Dyslipidemia “High Cholesterol”
Fats (lipids) are carried in bloodstream in two forms: as cholesterol and triglycerides. We know that high levels of “bad” (LDL) cholesterol and triglycerides are associated with build up of fatty deposits inside our arteries, leading to blockage of blood flow and leading serious cardiovascular outcomes, such as heart attacks, stroke, kidney failure, problems in circulation etc. Importantly, taking steps to reduce these high levels can reduce the chances of bad outcomes. Interestingly, the “good” (HDL) cholesterol actually can do the opposite and help remove some of the fat build up and improve outcomes. Because of this knowledge specialists have focused over past several decades on figuring out how to help patients to achieve desired blood levels of these different fats. Endocrinologists are trained to diagnose and treat disorders of lipid metabolism.
The most recent (2020) update of guidelines by American Association of Clinical Endocrinologists (AACE) for the management of dyslipidemia to prevent atherosclerotic cardiovascular disease (ASCVD) have comprehensively classified benefits and risks of treatments based on a personalized approach. The target lipid levels depend on individual person’s risks for heart attacks and stroke: for example, the higher risk category the lower the target levels for “bad” cholesterol are.
Risk factors taken into consideration include family history, age, high blood pressure, diabetes, obesity, smoking, thyroid disease, chronic kidney disease, chronic inflammatory disease, medications, etc. This makes it more complex in making correct decisions leading to appropriate therapeutic regimens.
The first line recommendation consists of lifestyle modifications such as healthy eating leading to weight loss, increased physical activity, and smoking cessation. If unable to achieve the established goals, then adding medications with favorable efficacy vs. side effect risk for the specific problem (high LDL-cholesterol, high triglycerides or both) should be considered. Statins (HMG-CoA reductase inhibitors) have become mainstay medications since they are not only effective at lowering “bad” cholesterol but also have been shown in numerous studies to lead to reduction in cardiovascular events (heart attacks, stroke) in a wide range of populations. Some patients cannot tolerate statins but there are a number of additional FDA-approved therapeutic options to get to the target. Results of multiple clinical trials support the use of or the addition to statins of ezetimibe, PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitors, colesevelam (bile acid sequestrant), bempedoic acid (adenosine triphosphate citrate lyase inhibitor), fenofibrates, niacin/nicotinic acid, and prescription grade omega-3 fatty acid. These medications can be recommended alone or in combination once a patient’s risk for cardiovascular disease events is established. Options for any therapeutics in light of their expected benefits vs. potential risks are then always discussed with the patient.
As specialists in disorders of lipid metabolism, at GDI we have the necessary expertise to establish the diagnosis and risk category to provide a guide to the most effective therapeutic regimen. Indeed, one of us (Dr. George Grunberger) has been an author of the national guidelines and algorithms on dyslipidemia for AACE for many years.
For patients with diabetes, the first-line treatment of hypertension after lifestyle modification is usually a medication from one of the classes known as ACE inhibitors (those ending in “-pril”) or ARBs (those ending in “-sartan”) – because they can also protect the kidneys. If the blood pressure still does not meet the recommended goal adding a beta blocker (ending in “-olol”), a calcium channel blocker (ending in “-ipine”) or a diuretic (such as hydrochlorothiazide or chlorthalidone) until the blood pressure goal is reached is advised. If the initial blood pressure exceeds 150/100 mmHg, two classes of medications are recommended as the initial treatment. The order in which these medications are added is not as important as making sure blood pressure goal is achieved.