LATEST UPDATES ON DYSLIPIDEMIA

An Appraised Discussion of the Latest Philippine Dyslipidemia Guidelines

by Dr. JD Alcaraz

Early this year, the collaboration of the Philippine Heart Association, the Philippine Lipid and Atherosclerosis Society, and the Philippine Society of Endocrinology, Diabetes, and Metabolism provided us an update on the 2005’s local Clinical Practice Guidelines for the Management of Dyslipidemia. The update answered applicability issues of the different prevailing dyslipidemia guidelines from the different acclaimed international societies such as the ACC/ AHA, ESC etc.

The following is a summary of the recommendations:

Parameters Established ASCVD Diabetes with ASCVD Diabetes without ASCVD Non-DM with ≥ 45 y/o and ≥ 2 risk factors
Recommendation Statins are recommended Statins are recommended Statins are recommended Statins are recommended
Lipid profile Screening: No

Monitoring : Yes

Screening: No

Monitoring : Yes

Screening: No

Monitoring : Yes

Screening: Yes

Monitoring : Yes

Frequency of Monitoring 6-8 weeks, then every 3-6 months 6-8 weeks, then every 3-6 months 6-8 weeks, then every 3-6 months 3 months, then yearly
Percent reduction or mg/dl reduction 25-30%

Treatment goal LDL-C level of ≤ 70 mg/dl

25- 29%

Treatment goal LDL-C level of ≤ 70 mg/dl

18-29%

Treatment goal LDL-C level of ≤ 70 mg/dl

29%

Treatment goal LDL-C level of ≤ 70 mg/dl

Time to achieve target level 1 – 5 years (mean 33 months) 3 – 5 years 3.2 – 8 years Range: 1.9 – 5 years

Mean: one year

Philippine Dyslipidemia Guidelines 2015

  1. LIFESTYLE
    1. For individuals at any level of cardiovascular risk, especially those with established ASCVD, a low-fat, low-cholesterol diet, rich in fruits and vegetables, is RECOMMENDED.
    2. For individuals at any level of cardiovascular risk, cigarette smoking cessation is STRONGLY RECOMMENDED.
    3. For individuals at any level of cardiovascular risk, adequate exercise is RECOMMENDED (approximately 150 MINUTES of moderate to high intensity exercise per week)
  1. PRIMARY PREVENTION
    1. For non-diabetic individuals aged ≥ 45 years with LDL-C ≥ 130 mg/dL and ≥ 2 risk factors*, without ASCVD, statins are RECOMMENDED for the prevention of cardiovascular events.
      *Risk factors are: Male, postmenopausal women, smoker, hypertension, BMI > 25 kg/m2, family history of premature CHD, familial hypercholesterolemia, microalbuminuria, proteinuria, and left ventricular hypertrophy
      **Patients who fulfill the criteria for Familial Hypercholesterolemia should be initiated therapy for aggressive LDL-C lowering
    2. For diabetic individuals without evidence of ASCVD, statins are RECOMMENDED for primary prevention of cardiovascular events.
  1. SECONDARY PREVENTION
    1. For individuals with ASCVD, statin therapy is RECOMMENDED
    2. For individuals with ACS, early high-intensity statin therapy is RECOMMENDED  (and should be continued when already on statin therapy).
    3. For individuals with evidence of ACSVD or diabetes, the use of the lipid profile is RECOMMENDED for monitoring of treatment response since ALL patients with ASCVD should be on lipid-lowering therapy.
    4. For individuals without evidence of ASCVD but aged > 45 years AND with 2 or more risk factors*, the use of lipid profile for screening is RECOMMENDED
    5. For individuals on lipid-lowering therapy, the use of lipid profile for monitoring of treatment response is RECOMMENDED.
  1. NON STATIN THERAPY
    1. For diabetic individuals without evidence of ASCVD, fibrates are NOT RECOMMENDED for the primary prevention of cardiovascular events.
    2. Among patients with ASCVD fibrates are NOT RECOMMENDED as alternative to statins?
    3. Among individuals with ASCVD, omega3-fatty acids are NOT RECOMMENDED as an alternative to statins for secondary prevention of cardiovascular events

These recommendations were based on the following parameters: quality of evidence, significance of clinical outcomes, and the number needed to treat (NNT). This is shown in the table below:

Using the AGREE II appraisal tool for CPGs, where the following parameters are counterchecked (scope

and purpose, stakeholder involvement, rigour of development, clarity of presentation, applicability and editorial independence), the recommendations made by the collaborating societies are evidence-based and unbiased. Using the AGREE II tool to critically appraise the process used to make the recommendations, its overall guideline assessment score is a whopping 87.5%.