III. Management: General Measures

  1. See Low Fat Diet
  2. Aerobic Exercise for at least 120 minutes per week (900 kcal expended per week)
    1. Raises HDL Cholesterol linearly with cummulative amount of aerobic Exercise
    2. Lowers Total Cholesterol 3.9%, LDL Cholesterol 3.9% and serum Triglycerides 7.1%
    3. Halbert (1999) Eur J Clin Nutr 53(7):514-22 [PubMed] (or open in [QxMD Read])
  3. Weight loss in Obesity (11 kg or 24 lb)
    1. Lowers LDL 10%, Triglycerides 24%, raises HDL 8%
    2. Katzel (1995) Metabolism 44:307-14 [PubMed] (or open in [QxMD Read])

IV. Management: Approach (ACC/AHA 2013)

  1. ACC/AHA Guidelines as of 2013 changes
    1. Statins are the preferred AntiHyperlipidemic and combinations are not recommended in most cases
    2. Patients are risk stratified to high or low risk Statin dose without the chasing of specific LDL Cholesterol goals
    3. Framingham calculator is replaced with a new 10 year cardiovascular risk calculator to help risk stratify (including Statin dosing)
  2. High Intensity Protocol (with goal LDL Cholesterol decrease of >50%)
    1. Indications
      1. LDL Cholesterol > 190 mg/dl or
      2. Known cardiovascular disease or other serious risk factors or
      3. Diabetes Mellitus and age >40-50 years old (especially if 10 year cardiovascular risk >7.5%)
    2. Preparations
      1. Atorvastatin (Lipitor) 40-80 mg daily
      2. Rosuvastatin (Crestor) 20-40 mg daily
  3. Moderate Intensity Protocol (with goal LDL Cholesterol decrease of >50%)
    1. Indications
      1. 10 year cardiovascular risk >7.5% or
      2. Diabetes Mellitus and age <40-50 years old (especially if 10 year cardiovascular risk <7.5%)
      3. Age over 75 years old (or may continue on high intensity protocol if tolerating without adverse effects)
    2. Preparations (with goal LDL Cholesterol decrease of >50%)
      1. Atorvastatin (Lipitor) 10-20 mg daily
      2. Rosuvastatin (Crestor) 5-10 mg daily
      3. Simvastatin (Zocor) 20-40 mg daily
      4. Pravastatin (Pravachol) 40-80 mg daily
      5. Lovastatin (Mevacor) 40 mg daily
      6. Fluvastatin (Lescol) 80 mg daily
      7. Pitavastatin (Livalo) 2-4 mg daily
  4. References
    1. (2014) Presc Lett 21(1): 1-2

V. Management: Approach - Older

  1. General
    1. Guidelines push for lower LDL Cholesterol
      1. LDL Cholesterol <70 mg/dl in coronary disease and Diabetes Mellitus
      2. Guidelines updated in 2014 to risk stratify to high intensity or low intensity management as above
    2. Guidelines may require high dose
      1. Most potent agents: Zocor, Lipitor, Crestor
        1. Doubling dose lowers LDL Cholesterol 6%
      2. Guidelines of 2014 de-emphasize adding other agents to Statins (due to lack of efficacy)
        1. Agents typically combined with Statins: Niacin, Cholestyramine, zetia
        2. Lowers LDL Cholesterol additional 10-15%
        3. However neither Zetia or Niacin have shown added benefit beyond Statin alone
    3. Old age should not be a sole reason to not prescribe a Statin
      1. Statins are associated with a 30% reduction in cardiovascular events
      2. If a patient is considered a candidate for revascularization, they should be a candidate for Statin use
    4. References
      1. (2004) Prescriber's Letter 11(8):43
      2. Kopecky (2012) Mayo POIM, Rochester
  2. Serum Triglyceride <150 mg/dl (Primarily LDL Disorder)
    1. First-line
      1. HMG-CoA Reductase Inhibitors (Statins) are the mainstays of therapy
    2. Second-line agents (not recommended as of 2013 ACC/AHA guidelines)
      1. Second: Niacin or Ezitimibe
        1. However neither has been shown to improve outcomes over Statin alone
      2. Third: Bile Binding Resin (Cholestyramine)
        1. Consider adding Colesevelam (Welchol) in Diabetes Mellitus
    3. Adjunctive agents
      1. Plant Sterols and stanols
  3. Serum Triglyceride 150 to 400-500 mg/dl (Mixed lipid disorder)
    1. First-line
      1. HMG-CoA Reductase Inhibitors (Statins) are the mainstays of therapy
    2. Second-line agents (not recommended as of 2014 ACC/AHA guidelines)
      1. Second: Niacin (not recommended as of 2014 ACC/AHA guidelines)
      2. Third: Cholesterol absorption inhibitor (Ezitimibe)
      3. As noted above, neither Niacin nor Ezetimibe have been shown to improve outcomes over Statin alone
  4. Serum Triglyceride >400-500 mg/dl: See Hypertriglyceridemia
    1. HMG-CoA Reductase Inhibitors (Statins) are still the mainstays of therapy
    2. Some specific Triglyceride management agents may be used with Statins with caution (due to Rhabdomyolysis risk)
      1. Tricor may be used with Statins with caution
      2. Do not use Gemfibrozil with Statins
      3. Nicotinic Acid (Niacin) may be used with Statins with caution (however see lack of efficacy data above)
    3. Adjuncts
      1. Fish oil
  5. Coronary Artery Disease Prevention
    1. HMG-CoA Reductase Inhibitor (Statin)
  6. Medication not recommended if only HDL Cholesterol low
    1. Raise HDL Cholesterol with non-medication measures
    2. Focus medication use on lowering LDL Cholesterol
    3. Birjmohun (2005) J Am Coll Cardiol 45:185-97 [PubMed] (or open in [QxMD Read])
  7. Hyperlipidemia in age over 65 years
    1. Low HDL increases MI risk in age over 65 years
    2. Other Hyperlipidemia does not predict MI risk age >65
    3. Psaty (2004) J Am Geriatr Soc 52:1639-47 [PubMed] (or open in [QxMD Read])

