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【論文摘要】Taiwan Lipid Guidelines: High Risk Patients & Statin Intolerance
摘要
The Taiwan Society of Lipids and Atherosclerosis have published and updated guidelines/consensus regarding management of dyslipidemia for general population (2003, 2009, and 2017) and people with familial hypercholesterolemia (FH; 2014), as well as those with statin intolerance (2019). Through a protocol of writing group formation, data collection, and drafting, followed by several rounds of expert meetings and amendments, the latest versions of guidelines/consensus were finalized after nationwide public hearing. In Taiwan, the prevalence of hyperlipidemia increased due to lifestyle and dietary habit changes. Low density lipoprotein cholesterol (LDL-C) and non-high density lipoprotein cholesterol (non-HDL-C) are all significant predicting factors of coronary artery disease. We recognized that lipid control is especially important in patients with existed atherosclerotic cardiovascular diseases (ASCVD), including coronary artery disease (CAD), ischemic stroke and peripheral arterial disease (PAD). Because the risk of ASCVD is high in patients with diabetes mellitus (DM), chronic kidney disease (CKD) and FH, lipid control is also necessary in these patients. With the background, the 2017 Taiwan lipid guidelines (J Formos Med Assoc. 2017;116:217-248) focused on these high risk patients. In the guidelines, lifestyle modification is emphasized as the first step to control lipid. Statin is recommended as the first line therapy. Combination therapy with statin and other lipid-lowering agents, including ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, may be considered in some clinical settings. For patients with acute coronary syndrome (ACS) and stable CAD, LDL-C ＜ 70 mg/dL is the major target. A lower target of LDL-C ＜55 mg/dL can be considered in ACS patients with DM. After treating LDL-C to target, non- HDL-C can be considered as a secondary target for patients with triglycerides ≥ 200 mg/dL. The suggested non-HDL-C target is ＜ 100 mg/dL in ACS and CAD patients. For patients with ischemic stroke or transient ischemic attack presumed to be of atherosclerotic origin, statin therapy is beneficial and LDL-C ＜ 100 mg/dL is the suggested target. For patients with symptomatic carotid stenosis or intracranial arterial stenosis, LDL-C should be lowered to ＜ 100 mg/dL. Statin is necessary for DM patients with CV disease and the LDL-C target is ＜ 70 mg/dL. For diabetic patients who are ≥ 40 years of age, or who are ＜ 40 years of age but have additional CV risk factors, the LDL-C target should be ＜ 100 mg/dL. After achieving LDL-C target, combination of other lipid-lowering agents with statin is reasonable to attain TG ＜ 150 mg/dL and HDL-C ＞40 in men and ＞50 mg/dL in women in DM. In adults with glomerular filtration rate (GFR) ＜ 60 mL/min/1.73m2 without chronic dialysis (CKD stage 3-5), statin therapy should be initiated if LDL-C ≥ 100 mg/dL. For FH, mutations in LDL receptor and apolipoprotein B genes are the common causes. Diagnosis of FH usually depends on family history, clinical history of premature CAD, physical findings of xanthoma or corneal arcus and high levels of LDL-C. In addition to conventional lipid lowering therapies, adjunctive treatment with mipomersen, lomitapide, or PCSK9 inhibitors become necessary to further reduce LDL-C in patients with FH. The target is LDL-C ＜ 70 mg/dL for FH adults and ＜ 70 mg/dL for those with ASCVD. Since statins are recommended as first line therapy, varieties of adverse effects, mainly muscular and hepatic, reported in some patients may interfere long-term drug compliance. In general, statin is a safe and well-tolerated medication. To help health care professionals to diagnose and manage individuals who develop muscular and hepatic side effects after statin therapy, criteria were recommended to identify patients with statin intolerance in the 2019 Taiwan Society of Lipids and Atherosclerosis expert consensus statement on statin intolerance (J Formos Med Assoc.in press). Overall, these recommendations are to help the health care professionals in Taiwan to treat hyperlipidemia with current scientific evidences. The 2017 Taiwan lipid guidelines for high risk patients were supported by Health Promotion Administration, Ministry of Health and Welfare, and endorsed by the Taiwan Society of Cardiology, Taiwan Society of Cardiovascular Intervention, Taiwan Stroke Society, Taiwan Diabetes Association, Taiwanese Association of Diabetes Educators, and Taiwan Nephrology Association.