Lipid Management in Patients with Endocrine Disorders: An Endocrine Society Clinical Practice Guideline
Hormones regulate every pathway involved in lipoprotein metabolism. Hence, it is predicted that endocrine disease might enhance atherosclerotic cardiovascular disease (ASCVD) risk. There exists limited scientific evidence for appropriate cholesterol management of endocrine diseases. Newman and colleagues (2020) published evidence-based guidelines in “The Journal of Clinical Endocrinology & Metabolism”, titled “Lipid Management in Patients with Endocrine Disorders: An Endocrine Society Clinical Practice Guideline”.
Due to the vastness of paper, this month we are going to summarize Screening and cardiovascular disease risk assessment, Hypertriglyceridemia and Diabetes Mellitus.
Objective:
To describe lipid abnormalities and cardiovascular disease (CVD) risk in endocrine diseases.
To investigate the treatment effect of the underlying endocrine disorder on the lipid profile and/or ASCVD risk.
To investigate the evidence for using lipid-lowering medications, in addition to diet and physical activity, in patients with these endocrine diseases.
Method:
Recommendations are made based on currently available clinical evidence and scientific and medical knowledge. Guidelines are divided into three sections. The first section comprises guidelines to address lipid measurement and ASCVD risk assessment. The second section addresses endocrine diseases. The third section of the guideline discusses implementation, including lifestyle therapy, and the efficacy and safety of lipid-lowering medications.
Findings:
Recommendations for screening and cardiovascular disease risk assessment in patients with endocrine diseases:
Determine if the patient has established ASCVD or long-standing diabetes. If not, proceed with the risk assessment.
Using the Pooled Cohort Equations 10-year risk should be calculated. Assess for the presence of additional risk-enhancing factors.
As per the Endocrine Society, persistent Cushing syndrome and Cushing disease, high-dose chronic glucocorticoid therapy, and possibly adult GHD, acromegaly, and hypothyroidism are considered as risk-enhancing factors.
In borderline-to-intermediate risk patients (10-year ASCVD risk of 5% to 19.9%), consider a coronary artery calcium score, particularly when risk enhancing factors are present.
Conduct a clinician-patient risk discussion, including discussion of lifetime risk and lifetime lipid-lowering treatment benefit, along with patient preferences.
Recommendations for Hypertriglyceridemia:
In adults, with fasting TG levels between 500 – 1000 mg/dL, guidelines recommend pharmacologic treatment as an adjunct to diet and exercise to prevent pancreatitis. However, in TG levels above 1000 mg/ dl, an adequate response to medications is not often observed. Hence, control of diabetes, modification of diet, and weight loss are essential.
Guidelines don’t suggest the use of plasmapheresis as first-line therapy to reduce TG levels in TG-induced pancreatitis until and unless all conventional methods of lowering TG have failed (eg, over 10 000 mg/dL [112.9 mmol/L]) or in extremely high-risk situations such as pregnancy.
In patients without diabetes who have TG-induced pancreatitis, guidelines suggest against the routine use of insulin infusion. Insulin therapy should be only used to normalize glucose levels.
In adults who are on statins and still have moderately elevated TG levels >150 mg/dL (1.7 mmol/L), and who have either ASCVD or diabetes plus 2 additional risk factors, guidelines suggest adding eicosapentaenoic acid (EPA) ethyl ester (4g/day) to reduce the risk of CVD. Fibrate can be considered if EPA ethyl ester is not available or accessible.
In patients with elevated TG (>150 mg/dL to 499 mg/dL), guidelines suggest checking TG before starting a bile acid sequestrant and also after a few months of treatment.
Recommendations for Type 2 diabetes mellitus:
In adults with T2D and other CV risk factors, we recommend statin therapy in addition to lifestyle modification to reduce CV risk. Guidelines add that, Statins should not be used in women who are pregnant or trying to become pregnant.
In adults with T2D and other CV risk factors, guidelines suggest lowering LDL-C to achieve a goal of LDL-C <70 mg/dL (1.8 mmol/L) to reduce CV risk.
In adults with T2D on a statin at LDL goal with residual TG over 150 mg/dL (1.7 mmol/L) and with 2 additional traditional risk factors or risk enhancing factors, we suggest adding EPA ethyl ester (4g/day) to reduce CV risk.
In adults with T2D with CKD stages 1–4 and postrenal transplant, guidelines suggest statin therapy, irrespective of the CV risk score, to reduce CV risk. Renal clearance of statin should be considered while prescribing a statin.
In adults with T2D and diabetic retinopathy, guidelines suggest fibrates in addition to statins to reduce retinopathy progression.
Recommendations for Type 1 diabetes mellitus:
In adults with T1D age 40 years and older and/ or with a duration of diabetes > 20 years, and/or microvascular complications, guidelines suggest statin therapy, irrespective of the CV risk score, to reduce CV risk.
In adults with T1D with CKD in stages 1 to 4, guidelines suggest statin therapy, irrespective of the CV risk score, to reduce CV risk.
In adults with T1D with obesity, or with high TG and low HDL-C, guidelines suggest statin therapy, irrespective of the CV risk score, to reduce CV risk.
In adults with T1D and diabetic retinopathy, guidelines suggest statin therapy, irrespective of the CV risk score, to reduce CV risk.
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