Management of hypercholesterolemia. Approach to diet and drug therapy

The benefit of lowering elevated plasma low-density lipoprotein cholesterol levels and preventing coronary artery disease is now well documented. The guidelines formulated by the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults provide a rational approach to lipid level management. Once an elevation in low-density lipoprotein cholesterol level has been confirmed in an accurate and precise laboratory, the initial step in therapy remains regulation of diet. Pharmacologic intervention is recommended only if patients do not achieve desirable low-density lipoprotein cholesterol levels after an adequate period receiving regulated diet. The guidelines provide a mix of specific low-density lipoprotein level cutoff points and additional cardiovascular risk factors on which to base decisions in regard to drug therapy. The initial approach should be monotherapy with either a bile acid binding resin or nicotinic acid, with selection based on a variety of factors, including patient age, sex, and the severity and exact type of lipid disorder. Should difficulties or inadequate control occur with either of these agents, the hydroxy-methylglutaryl-coenzyme A reductase inhibitors should be utilized, since their ability to reduce low-density lipoprotein cholesterol levels is significantly greater than that of the other available agents. If inadequate control is obtained with monotherapy, combination therapy is recommended. Optimal combinations of drugs and dosages have yet to be fully assessed and will ultimately depend on patient acceptance, efficacy, side effects, and cost effectiveness. Severely affected subjects may require triple-drug therapy. Other agents, such as fibric acid derivatives and probucol, have only a limited role when elevated low-density lipoprotein cholesterol level is the only abnormality. In patients with combined hyperlipidemias, especially when the very low-density lipoprotein level is significantly increased, the fibrates may even be used for initial therapy.