Pharmacist Disease State Guides
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      Dyslipidemia

      Disease State Overview

      Dyslipidemia is characterized by the following lipid abnormalities:  

      • ​High levels of total cholesterol, low-density lipoprotein (LDL), or triglycerides 
      • ​Low levels of high-density lipoprotein (HDL) 
      • ​A combination of these abnormalities.  

      Risk of Condition 

      ​​If left untreated, dyslipidemia can lead to the development of atherosclerotic cardiovascular disease (ASCVD) which includes the following conditions:  

      Atherosclerotic Cardiovascular Disease (ASCVD) Conditions 

      • Acute Coronary Syndrome (ACS)  
        • ​Heart Attack  
        • ​ST-Segment Elevation Myocardial Infarction (STEMI) 
        • ​Non-ST-Segment Elevation (NSTEMI) 
        • ​Unstable Angina 

      • ​Stroke or Transient Ischemic Attack (TIA) 

      • Stable Angina

      • Coronary or other Arterial Revascularization  

        • ​Percutaneous Coronary Intervention (PCI) 
        • ​Coronary Artery Bypass Grafting (CABG) 
      • Peripheral Artery Disease (PAD) 

      Medication 

      Role of Medication 

      Current guidelines published by American College of Cardiology and the American Heart Association (ACC/AHA) provide guidance for the treatment of patients with dyslipidemia, with the mainstay of treatment being statin therapy. Treatment goals are focused on reduction of LDL-C levels and ASCVD risk reduction. Choice of therapy is based on multiple factors including LDL-C levels, concomitant conditions, age, and ASCVD risk. Other factors to consider when selecting the most appropriate medication include medication side effect profile, medication tolerability, insurance coverage, patient preference, and concurrent medications.  

      2019 ACC/AHA Statin Recommendations 

      Statin Use Recommendations

      • High Intensity Statins
        • Patients 20 to 75 years of age with primary severe hypercholesterolemia (LDL-C levels of ≥ 190 mg/dL) 
        • Patients 40 to 75 years of age with diabetes and multiple ASCVD risk enhancers* 
        • Patients with clinical ASVCD (secondary ASCVD prevention
      • Moderate-Intensity Statins
        • Patients 40 to 75 years of age with diabetes (regardless of ASCVD risk) 
        • Patients 40 to 75 years of age with a 10-year ASCVD risk ≥ 7.5% 
      • Low-Intensity Statins
        • Not recommended unless high or moderate intensity statin is not tolerated

      *ASCVD Risk Enhancers: family history of premature ASCVD, persistently elevated LDL-C (>160mg/dL), CKD, metabolic syndrome, preeclampsia, premature menopause, RA, psoriasis HIV, ethnicity (South Asian), persistently elevated triglycerides (>175mg/dL) 

      Statin Intensity Categories

      • High-Intensity Statins
        • LDL-C Lowering
          • 50%
        • Statin Therapy
          • Atorvastatin 40 - 80 mg 
          • Rosuvastatin 20 - 40 mg 
      • Moderate-Intensity Statins
        • LDL-C Lowering
          • 30-49%
        • Statin Therapy
          • Atorvastatin 10 - 20 mg 
          • Rosuvastatin 5 - 10 mg 
          • Simvastatin 20 - 40 mg 
          • Pravastatin 40 - 80 mg 
          • Lovastatin 40 mg 
          • Fluvastatin 40 mg twice daily 
          • Fluvastatin XL 80 mg 
          • Pitavastatin 2 - 4 mg
      • Low-Intensity Statins
        • LDL-C Lowering 
          • <30%
        • Statin Therapy
          • Simvastatin 10 mg  
          • Pravastatin 10–20 mg  
          • Lovastatin 20 mg  
          • Fluvastatin 20–40 mg  
          • Pitavastatin 1 mg 

       

      Alternative Medications 

      While statins remain the preferred treatment for dyslipidemia, other medications may be needed either in place of statins or in conjunction with statin therapy in situations where statins are either not tolerated or LDL-C lowering goals are not achieved with a maximally tolerated statin.  

      • Drug Class: Intestinal Cholesterol Absorption Inhibitor  
        • Drug Names: 
          • Ezetimibe 
        • Place in Therapy
          • Add to maximally tolerated statin in patients with clinical ASCVD (secondary prevention) whose LDL-C remains > 70 mg/dL 
          • Add to maximally tolerated statin in patients 20-75 years with severe dyslipidemia (LDL-C > 190 mg/dL) whose LDC-C remains >100 mg/dL  
          • Reasonable to add to maximum tolerated statin in adults with diabetes and a 10-year ASCVD risk of >20% 
      • Drug Class: PCSK9 Inhibitor 
        • Drug Names:
          • Alirocumab (Praluent)  
          • Evolocumab (Repatha) 
        • Place in Therapy:
          • Add to maximally tolerated statin + ezetimibe in patients with clinical ASCVD (secondary prevention) whole LDL-C > 70 mg/dL 
          • Add to maximally tolerated statin + ezetimibe in patients 30-75 years with severe dyslipidemia (LDL-C > 190 mg/dL) whose LDC-C remains >100 mg/dL 
      • Drug Class: Bile Acid Sequestrants
        • Drug Names: 
          • Cholestyramine  
          • Colesevelam 
          • Colestipol  
        • Place in Therapy:
          • Patients with very severe hypercholesterolemia despite maximally tolerated cholesterol lowering therapy (statin + ezetimibe) who are not eligible for a PCSK9 inhibitor  
      • Drug Class: Omega-3 Fatty Acids
        • Drug Names:
          • DHA ethyl ester (Lovaza)  
          • EPA ethyl ester / Icosapent Ethyl (Vascepa)  
        • Place in Therapy
          • Recommended only in patients with severe hypertriglyceridemia (> 500 mg/dL) to reduce risk of acute pancreatitis 
      • Drug Class: Fibrates
        • Drug Names: 
          • Fenofibrate  
          • Gemfibrozil 
        • Place in Therapy:

