The primary recommendation for patients with hypercholesterolemia consists of lifestyle changes. Patients should aim to eat a healthy diet rich in fruits, vegetables, lean meats, and whole grains. They should limit their fat and sodium intake. Weight loss is important for lowering cholesterol levels, and it is recommended that patients get 150 minutes of exercise each week or exercise 30 minutes a day five days a week. Additionally, patients should be counseled to quit smoking, as toxins in cigarettes can act synergistically with high cholesterol levels in the blood and accelerate atherosclerosis.
Statins are the most effective way of lowering LDL levels. They also mildly raise HDL and decrease TAGs. They work by inhibiting the enzyme HMG-CoA Reductase within the cholesterol formation pathway. Before putting patients on a statin, physicians should check liver enzymes, as statin use can cause hepatic damage as well as muscle injury. Statins should be discontinued if liver enzymes are elevated three times the normal values.
Niacin inhibits hormone-sensitive lipase, thereby increasing HDL levels and decreasing LDL levels. However, recent research has demonstrated no benefit in morbidity or mortality in patients taking niacin, even if it changes their cholesterol levels favorably. Common side effects include hyperglycemia, flushing, hyperuricemia, hepatotoxicity, and myopathy.
Ezetimibe functions at the intestinal brush border to prevent cholesterol absorption into systemic circulation. It is known to decrease LDL levels. Side effects include hepatotoxicity and GI distress.
Fibrates are the most effective way to decrease TAGS, as they upregulate lipoprotein lipase, an enzyme that degrades triglycerides into free fatty acids. They also increase HDL levels by activating the PPAR-alpha transcription factor and driving reverse cholesterol transport. Common side effects include myopathy and cholesterol gallstones.
Bile acid resins bind bile acids and prevent their re-absorption into systemic circulation. Therefore, the body’s cholesterol stores are used to synthesize new bile acids. These drugs slightly increase HDL and TAG levels and lower LDL levels. Side effects include GI distress, cholesterol gallstones, and decreased absorption of the fat soluble vitamins A,D,E, and K.
Routine screening for hyperlipidemia should begin at age 35 or older in otherwise healthy men. However if a patient has other risk factors, then screening should begin earlier for men between the ages of 20-35 years old.
Routine screening for hyperlipidemia should begin at age 45 or older in otherwise healthy women. However if a patient has other risk factors, then screening should begin earlier for women between the ages of 20-45 years old.
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