Management of Elevated Low-Density Lipoprotein (LDL) Cholesterol

Risk Assessment and Treatment Goals

The American College of Cardiology recommends that LDL cholesterol is the primary target for cholesterol-lowering therapy, with goals based on individual cardiovascular risk 1
The American Diabetes Association recommends target LDL levels for adults with diabetes or coronary heart disease (CHD) should be <100 mg/dL (2.60 mmol/L) 3, 4
For very high-risk patients, the American Heart Association suggests an LDL goal of <70 mg/dL is a reasonable therapeutic option 2
For patients with 2+ risk factors but 10-year CHD risk <20%, the American College of Cardiology recommends the LDL goal is <130 mg/dL 1
For patients with 0-1 risk factor, the American College of Cardiology recommends the LDL goal is <160 mg/dL 1
The American Diabetes Association recommends HDL cholesterol goals should be >40 mg/dL (>50 mg/dL for women) and triglycerides <150 mg/dL 3, 4

The American Diabetes Association recommends lifestyle modifications should be initiated first for all patients with elevated LDL cholesterol 3, 1
Dietary recommendations include limiting saturated fat to 7-10% of total calories, limiting dietary cholesterol to 200-300 mg/day, reducing trans-fatty acid intake, considering adding plant stanols/sterols (2 g/day), and increasing viscous (soluble) fiber (10-25 g/day) 5, 1
Regular physical activity should be encouraged to improve lipid profile and reduce cardiovascular risk 3
Weight loss for overweight/obese patients can reduce triglycerides and modestly lower LDL 3, 5

The American Diabetes Association recommends HMG-CoA reductase inhibitors (statins) as the preferred first-line agents for LDL reduction 3, 1, 6
The American Heart Association recommends initiating statin therapy in high-risk patients with LDL ≥100 mg/dL 2, 7
For patients with diabetes and LDL between 100-129 mg/dL, various treatment strategies are available, including more aggressive lifestyle modifications or statin therapy 3, 4
When LDL-lowering drug therapy is employed in high-risk persons, intensity should be sufficient to achieve at least a 30-40% reduction in LDL levels 2

For patients not achieving LDL goals on statins alone, consider adding bile acid binding resins 3, 6
For patients with combined hyperlipidemia (elevated LDL and triglycerides), improved glycemic control plus high-dose statin is first choice 8
Statin plus fibrate (fenofibrate preferred over gemfibrozil due to lower myopathy risk) is recommended for patients with combined hyperlipidemia 9, 6
Statin plus nicotinic acid (with careful monitoring of glycemic control in diabetic patients) is recommended for patients with combined hyperlipidemia 9, 6

Combination therapy with statins and fibrates (especially gemfibrozil) increases risk of myositis; monitor closely 9, 6
Nicotinic acid should be used with caution in patients with diabetes due to potential effects on glycemic control 9
For patients with triglycerides >400 mg/dL, focus on triglyceride lowering first through glycemic control, fibrates, or high-dose statins 8

The American Diabetes Association recommends checking lipid levels every year in adults with diabetes; if at low-risk levels, assessment may be repeated every 2 years 3, 4
After initiating therapy, laboratory follow-up between 4-12 weeks is recommended 9
Once goals are achieved, monitor every 6-12 months 9