VI. Management: Adjuvant Therapy

  1. Garlic
    1. Stevinson (2000) Ann Intern Med 133:420-9 [PubMed] (or open in [QxMD Read])
  2. Plant Sterols and stanols (e.g. Benecol, Promise Activ)
    1. Dose 2 grams daily lowers LDL by 10%
  3. Fish oils (Omega-3 Fatty Acids)
    1. Lowers Triglycerides (4%: 1 g/day, 10-40%: 2-4g/day)
    2. Unfortunately raises LDL Cholesterol 5-10%
    3. Marginal effect on HDL Cholesterol
  4. Soluble Dietary Fiber
    1. Lowers LDL Cholesterol 7% for 10 grams of fiber
    2. Sources
      1. Psyllium, Barley, Beans
      2. Oat bran (e.g. cheerios, oatmeal)
    3. Brown (1999) Am J Clin Nutr 69:30-42 [PubMed] (or open in [QxMD Read])
  5. Dietary Soy Proteins 25 grams per day (4% lowering)
    1. Anderson (1995) N Engl J Med 333:276-82 [PubMed] (or open in [QxMD Read])
  6. Unsaturated fat nuts (pistachios, almonds)
  7. Glucophage (Metformin)
  8. Rosiglitazone or Pioglitazone
  9. Orlistat (Xenical)
  10. Policosanol (sugar cane derivative)
  11. Red-yeast rice
    1. Contains natural HMG-CoA reductase agent
    2. Currently unregulated and dose not standardized
    3. Not recommended until standardized dosing available
    4. May be an alternative for patients not tolerant to Statin medications
      1. Example Monocolin K 5-10 mg daily
  12. Lactobacillus reuteri (Cardioviva)
    1. Probiotic may decrease fat and Cholesterol gastrointestinal absorption
    2. May lower LDL 10% (similar effect to fiber, Benecol)
    3. Jones (2012) Eur J Clin Nutr 66: 1234-41 [PubMed] (or open in [QxMD Read])

VII. Management: Measures that are not effective (not recommended)

  1. Estrogen Replacement Therapy
    1. No longer recommended for CAD prevention
    2. Recent studies suggest increased cardiovascular risk
      1. See Hormone Replacement for details
    3. Lipid effects
      1. LDL lowered (15%)
      2. HDL raised (15%)
      3. Triglycerides
        1. Raised: Oral Estrogen Replacement (considerably)
        2. No effect: Transdermal Estrogen
  2. Antioxidants do not affect lipid levels
    1. No benefit with Vitamin E, C, Beta Carotene, Selenium
    2. Brown (2001) N Engl J Med 345:1583-92 [PubMed] (or open in [QxMD Read])

VIII. Management: Combination Regimens

  1. General
    1. Combination regimens can lower LDL 40-50%
  2. Combinations without risk
    1. HMG-CoA Reductase Inhibitors and Bile Binding Resin
    2. HMG-CoA Reductase Inhibitors and Ezetimibe (Zetia)
      1. Early studies suggest benefit with low toxicity
      2. Allows lipid control at lower Statin dose
  3. Combinations to use with caution
    1. Statin and Nicotinic Acid (Niacin)
      1. Risk of Myopathy, Hepatitis And Rhabdomyolysis
      2. Zocor + Niacin lowered LDL 42% and raised HDL 26%
      3. Brown (2001) N Engl J Med 345:1583-92 [PubMed] (or open in [QxMD Read])
    2. Advicor (Niacin and Lovastatin)
      1. Appears relatively safe and well tolerated
        1. Limited Myopathy and hepatitis risk
      2. Efficacy
        1. Lowers LDL up to 32-47%
        2. Lowers Triglycerides 24-45%
        3. Raises HDL 18-40%
  4. Contraindicated combinations
    1. Statin and Gemfibrozil (Lopid)
      1. Risk of severe Myopathy and Rhabdomyolysis
      2. Fenofibrate appears safer with Statins

Images: Related links to external sites (from Google)

Ontology: Antilipemic agent (C0003367)

Definition (CSP) agent that promotes a reduction of lipoprotein levels in the blood.
Concepts Pharmacologic Substance (T121)
MSH D000960
SnomedCT 57952007, 373267003
English antihyperlipoproteinemic agent, Antilipemic agents, ANTILIPEMIC AGENTS, Antilipemic agent, NOS, antihyperlipemic, antihyperlipemics, antihyperlipemics (medication), 806 ANTILIPEMIC AGENTS, [CV350] ANTILIPEMIC AGENTS, Lipid lowering agents, antilipemic, antilipemic agent, lower lipid drug, antilipemic drugs, drug lipid lowering, antihyperlipidemics, drugs lipid lowering, agents lipid lowering, antilipemic agents, lipid lowering agent, antilipemics, antihyperlipidemic, lipid lowering drug, Antilipemic agent, Lipid lowering drug, Lipid lowering agent, Antilipaemic agent, Antilipemic agent (product), Antilipemic agent (substance)
Swedish Lipidsänkande medel
Finnish Hyperlipidemialääkkeet
Spanish agente hipolipemiante (producto), agente hipolipemiante (sustancia), agente hipolipemiante