A new algorithm on lipid management and prevention of cardiovascular disease from the American Association of Clinical Endocrinologists* (AACE) and the American College of Endocrinology (ACE) is “a nice cookbook” that many clinicians, especially those who are not lipid experts, will find useful, according to writing committee chair Yehuda Handelsman, MD.
Dr. Yehuda Handelsman
The algorithm, published Oct. 10 in Endocrine Practice as 10 slides, or as part of a more detailed consensus statement, is a companion to the 2017 AACE/ACE guidelines for lipid management and includes more recent information about new therapies.
“What we’re trying to do here is to say, ‘focus on LDL-C, triglycerides, high-risk patients, and lifestyle. Understand all the medications available to you to reduce LDL-C and reduce triglycerides,’ ” Dr. Handelsman, of the Metabolic Institute of America, Tarzana, Calif., explained in an interview.
“We touch on lipoprotein(a), which we still don’t have medication for, but it identifies people at high risk, and we need that.”
Clinicians also need to know “that we’ve got some newer drugs in the market that can manage people who have statin intolerance,” Dr. Handelsman added.
“We introduced new therapies like icosapent ethyl” (Vascepa, Amarin) for hypertriglyceridemia, “when to use it, and how to use it. Even though it was not part of the 2017 guideline, we gave recommendations based on current data in the algorithm.”
Although there is no good evidence that lowering triglycerides reduces heart disease, he continued, many experts believe that the target triglyceride level should be less than 150 mg/dL, and the algorithm explains how to treat to this goal.
“Last, and most importantly, I cannot fail to underscore the fact that lifestyle is very important,” he emphasized.
Robert H. Eckel, MD, of the University of Colorado at Denver, Aurora, and president of medicine and science at the American Diabetes Association, who was not involved with this algorithm, said in an interview that the algorithm is important since it offers “the clinician or health care practitioner an approach, a kind of a cookbook or application of the guidelines, for how to manage lipid disorders in patients at risk ... It’s geared for the nonexperts too,” he said.
Dr. Robert H. Eckel
Dyslipidemia treatment summarized in 10 slides
The AACE/ACE algorithm comprises 10 slides, one each for dyslipidemic states, secondary causes of lipid disorders, screening for and assessing lipid disorders and atherosclerotic CVD (ASCVD) risk, ASCVD risk categories and treatment goals, lifestyle recommendations, treating LDL-C to goal, managing statin intolerance and safety, management of hypertriglyceridemia and the role of icosapent ethyl, assessment and management of elevated lipoprotein(a), and profiles of medications for dyslipidemia.
The algorithm defines five ASCVD risk categories and recommends increasingly lower LDL-C, non–HDL-C, and apo B target levels with increasing risk, but the same triglyceride target for all.
First, “treatment of lipid disorders begins with lifestyle therapy to improve nutrition, physical activity, weight, and other factors that affect lipids,” the consensus statement authors stress.
Next, “LDL-C has been, and remains, the main focus of efforts to improve lipid profiles in individuals at risk for ASCVD” (see table).
“We stratify [LDL-C] not as a one-treatment-target-for-all,” but rather as extreme, very high, high, moderate, and low ASCVD risk, Dr. Handelsman explained, with different treatment pathways (specified in another slide) to reach different risk-dependent goals.
“Unlike the ACC [American College of Cardiology] guideline, which shows if you want to further reduce LDL after statin give ezetimibe first, we say ‘no’,” he noted. “If somebody has an extreme risk, and you don’t think ezetimibe will get to a goal below 55 mg/dL, you should go first with a PCSK9 [proprotein convertase subtilisin/kexin type 9] inhibitor, and only then add ezetimibe or [colesevelam] or other drugs,” he said.
The consensus statement authors expand on this scenario. “Treatment for patients at extreme risk should begin with lifestyle therapy plus a high-intensity statin (atorvastatin 40 to 80 mg or rosuvastatin 20 to 40 mg, or the highest tolerated statin dose) to achieve an LDL-C goal of less than 55 mg/dL.”
“If LDL-C remains above goal after 3 months,” a PCSK9 inhibitor (evolocumab [Repatha, Amgen] or alirocumab [Praluent, Sanofi/Regeneron]), the cholesterol absorption inhibitor ezetimibe, or the bile acid sequestrant colesevelam (Welchol, Daiichi Sankyo) or the adenosine triphosphate-citrate lyase (ACL) inhibitor bempedoic acid (Nexletol, Esperion) “should be added, depending on required LDL-C lowering, and a third agent should be added if the combination fails to achieve the goal.”
However, “because the cost of ezetimibe is low, it may be preferred over PCSK9 inhibitors as second-line therapy to achieve an LDL-C below 70 mg/dL for patients who require no more than 15%-20% further reduction to reach goals.”
For patients at moderate or high risk, lipid management should begin with a moderate-intensity statin and be increased to a high-intensity statin before adding a second lipid-lowering medication to reach an LDL-C below 100 mg/dL.
According to the consensus statement, the desirable goal for triglycerides is less than 150 mg/dL.
In all patients with triglyceride levels of at least 500 mg/dL, statin therapy should be combined with a fibrate, prescription-grade omega-3 fatty acid, and/or niacin to reduce triglycerides.
In any patient with established ASCVD or diabetes with at least 2 ASCVD risk factors and triglycerides of 135-499 mg/dL, icosapent ethyl should be added to a statin to prevent ASCVD events.