Selecting a Treatment Regimen Step 4: Clinical Intervention (if not a goal)
ÎTherapeutic life-style changes, advocated for all patients, has been shown to significantly reduce atherogenic lipoprotein and TG levels, resulting in decreased need for lipid altering medications.
• American Heart Association recommends reductions in the intake of added sugars. A prudent upper limit of intake is half of the discretionary calorie allowance, which for most American women is no more than 100 calories per day and for most American men is no more than 150 calories per day from added sugars.
• Therapeutic options for enhancing LDL-C lowering include plant stanol (2 g/day), and increased viscous (soluble) fiber (10-25 g/day). If plant sterols are used, monitor phytosterol levels.24
• Reduce trans fats. • There is very little if any relationship between cholesterol in the diet and atherosclerosis, calling into question whether cholesterol intake needs to be restricted.
• Weight reduction. • Increased physical activity.
ÎPharmacologic therapy if goals not achieved.
• First priority: LDL lowering. ▶ Achieving LDL particle number, apoB or non-HDL-C targets: Lipid altering therapies have well-characterized effects on LDL particle number, apoB, non-HDL-C and TG (Tables 7A and 7B). Combination therapy strategies are frequently needed to achieve these targets (Table 8).
• Second priority: Manage TG. ▶ In those patients with TG values > 500 mg/dL, reduce TG to < 500 mg/dL using lifestlye, glycemic control, and pharmacologic therapy as indicated (Table 7).
▶ In patients with TG elevation < 500 mg/dL primary attention should be paid to achieving LDL particle number (measured ApoB or NMR LDL-P) goals. If LDL particle number testing is not available, achieve non-HDL-C goals of therapy.
ÎAchieving LDL-C targets: When drug therapy is considered, begin with a statin dose estimated to achieve LDL-C goal (Table 6).
• Statin doses that lower LDL (apoB, non-HDL-C) levels by 30% to 40% may provide a similar percentage reduction in CHD risk over 5 years (standard doses).7
• Similar reductions can be achieved by combining lower doses of statins with bile acid sequestrants, nicotinic acid, ezetimibe, or plant stanol.
• Fibrates or nicotinic acid can be considered in patients with dyslipoproteinemia with elevated TG and low HDL-C in combination with, statins. Notes: Fibrates do not increase LDL-P lowering beyond that achieved with statin but do reduce remnants and raise total HDL-P. Niacin does reduce LDL-P beyond what a statin does, but does not increase total HDL-P.
• If LDL (apoB), non-HDL-C goal is not achieved, increase statin dose or add nicotinic acid or ezetimibe or bile acid sequestrant.
12 • If goal is not achieved after 12 weeks, intensify therapy or refer to a lipidologist.
