CoA reductase inhibitors) are the first-line pharmacological therapy for LDL-C reduction, as recommended by the American Diabetes Association 5, 2
Statins have been shown to significantly reduce coronary and cerebrovascular events in patients with diabetes and hyperlipidemia, according to the American Diabetes Association 2

For patients who cannot tolerate statins, considering bile acid-binding resins or fenofibrate is recommended by the American Diabetes Association 5
For combined hyperlipidemia, improved glycemic control plus high-dose statin is the first choice, as recommended by the American Diabetes Association 5
For severe hypertriglyceridemia (≥1,000 mg/dL), fibric acid derivatives (gemfibrozil, fenofibrate) are recommended with severe dietary fat restriction (<10% of calories) by the American Diabetes Association 5, 6

In patients with diabetes, LDL-C goal is <100 mg/dL, as recommended by the American Heart Association and the American Diabetes Association 1, 5
Treatment of LDL cholesterol is considered the first priority for pharmacological therapy of dyslipidemia in diabetes, according to the American Diabetes Association 5
Improved glycemic control is the first priority for triglyceride lowering in diabetic patients, as recommended by the American Diabetes Association 5

Considering combination therapy for patients not reaching goals on monotherapy is recommended by the American Diabetes Association 2
Options include statin plus resin, statin plus niacin, or statin plus fibrate, as recommended by the American Heart Association and the American Diabetes Association 1, 5
Caution: The combination of statins with nicotinic acid or fibrates (especially gemfibrozil) may increase risk of myositis, according to the American Diabetes Association 5

Ruling out secondary causes of hyperlipidemia (liver function test, thyroid-stimulating hormone level, urinalysis) before initiating drug therapy is recommended by the American Heart Association 1
Monitoring for statin-related adverse effects, including myopathy and rhabdomyolysis, particularly in patients over 65 years, those with hypothyroidism or renal impairment, and those on combination therapy, is recommended by the American Diabetes Association 5
Combination of statins with nicotinic acid may worsen hyperglycemia in diabetic patients; use with caution and monitor glucose levels frequently, as recommended by the American Diabetes Association 5
When using combination therapy with statins and fibrates, the risk of myositis is higher with gemfibrozil than with fenofibrate, according to the American Diabetes Association 6