Lipid Management in Patients with Endocrine Disorders

Publication Date: September 18, 2020
Last Updated: March 16, 2022

Assessment

1. Screening and Cardiovascular Disease Risk Assessment

Measurement of Lipids

1.1 In adults with endocrine disorders, we recommend a lipid panel for the assessment of TG levels and for calculating LDL-C. Technical Remarks:
  • Non-fasting lipid panels are acceptable for initial screening.
  • If TG levels are elevated or if genetic dyslipidemia is suspected, repeat a fasting lipid panel.
  • If lipoprotein(a) [Lp(a)] levels are measured, fasting or non-fasting samples can be obtained.
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CV Risk Assessment

1.2 In adults with endocrine disorders, we recommend conducting a CV risk assessment by evaluating traditional risk factors, including calculation of 10-year ASCVD risk using a tool such as the Pooled Cohort Equations. ()
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1.3 In adults with endocrine disorders at borderline or intermediate risk (10-year ASCVD risk 5%–19.9%), particularly those with additional risk-enhancing factors, in whom the decision about statin treatment and/or other preventive interventions is uncertain, we suggest measuring coronary artery calcium (CAC) to inform shared decision-making. ()

Technical Remarks:

  • Borderline and intermediate CV risk are defined as 5%–7.4% and 7.5%–19.9% 10-year ASCVD risk using the Pooled Cohort Equations.
  • Risk enhancing factors are additional features, including diseases, that enhance the risk of ASCVD beyond the risk associated with major risk factors and/or the calculated 10-year risk of ASCVD.
  • In patients with additional risk-enhancing factors, including elevated Lp(a) as described below, risk assessment should consider traditional 10-year ASCVD risk assessment and the presence of risk-enhancing factors. The CAC score should be considered when risk assessment and treatment decisions remain uncertain.
  • At present we suggest measuring CAC as the preferred tool for assessment of subclinical atherosclerosis. Other techniques to assess atherosclerotic burden are being developed.
  • CAC=0 marks very low risk of ASCVD. In patients with baseline CAC=0, evidence suggests that it is reasonable to repeat a CAC scan after 5–7 years in low risk patients, 3–5 years in borderline to intermediate risk patients, and in 3 years for high risk patients or those with diabetes.
  • In patients without diabetes or ASCVD and with LDL >70 mg/dL (1.8 mmol/L), and 10 year ASCVD risk, >7.5%, or 10 year ASCVD risk 5–7.4% plus one or more risk enhancing factors, or CAC score over the 75th percentile for age, sex, and race, or CAC score >100, the initiation of a statin, as adjunct to diet and exercise, is advised after a discussion of the risk/benefit with the patient.
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1.4 In adult patients with a family history of premature ASCVD, or a personal history of ASCVD or family history of high Lp(a), we suggest measuring Lp(a) to inform decision making about short-term and lifetime ASCVD risk and the need to intensify LDL-C–lowering therapy.
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Technical Remarks:

  • Lp(a) ≥50 mg/dL (125 nmol/L) enhances risk of ASCVD.
  • Lp(a) testing does not need to be repeated if it has previously been measured (i.e., in childhood or early adulthood).
  • It is not yet known whether reducing Lp(a) reduces ASCVD risk.
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Hypertriglyceridemia

2. Hypertriglyceridemia

2.1 In adults with fasting TG levels over 500 mg/dL (5.6 mmol/L), we recommend pharmacologic treatment as adjunct to diet and exercise to prevent pancreatitis. ()

Technical Remark:

  • Patients with TG levels over 1000 mg/dL (11.3 mmol/L) often do not get an adequate response to medications and therefore, control of diabetes, modification of diet, and weight loss are essential.
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In patients with triglyceride-induced pancreatitis, we suggest against the use of acute plasmapheresis as first-line therapy to reduce triglyceride levels. ()

Technical Remark:

  • Plasmapheresis may be useful in those who do not respond to conventional methods of lowering TG such as individuals who have extraordinarily elevated TG levels (e.g., over 10,000 mg/dL [112.9 mmol/L]) or in extremely high-risk situations such as pregnancy.
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2.3 In patients without diabetes who have TG-induced pancreatitis, we suggest against the routine use of insulin infusion. ()

Technical Remark:

  • When uncontrolled diabetes is present, insulin therapy should be used to normalize glucose levels.
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2.4 In adults who are on statins and still have moderately elevated TG levels >150 mg/dL (1.7 mmol/L), and who have either ASCVD or diabetes plus two additional risk factors, we suggest adding eicosapentaenoic acid (EPA) ethyl ester to reduce the risk of CVD. ()

Technical Remarks:

  • Risk factors include traditional risk factors and risk-enhancing factors.
  • The dose of EPA ethyl ester is 4 gms/day.
  • If EPA ethyl ester is not available or accessible, then it is reasonable to consider a fibrate.
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2.5 In patients with elevated TG (>150 mg/dL to 499 mg/dL [1.7 mmol/L to 5.6 mmol/L]), we suggest checking TG before and after starting a bile acid sequestrant. ()

Technical Remark:

  • Bile acid sequestrants are contraindicated when TG are above 500 mg/dL (5.6 mmol/L).
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Overview

Title

Lipid Management in Patients with Endocrine Disorders

Authoring Organization

Endocrine Society