Lipid Management in Patients with Endocrine Disorders

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.

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.

Technical Remark:

• When uncontrolled diabetes is present, insulin therapy should be used to normalize glucose levels.

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.

Technical Remark:

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

Technical Remarks:

• High intensity statins should be chosen in patients with ASCVD or those with risk factors for ASCVD or risk enhancing factors.
• Statins should not be used in women who are pregnant or trying to become pregnant.
• In patients over the age of 75, continuation of statin treatment or initiation of statin treatment depends upon ASCVD risk, prognosis, potential interacting medications, polypharmacy, mental health and the wishes of the patient.

Technical Remarks:

• A statin should be added to lifestyle modifications if LDL-C is >70 mg/dL (1.8 mmol/L).
• LDL-C should be <55 mg/dL(1.4 mmol/L) in patients with established CVD or multiple risk factors.
• Additional LDL-lowering therapy (ezetimibe, proprotein convertase subtilisin/kexin type 9 inhibitor [PCSK9]) may be needed if the LDL-C goal is not reached with statins.
• Risk factors include traditional risk factors and risk-enhancing factors.

Technical Remarks:

• Consider 4 g/d of EPA ethyl ester.
• If EPA ethyl ester is not available or accessible, then it is reasonable to consider a fibrate such as fenofibrate.

Technical Remarks:

• When selecting the statin, consider the renal clearance of the statin. Pitavastatin, pravastatin and rosuvastatin all have at least partial clearance through the kidney whereas atorvastatin, fluvastatin, lovastatin, and simvastatin are cleared via the liver.
• All statins require dose adjustments in CKD except for atorvastatin and fluvastatin.

Technical Remarks:

• This recommendation applies regardless of TG levels.
• The preferred fibrate is fenofibrate.

Technical Remarks:

• LDL should be the primary target for lipid-lowering therapy.
• Consider therapy if LDL is over 70 mg/dl (1.8 mmol/L).
• Statins should not be used in women who are pregnant or trying to become pregnant.

Technical Remarks:

• LDL should be the primary target for lipid-lowering therapy.
• Consider therapy if LDL is over 70 mg/dL (1.8 mmol/L).
• When selecting the statin, consider the renal clearance of the statin: Pitavastatin, pravastatin and rosuvastatin all have at least partial clearance through the kidney whereas atorvastatin, fluvastatin, lovastatin, and simvastatin are cleared via the liver.
• All statins require dose adjustments in CKD except for atorvastatin and fluvastatin.

Technical Remarks:

• LDL should be the primary target for lipid-lowering therapy.
• Consider therapy if LDL is over 70 mg/dL (1.8 mmol/L).

Technical Remarks:

• LDL should be the primary target.
• Consider therapy if LDL-C is over 70 mg/dL (1.8 mmol/L).

Technical Remarks:

• Diagnosis of MetS requires the presence of three of the following criteria:
  • Elevated TGElevated TGElevated TGElevated TGElevated TGElevated TGElevated TGElevated TG ≥150 mg/dL (1.7 mmol/L) or on TG-lowering medication
  • Reduced HDL-C <50 mg/dL (1.3 mmol/L) in women and <40 mg/dL (1.0 mmol/L) in men.
  • Systolic blood pressure ≥ 130 mm Hg or diastolic blood pressure ≥85 mm Hg or on blood pressure medication.
  • Elevated waist circumference (men ≥40 in [102 cm] and women ≥35 in [88 cm]), except for East and South Asian men ≥35 in (90 cm) and women ≥31.5 in (80 cm).
  • Hyperglycemia (but not yet with T2D) is defined by cutoffs for prediabetes according to fasting blood glucose, oral glucose tolerance and/or HbA1c.
• Body fat distribution can be assessed in clinical practice by measuring the waist size or the waist/hip ratio.
• Waist size measurement in people with body mass index greater than 35 kg/m² has potential limitations.

Technical Remarks:

• Reductions in LDL-C and increases in HDL-C are modest compared to the decrease in TG with lifestyle measures that produce weight loss.
• Lifestyle therapy-induced changes in the lipid profile in obesity have not been shown to reduce CVD events.

Technical Remarks:

• Calculation of 10-year risk for ASCVD may be done using the Pooled Cohort Equations.
• Elevated LDL-C is predictive of CV risk.

Technical Remark:

• As there are no data on the timing of lipid measurements after weight loss, we suggest reassessment of lipids after 5% weight loss and periodically thereafter and when the weight is stable.

Technical Remarks:

• Malabsorptive bariatric surgery procedures (e.g., Roux-en-Y gastric bypass) are more effective than restrictive procedures (e.g., banding, sleeve gastrectomy) in decreasing LDL-C levels.
• Both restrictive and malabsorptive procedures decrease TG.
• Reassess lipid profile 1 to 3 months after bariatric surgery and periodically thereafter and when the weight is stable.

Technical Remark:

• Hypothyroidism can elevate both cholesterol and TG levels, which improve with treatment.

Technical Remark:

• Changes in LDL-C have been observed as early as 3 months after the patient is euthyroid.

Technical Remark:

• Take into consideration the patient’s age and general health, the possibility of suppression of thyroid-stimulating hormone, and whether the patient has CVD.

Technical Remarks:

• Hormone therapy is a risk factor for increased CVD.
• Hormone therapy is described as estrogen +/– progesterone/a progestin.

Technical Remarks:

• Hormone therapy is a risk factor for increased CVD.
• Hormone therapy is described as estrogen +/– progesterone/a progestin.
• Menopause may be associated with an increase in LDL-C and a decrease in HDL-C.
• Risk factors may be traditional risk factors or risk-enhancing factors.

Technical Remarks:

• Early menopause enhances CVD risk.
• ASCVD risk should be calculated and followed after menopause.

Technical Remark: Supraphysiological doses of androgens will reduce HDL-C levels.