          • Recommended only in patients with severe hypertriglyceridemia (> 500 mg/dL) to reduce risk of acute pancreatitis 

            • Note: Fenofibrate is considered safer to use in patients also on a statin due to increased risk of myopathy with gemfibrozil and statins  

      Adherence 

      ​​Medication adherence is an essential component of treating dyslipidemia, especially because non-adherence to medications that treat asymptomatic conditions is common. Discuss barriers to adherence and provide appropriate solutions. You may use the DRAW tool within the Worksheets & Forms category of this Knowledge Base. If a patient is experiencing a side effect that is affecting their adherence, talk with them about other statin options. For additional help discussing statin therapy, review Addressing Barriers to Statin Initiation in the Clinical Resources category.

      ​ 

      Administration 

      ​​Statin medications (e.g. simvastatin and lovastatin) should ideally be taken in the evening for maximal benefit. All other statins can reasonably be taken at any time of day. To minimize risk of non-adherence, patients should be advised to take their statin medication when they can best remember regardless of which statin they are on.  

      ​ 

      ​Patients should be counseled on the interaction with grapefruit juice that may increase the concentrations of CYP3A4 metabolized statins (e.g. simvastatin, lovastatin and atorvastatin).​ 

       

      Monitoring 

      ​​Statin-Associated Muscle Symptoms (SAMS) 

      ​Statin-Associated Muscle Symptoms (SAMS) has been observed in roughly 5% to 20% of patients. Patients should be counseled on this potential risk and dose or dose frequency may need to be adjusted in these patients. SAMS is not a class effect and patients may benefit from trying a different statin. Per guideline recommendations, Coenzyme Q10 is not recommended for routine use in patients who take statins or who have SAMS.  

      ​ 

      ​Statin and Diabetes Risk  

      ​Statins may increase a patient’s risk of getting diabetes in patients at higher risk of developing diabetes. Individuals at higher risk for developing diabetes may benefit from close monitoring of blood glucose after starting a statin Patient’s should be advised that the cardiovascular and mortality benefit of statins outweighs the potential risk of developing diabetes. 

      ​​ 

      Monitoring Frequency & Treatment Goals  

      Lipids should be monitored 4 to 12 weeks after statin initiation or dose adjustment and every 3 to 12 months thereafter to assess medication benefit and adherence to treatment. LDL-C goals are as follows based on indication for use.  

      Primary Prevention

      • Intermediate Risk
        • Lower LCL-C by 30-49% 
      • High Risk
        • Lower LCL-C by  > 50%

      Secondary Prevention

      • Lower LCL-C by > 50% to achieve an LDL-C of < 70 mg/dL 

      Severe Hypercholesterolemia 

      • Lower LCL-C by > 50% to achieve an LDL-C of < 100 mg/dL 

       

      Lifestyle Education 

      Lifestyle modifications are important in the management of dyslipidemia to help lower LDL and raise HDL. Patients should be counseled on appropriate lifestyle changes appropriate for them. Discussion points may include: 

      • Advise patients to follow a healthy diet including vegetables, fruits, whole grains, legumes, healthy proteins, low-fat poultry, and limited sweets and added sugars.  
      • Educate patients to maintain a healthy weight or lose weight if overweight or obese  
      • Encourage patients to engage in regular physical activity  
      • In patients who smoke, recommend smoking cessation and provide counseling on appropriate options and resources  
      • Recommend patient limit alcohol consumption. 

      Additional Points 

      Statins & ASCVD Risk Reduction  

      ​​Consider using the ASCVD Risk Score Calculator to determine a patients 10-year ASCVD risk if they do not already have established ASCVD. This risk estimator will calculate a patient’s risk with and without a statin which can help guide your conversation with patients regarding the importance of statin therapy. ​ 

      ASCVD Risk Score Calculator Link:  http://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate/ 

       

      Statins and Pregnancy:  

      Statins are contraindicated in pregnant females or those who may become pregnant. Statins should be discontinued immediately if pregnancy occurs during treatment. 

       

       

      Resources 

      1. 2017 American Association of Clinical Endocrinologists and American College of Endocrinology Guidelines for Management of Dyslipidemia and Prevention of Cardiovascular Disease. Endocrine Practice. 2017;23(2):: 1-87.
        https://pro.aace.com/pdfs/education/lipid-guidelines.pdf 
      2. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/ APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018;Nov 10. 
        https://www.jacc.org/doi/pdf/10.1016/j.jacc.2018.11.003  
      3. Arnett DK et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019; 140(11): e596-e646. 
        https://www.ahajournals.org/doi/10.1161/CIR.0000000000000678