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The choice of the lipid-lowering agent depends on the pattern of the lipid disorder.5,6 See TABLE 87.4. Use the following agents in addition to diet.
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Treatment should commence with a statin. If LDL-C levels are not reduced to target levels or a maximally tolerated dose on a statin, add one of ezetimibe,5,8 bile acid binding resin or nicotinic acid. These agents can be used as monotherapy if statins cannot be tolerated.
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Hypercholesterolaemia especially ↑ LDL-C
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Choose from the following.6,9
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HMG-CoA reductase inhibitors (statins—see TABLE 87.4): supported by evidence but be cautious in patients with muscle or hepatobiliary disease. Typical reduction is 30–50%.9
adverse effects: GIT side effects, myalgia, abnormal liver function (uncommon)
monitor: measure LFTs (ALT and CPK) and CK as baseline
repeat LFTs after 4–8 weeks. It is no longer recommended to continue to monitor these unless patient becomes symptomatic.5
Additional drug therapy (options):
Ezetimibe 10 mg daily (especially if statin-intolerant). Reduces LDL by about 18%.9
Combination: ezetimibe + statin (consider if cholesterol above target)8
Bile acid binding resins (typically reduce LDL by 15–24%):
e.g. cholestyramine 4 g daily in fruit juice increasing to maximum tolerated dose (often poorly tolerated)
adverse effects: GIT side effects (e.g. constipation, offensive wind)
Fibrates: consider if above drugs not tolerated (e.g. fenofibrate 145 mg (o) daily—special care with renal impairment)
Nicotinic acid
nicotinic acid 250 mg (o) bd with food daily, increase gradually to max. 1000 mg tds if necessary (effective lipid reduction)
adverse effects: flushing (common), gastric irritation, gout
minimise side effects with gradual introduction; take with food
Evolocumab: a new monoclonal antibody agent for familial hypercholestoerolaemia and muscle-related statin intolerance10
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Resistant LDL-C elevation
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Combination statin + ezetimibe
Combined statin and resin
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Moderate to severe (isolated or predominant) TG elevation6
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Note: Slow response; monitor LFTs; predisposes to gallstones and myopathy
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Note: Reduction in alcohol intake is important.
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Massive hypertriglyceridaemia (TG) 10 mmol/L:
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Mixed hyperlipidaemia (↑ TG + ↑ LDL-C)
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If TG <4: a statin
If TG >4: a fibrate
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Consider combination therapy, e.g.:
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fish oil + statin
fibrate + resin
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Note: Statin + gemfibrozil increases risk of myopathy and should ideally be avoided.
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Familial hypercholesterolaemia11
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This is a dominant inherited condition causing accelerated cardiovascular disease by 20–40 years. Diagnosis requires exclusion of secondary causes, e.g. nephrotic syndrome. Refer to Dutch lipid diagnostic criteria.11