Treatment

• Encourage all patients to make lifestyle modifications

• Initiate pharmacologic therapy based on the patient's age, LDL level, and ASCVD risk.

  • Statins: first-line

  • Nonstatin lipid-lowering agents: may be added to statins if treatment goals are not met.

    • If treatment goals are not reached with maximally tolerated statin treatment, consider adding ezetimibe.

    • If goals are still not reached, a bile-acid sequestrant or PCSK9 inhibitor may be added.

• Patients with familial lipid disorders

  • Consider specialist referral.

  • Treatment should involve lifestyle modifications and pharmacologic therapy with individualized treatment goals.

• Xanthomas and xanthelasmas can be treated for cosmetic reasons, but recurrence is common.

The goal of treatment is to reduce the risk of cardiovascular diseases. Therefore, the decision to treat hypercholesterolemia should be based on a patient's 10-year ASCVD risk.

In severe hypercholesterolemia (LDL ≥ 190 mg/dL) that is not adequately controlled with medical therapy, LDL apheresis may be used in consultation with a lipid specialist.

Indications for treatment

• Patients ≥ 20 years of age with clinical ASCVD: Consider high-intensity statin therapy.

• Patients 20–75 years of age and LDL ≥ 190 mg/dL: high-intensity statin therapy

• Patients 40–75 years of age and LDL 70–189 mg/dL: Treatment is based on the 10-year ASCVD risk.

  • High (≥ 20%): high-intensity statin therapy

  • Borderline to intermediate (5–20%)

    • Review ASCVD risk-enhancing factors and consider moderate-intensity statin therapy depending on result.

    • If the benefit of treatment is unclear in patients with intermediate-risk, consider coronary artery calcium scoring.

• Patients 40–75 years of age with diabetes mellitus

  • Initiate moderate-intensity statin therapy.

• Patients 20–39 years of age if LDL ≥ 160 mg/dL and family history positive for premature ASCVD: Consider statin therapy.

If high-intensity statin therapy is indicated but not tolerated, consider moderate-intensity statins or low-intensity statins.

• Ezetimibe

• Bile-acid sequestrants, e.g., colesevelam

• PCSK9 inhibitors, e.g., evolocumab or alirocumab

Base treatment decisions on average of ≥ 2 fasting lipid panels taken within 2 weeks to 3 months of each other. The goal of medical therapy is to lower LDL to ≤ 130 mg/dL.

• Children with LDL ≥ 130 mg/dL or elevated triglycerides : lifestyle modifications

• Children ≥ 10 years

  • Consider medical therapy if fasting lipids remain elevated after 6 months despite lifestyle modifications.

  • Base treatment decision on LDL levels, traditional ASCVD risk factors, family history of premature ASCVD , and the presence of high- or medium-risk conditions.

• Children < 10 years: medical therapy not generally recommended, except in the following situations:

  • Clinical ASCVD in patients ≤ 20 years or cardiac transplantation

  • Severe primary hyperlipidemia: LDL ≥ 400 mg/dL and/or TG ≥ 500 mg/dL

• Consult a lipid specialist for treatment of:

  • Triglycerides > 500 mg/dL: Consider pharmacotherapy to reduce the risk of acute pancreatitis.

  • LDL ≥ 250 mg/dL