EU experts outline management of triglycerides/HDL cholesterol

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Nearly 50 percent of  deaths in Europe are caused by cardiovascular disease (CVD), and CVD management has a price tag of €192 billion ($282 billion U.S.) per year. A new guidance released by the European Atherosclerosis Society Consensus Panel outlined best practices for how to optimally manage triglycerides and HDL cholesterol in CVD patients.

The guidelines published in the latest issue of European Heart Journal recommend that integrating therapeutic targeting of elevated triglycerides ( >1.7 mmol/L or 150 mg/dL),a marker of triglyceride-rick lipoproteins (TRLs) and/or low HDL cholesterol (1.0 mmol/L or 40 mg/dL), can produce benefit. However, M. John Chapman, MD, of the Pitie´-Salpetriere University Hospital, Paris, and president of the European Atherosclerosis Society and colleagues said that lifestyle interventions should be the first step.

Although the healthcare system has undergone many improvements, CVD is still a major health burden. Managing patients with this disease is important and lifestyle interventions and pharmacotherapy to lower plasma levels, LDL cholesterol and blood pressure, among others, is vital.

In the guidance, Chapman and colleagues focused on patients with cardiometabolic risk factors including obesity, insulin resistance, dyslipidemia and hypertension, which all increase the risk of CVD and type 2 diabetes.

“The EAS Consensus Panel is well aware of uncertainties and controversies regarding triglycerides and HDL-C levels, both as risk markers or targets of therapy,” the authors wrote. However, they recommended that targeting high triglyceride levels and low HDL cholesterol can be of benefit in CVD patients. The panel recommended multiple lifestyle interventions, including stop cessation, increased physical activity, adopting a Mediterranean-type diet, losing weight and restricting alcohol intake.

“If inadequately corrected, adding niacin or a fibrate, or intensifying LDL-C lowering therapy may be considered,” the authors wrote. A fenofibrate may be the preferred fibrate for combination with statin and can also benefit patients with type 2 diabetes with mild-to-moderate retinopathy.

The panel also recommended that:

  • Pre-treatment serum transaminases, creatine phosphokinase and creatine be measured;
  • Creatine phosphokinase should be repeated if myalgia is reported or if there are known risk factors for myopathy;
  • Treatment should be discontinued if levels exceed five times the upper limit of normal and/or symptoms are severe;
  • Alanine and aspartate transaminases should be monitored three months after starting therapy and every year thereafter but more frequently if statin dose is up-titrated; and
  • Serum creatinine should be monitored with statin/fenofibrate combinations.

If patients are intolerant of niacin and fenofibrate, a high dose of omega-3 datth acids ethyl esters could be considered.

“The panel believes there is insufficient evidence to permit definition of targets for triglycerides or HDL-C for these high-risk patients. Instead, the panel proposes that treatment should be tailored to the individual to achieve desirable levels below (for triglycerides or non-HDL-C) or above (for HDL-C) the recommended cut-offs.”

The panel did also acknowledge the current limitations within the evidence base for fibrates, niacin and omega-3 acids.

“Clearly, there is a need for well-defined trials to evaluate the efficacy and safety of these therapeutic combinations in high-risk patients at LDL-C goal with elevated triglycerides and/ or low HDL-C,” the authors concluded.