Lipid Management Guideline

Introduction to Lipid Management

High-intensity statin therapy is recommended as the first-line approach for lipid management, according to the American College of Cardiology 1
Emphasize diet, exercise, and weight management alongside pharmacotherapy, as recommended by the American Heart Association 2, 1

Ezetimibe 10 mg daily is recommended as the first-line non-statin medication for hyperlipidemia management due to its established safety profile, efficacy, and cardiovascular outcome benefits, as supported by the American College of Cardiology and the American Heart Association 3, 1
Dual therapy with a high-intensity statin + ezetimibe is a recommended combination therapy approach, as supported by the International Lipid Expert Panel (ILEP) 4

The following combination therapy approaches are recommended:

Therapy	Components
Dual therapy	High-intensity statin + ezetimibe
Triple therapy	High-intensity statin + ezetimibe + bempedoic acid
Quadruple therapy	High-intensity statin + ezetimibe + bempedoic acid + PCSK9i/inclisiran

A PCSK9 inhibitor may be considered if there is still an inadequate response to statins and ezetimibe, according to the American College of Cardiology 1
PCSK9 inhibitors, such as those administered via subcutaneous injection every 2-4 weeks, are recommended for patients with very high cardiovascular risk or familial hypercholesterolemia, with a strength of evidence rated as high 3, 1
Bempedoic acid may be beneficial for further LDL-C reduction or if evidence-based agents are contraindicated or not tolerated, but may cause tendon rupture and hyperuricemia, with a recommendation to monitor uric acid levels 1, 5
Bile acid sequestrants, such as colesevelam, cholestyramine, and colestipol, may be considered, but may increase triglycerides and cause vitamin deficiencies, with a strength of evidence rated as low 1, 2

Ezetimibe can be part of combination therapy for homozygous familial hypercholesterolemia (HoFH) 6
For patients with high triglycerides (≥500 mg/dL), fibrates may be considered to reduce pancreatitis risk, while avoiding bile acid sequestrants which may worsen hypertriglyceridemia, with a strength of evidence rated as moderate 1, 7, 2
Omega-3 fatty acids (1g/day) may be reasonable for cardiovascular risk reduction, with a strength of evidence rated as low 2
Referral to a lipid specialist should be considered for patients with ASCVD who fail to achieve adequate LDL-C reduction despite combination therapy 8
Careful evaluation of potential interactions between lipid-lowering therapies and immunosuppressive medications is necessary, with ezetimibe having fewer drug interactions compared to bile acid sequestrants 1

Check lipid panel 4-8 weeks after initiating therapy to assess response, as recommended by the American Heart Association, and monitor more frequently (every 3-6 months) in patients with conditions that may affect lipid metabolism, with a strength of evidence rated as high 5, 1
If LDL-C remains ≥70 mg/dL, add a PCSK9 inhibitor, as recommended by the American College of Cardiology 3, 9, 1